Exoskeletons for industrial application and their potential effects on physical

work load
Michiel P. de Looze, Tim Bosch, Frank Krause, Konrad S. Stadler, LEONARD O'SULLIVAN

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01-01-2016

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Ergonomics;59 (5), pp. 617-681

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 Exoskeletons for industrial application
and their potential effects on physical work load

Michiel P. de Looze a, b, Tim Bosch a, Frank Krause a,

Konrad S. Stadlerc, Leonard W. O’Sullivand

a
TNO, Leiden, The Netherlands
b
Faculty of Human Movement Sciences, VU University, Amsterdam, The Netherlands
c
Zurich University of Applied Sciences (ZHAW), Winterthur, Switzerland
d
University of Limerick, Ireland

Correspondence:
Prof.dr. M.P. de Looze, TNO, P.O. Box 3005, 2301 DA Leiden, The Netherlands,
T +31 88 866 52 56
E [email protected]

Key words
Exoskeleton, industry, physical workload, discomfort

Abstract

The aim of this review was to provide an overview of assistive exoskeletons that have specifically
been developed for industrial purposes and to assess the potential effect of these exoskeletons on
reduction of physical loading on the body. The search resulted in 40 papers describing 26 different
industrial exoskeletons, of which 19 were active (actuated) and 7 passive (non-actuated). For 13
exoskeletons, the effect on physical loading have been evaluated, mainly in terms of muscle activity.
All passive exoskeletons retrieved were aimed to support the low back. 10 to 40% reductions in back
muscle activity during dynamic lifting and static holding have been reported. Both lower body, trunk
and upper body regions could benefit from active exoskeletons. Muscle activity reductions up to
80% have been reported as an effect of active exoskeletons. Exoskeletons have the potential to
considerably reduce the underlying factors associated with work-related musculoskeletal injury.

Practitioner Summary

Worldwide, a significant interest in industrial exoskeletons does exist, but a lack of specific safety
standards and several technical issues hinder mainstay practical use of exoskeletons in industry.
Specific issues include discomfort (for passive and active exoskeletons), weight of device, alignment
with human anatomy and kinematics, and detection of human intention to enable smooth
movement (for active exoskeletons).

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1. Introduction

Despite the on-going trend in automation and mechanization in industry, many workers are still
exposed to physical workloads due to material handling (over 30 % of the work population in the
EU), repetitive movements (63%), and awkward body postures (46 %) (Eurofound, 2012). These
data, which have been relatively stable over the past decade, contribute to the fact that work-
related musculoskeletal disorders (WMSDs) still affect a considerable number of workers. In the
European Union, yearly more than 40 % of the workers suffer from low back pain or neck and
shoulder pain (Eurofound 2012).
Full-automation would solve these problems, but this is not always feasible. For instance, in dynamic
manufacturing or warehousing environments a high product mix and relatively small order sizes
dictate high levels of flexibility and in such cases full-automation is either not possible or
prohibitively expensive. In such a context of continuously varying products and tasks, the human
capacity to observe, decide and adopt proper actions within split seconds, is still required. Thus,
workers are still exposed to various production activities such as assembling or material handling
and hence are exposed to the associated risks for developing WMSDs. There is a growing movement
in modern industry towards human robot collaboration to improve use of robotics while retaining
the flexibility of humans (MacDougall, 2014). For manual handling tasks one solution is to use
exoskeletons. The main benefit of the application of an exoskeleton above any type of robot system
(classical robots, full-automation systems or humanoid robots), would be that, specifically in
dynamic environments, one will fully profit from the human’s creativity and flexibility, while he is
the one I charge, and there is thus no need for robot programming or teaching of robots.
An exoskeleton can be defined as a wearable, external mechanical structure that enhances the
power of a person. Exoskeletons can be classified as ‘active’ or ‘passive’. An active exoskeleton
comprises one of more actuators that augments the human’s power and helps in actuating the
human joints. These actuators may be electric motors, hydraulic actuators, pneumatic muscles, or
other types (Gopura and Kiguchi 2009). A strictly passive system does not use any type of actuator,
but rather uses materials, springs or dampers with the ability to store energy harvested by human
motion and to use this as required to support a posture or a motion. A passive exoskeleton for
instance may store energy when a person bends forward, and while in this position, this energy may
support the person to keep that position or to erect the body while lifting an object.
We can also distinguish exoskeletons by the supported body part(s): providing power or support to
the lower limbs (lower body exoskeletons), to the upper extremities (upper body exoskeletons), and
to both upper and lower extremities (full body exoskeletons). Additionally, some single-joint
exoskeletons have been described in literature.
Finally, exoskeletons can be classified according to the level that the exoskeleton fits or resembles
the human anthropometry. Anthropomorphic exoskeletons have exoskeleton joints with rotational
axes that are aligned with the rotational movement of the human joints, which is not the case in the
non-anthropomorphic types. A fully anthropomorphic type enables the exoskeleton robot to make
the same motions as the wearer thereby offering a large freedom of motion. But these systems pose
major design challenges to ensure close fit for different size users while simultaneously
accommodating natural movements by the user. Non-anthropomorphic types are generally simpler
and can be designed to have an optimized structure for specific tasks to be performed allowing more
effective energy consumption than anthropomorphic systems (Lee et al. 2012a).

