“It’s not about how much we lost, it’s about how much we have left.” A real statement spoken by a fictional Tony Stark, aka Ironman, one of the world’s most recognizable exoskeleton wearers. While Ironman was alluding to the Avengers ability to be victorious in Endgame, the quote also applies to people living with new (and increasing) disabilities. For those struggling with activities they want and need to do, one way to capitalize on “what we have left” might include exoskeleton technologies. But! Are exoskeletons ready for primetime?
What is an exoskeleton?
Exoskeletons are wearable devices that work in tandem with the user. They are placed on the user’s body and act to replace, recover, or enhance function that has been impaired, lost or diminished. Devices typically target either the upper extremities (hand, wrist, arm, shoulder) or lower extremities (legs, hips, ankles).
Who are they for?
Exoskeletons are designed for individuals with a wide range of abilities. Some are designed for able-bodied people who want to enhance their natural ability by increasing strength and/or endurance or decreasing stress on healthy joints. However, many are designed for people with disabilities including those arising from: arthritis, MS, stroke, traumatic or congenital brain injury, spinal cord injury, strain injury, Parkinson’s disease etc.
Where are they used?
Exoskeleton use by able-bodied people is predominantly in industry and military settings, however for people with disabilities, most exoskeleton use remains in clinical and research settings. There has been a push in recent years to make community exoskeleton use more mainstream. Widespread commercial availability could be game changing for people with disabilities as these devices are designed to facilitate everyday activities in an unadapted environment. This is particularly exciting for people with mobility issues as exoskeletons could reduce or eliminate the need for more cumbersome assistive devices like wheelchairs.
What’s on the market?
Upper extremity (UE) exoskeletons
There are some commercially available UE exoskeletons intended for personal use, like Myomo’s MyoPro; however, many are marketed as rehabilitation or industry specific tools. Ekso Bionics offers one of each. Their EksoUE, is a shoulder and arm rehab system that provides active assistance for functional activities of daily living; however, it is only available in certified rehab settings. While the technology offers promise for those limited by UE function, its limited accessibility is a barrier to widespread uptake and prescription by clinicians and ultimately insurance coverage of the product for individuals.
Alternatively, the Ekso EVO is a non-medically marketed exoskeleton designed to prevent workplace injuries, offering “power without pain”. It allows for increased strength throughout a user’s natural range of motion (5-15 lb lift assistance per arm). While this product is marketed to the manufacturing and construction sectors, it has potential to improve everyday functioning of people with UE weakness and fatigue. Going forward, it may be worth exploring its utility for in-home, personal use.
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EVO, the next evolution of EksoVest, is the world’s most durable, naturally-tracking, and assistive exoskeleton vest.
EVO features additional technology we’ve been working on, based on market feedback. We’ve improved the design, manufacturing, and ergonomics to ensure that EVO delivers an exceptional user experience for workers of all sizes and trades.
Most mobile UE exoskeletons are intended for users who can walk. However, for people unable to ambulate, Maestro has 2 commercially available devices; the table mounted Maestro Dynamic Arm Support and the wheelchair mounted Maestro Mobile. Both arm support systems amplify the strength in weakened limbs while the user is seated. Similarly, the ExoArm is an exciting product currently in development by Focal Meditech. Like the Maestro devices, it is a wheelchair-mounted, fully automated dynamic arm support system that assists the user in lifting in all directions (including against gravity). However, its advanced sensing technology can modify user support throughout the course of the day based on user fatigue and/or task requirements. It will be another excellent option to allow people with extremely limited arm and shoulder function to regain the ability to complete everyday activities independently.
Hand exoskeletons
For people with limited hand strength and mobility, there are also a number of hand exoskeletons commercially available including Bioservo’s Carbonhand; a grip enhancing device that adds extra strength when needed and reinforces hand function. It is available in a range of sizes and its low profile allows people to use it for daily activities both in the home and at work.
Lower extremity (LE) exoskeletons
ReWalk, Ekso Bionics’ EksoNR and its predecessor EksoGT are three of the more widely known LE exoskeletons. The EksoNR and EksoGT, like their UE counterpart, are only available in certified rehab centres; however, the ReWalk is available to purchase for personal use. The ReWalk provides powered hip and knee motion to enable people with spinal cord injuries to stand upright, walk and turn. It is controlled by user forward tilt and body shifting, allowing for a sequence of steps that mimics natural walking.
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EksoNR is a robotic exoskeleton specifically designed to be used in a rehabilitation setting to progress neurorehab patients so they can walk out of the device and back into their communities. As the first exoskeleton FDA-cleared for acquired brain injury, stroke, and spinal cord injury, EksoNR offers the industry’s most natural gait, re-teaching the brain and muscles how to properly walk again.
Pros of exoskeletons
Exoskeletons offer users an assistive device capable of facilitating function that closely resembles natural human movement. This technology not only allows people to engage in activities they were previously unable to do, but in an environment that requires little to no adaptation (Rupal et al. 2018). Preliminary studies show exoskeleton users enjoy improved cardiovascular health, increased social engagement and improved quality of life (Gorgey, 2018). With ever advancing technology and increasing investment in exoskeleton companies, one can assume that exoskeletons of the future will be increasingly intelligent, low profile and easier to use.
Cons of exoskeletons
Largely due to how expensive exoskeletons are to design, build and purchase, research into evaluating them remains minimal. As a result, very few standards surrounding their performance metrics (comfort, accuracy, cost, range of use, environmental compatibility, ease of use etc.) have been developed. Buying an exoskeleton can be a financial risk for individuals and/or clinicians unsure of its effectiveness. Similarly, effects of exoskeleton use on the human body (health care impact, safety, ergonomics etc.) are not well understood by researchers (Gorgey, 2018). Also, while they allow users to enjoy increased independence during activities, many exoskeletons require a high degree of training and continual support from caregivers for safe use (set up, supervision, removal etc.). Finally, while some exoskeletons are covered by health insurance plans, many are not, creating additional financial burden on individual users.
What’s the verdict?
While exoskeletons are, no doubt, the assistive devices of the future, research on their use for everyday activities is in its infancy. Their readiness for primetime is limited by their availability for personal use, cost, lack of standard performance metrics, and high degree of training and caregiver support for use. Anecdotally, exoskeletons have the potential to improve the lives of people with disabilities by changing the way they participate in society and daily life. Their potential for mainstream use increases with every new exoskeleton that emerges on the market. Like the Avengers franchise, support and excitement for exoskeletons will only grow as the technology evolves and adapts.
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References
Gorgey, A. 2018. Robotic exoskeletons: The current pros and cons. World Journal of Orthopedics, 9(9), 112-119. https://www.ncbi.nlm.nih.gov/pmc/articles/PMC6153133/ Rupal, B. S., Rafique, S., Singla, A., Singla, E., Isaksson, M., & Virk, G. S. (2017). Lower-limb exoskeletons: Research trends and regulatory guidelines in medical and non-medical applications. International Journal of Advanced robotic systems, Nov-Dec, 1-27. https://journals.sagepub.com/doi/pdf/10.1177/1729881417743554