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The main application area of exoskeletons has been for medical /rehabilitation purposes where the
devices are aimed to support physically weak, injured, or disabled people to perform a wide range of
motions involved in activities of daily living, such as walking, traversing stairs, sitting and standing
up, reaching and grasping (Viteckova et al. 2013). A small number of exoskeletons have also been
designed for military applications for soldiers to lift or carry heavy loads.
Several scientific literature reviews have addressed the technical aspects of exoskeletons (Yang et al.
(2008), Gopura and Kiguchi (2009), Lee et al. (2012) and Viteckova et al. (2013) with few, if any
addressing the effect on the human wearer. Vitechkova et al. (2013) conclude from their technical
review that, despite much progress in the field of supportive robotic technologies, such as power
sources, small and sensitive sensors, powerful computers, and lightweight materials, there is still a
need to further develop lightweight exoskeletons compatible with operators. Some key technical
issues that must be addressed: the design of actuators and artificial muscles, fast and effective
control loops, the anthropometric fit, and battery life-times.
In this literature review, we address the impact of exoskeletons on the user. We focus on
exoskeletons developed for use in occupational fields to support shop floor workers perform
physically demanding activities. The aim of this review is (1) to provide an overview of ‘industrial’
exoskeletons that have been developed or are under development, and (2) to assess the potential
effect of these exoskeletons in terms of physical load reduction on the wearer.

2. Methods

This review was based on an electronic literature search using the Scopus search engine which
accesses an estimated 40 million scientific papers. The authors’ personal databases were also
included in the search. To be included, papers had to be published in peer-reviewed journals in the
English language from January 1995 until August 2014. The review was confined to publications in
the formal scientific literature and did not include books or ‘grey’ research reports. The references
retrieved by this search were first screened on the basis of their titles and abstracts. In cases where
abstracts did not provide sufficient information, screening took place on full paper texts. Papers
fulfilling the inclusion criteria (see below) were included in this review. The literature retrieved in
this way was supplemented with relevant studies cited in the retrieved papers.

The following search terms were used: exoskeleton, wearable device, assistive device, and wearable
robot. An additional inclusion criteria was that papers considered exoskeletons with an occupational
purpose, i.e. to give physical support to workers in occupational settings. A simple reference to
‘work’, ‘worker’, ‘profession’, or an ‘occupational activity’ was considered to be sufficient for
inclusion, however, papers considering other applications outside of occupational settings (e.g.
rehabilitation, medical, tele-operations, military, and virtual reality), were excluded. We included all
types of exoskeletons, i.e. passive and active, anthropomorphic or not, and lower body, upper body
and full-body exoskeletons. But exoskeletons covering the hand and wrist only, were excluded from
the review as they were not considered suitable for manual handling tasks. We included all papers
on industrial exoskeletons irrespective of stage of design, ranging from early stage prototypes tested
in laboratory settings to commercially available products ready to be used in practice.

3
Hence the retrieved studies were summarized to provide an overview of industrial exoskeletons
(first aim of the study) while the scientific findings of the papers were used to summarise the
efficacy of active and passive exoskeletons (second aim) in terms of physical load reduction
provided.

3. Results

The search resulted in 40 papers in which an exoskeleton with an industrial purpose was described.
In these papers a total of 26 different industrial exoskeletons were described (Table 1). These were
broken down as 20 upper body, 4 full body, and 2 lower body exoskeletons, with 19 being active and
7 passive.
The exoskeletons were most frequently aimed to support: stooped working postures, static holding
of a load, dynamic lifting (and lowering) of a weight, and to support. Some studies also mentioned
carrying as an activity to be supported. Finally, some job specific activities were mentioned, i.e.
patient lifting and transfer (for three different exoskeletons), construction work, agricultural and
overhead carpentry work.
For 13 out of the 26 industrial exoskeletons, some evaluations of the physical load reductions were
performed (see Table 2 and 3, for passive and active exoskeletons, respectively). However, most
evaluations included only 1 to 3 participants. Scientific evaluation including statistical testing has
only been performed for five exoskeletons, i.e. PLAD (Personal Augmentive Lifting Device), the
Muscle Suit, BNDR (Bending Non-Demand Return), the HappyBack and the Bendezy.
All studies evaluating exoskeletons involved a repeated measures type experimental design to
include within-subject comparisons of with and with-out exoskeleton use. Remarkably, all studies
took place in a laboratory setting, except for one, namely the evaluation of PLAD by Graham et al.
(2009).
Physiological parameters studied included muscle activity (i.e. effort) in the back, shoulder, arm and
leg region mainly, as determined by the amplitude of the EMG signal, and muscle fatigue as
determined by the combination of amplitude increase and decrease in frequency content over time
in the EMG signal. Biomechanical parameters studied included the loading on the back expressed by
the estimated net joint torque, spinal compression and shear forces for the lumbar or thoracic
regions. Generally, positive effects, either tested statistically or not, have been reported for the
physiological (EMG) and biomechanical parameters, both for the passive and the active
exoskeletons.

4. Discussion

The development of passive and active exoskeletons to support humans date back to the 1960s and
1970s. Currently available lightweight materials and new technologies in sensing and actuating
enable the development of a next generation of exoskeletons. Most exoskeletons have been
developed to give support to disabled people in their daily activities. The development of
exoskeletons suitable for industrial applications lags behind. This review extracted a total of 40
papers from the literature presenting 26 different exoskeletons. Eighteen of these papers have been
published in 2010 or later, showing the current, high interest in industrial exoskeleton applications.

4
Effects of passive exoskeletons on physical load
For six passive exoskeletons the effectiveness in terms of physical load reduction has been evaluated
for the activities of dynamic lifting and static trunk bending. The amount of assistance by the PLAD
device in dynamic lifting and lowering has been evaluated in a series of laboratory experiments
(Abdoli-Eramaki et al. 2006, 2007, 2008, Frost et al. 2009, Godwin et al. 2009, Lotz et al. 2009, Sadler
et al. 2011, Whitfield et al. 2014). The PLAD principle comprises elastic elements that are situated in
parallel to the erector spinae, so as to permit a sharing of the load between the spine, shoulders,
pelvis and lower extremities. When the PLAD is worn during lifting tasks, energy is stored within the
elastic elements as the upper body is lowered and/or the trunk is flexed. On the ensuing upward
phase, this stored energy is released (Abdoli-Eramaki et al. 2006). As a result, the muscular activity
required to lift is lowered. Back muscle EMG amplitude decrease ranged from 10 to 40% across
several studies (Abdoli-Eramaki et al. 2006, Abdoli-Eramaki et al. 2008, Frost et al. 2009, Whitfield et
al. 2014). As an effect of this, the manifestation of muscle fatigue in the EMG signal (as defined as
the combination of an amplitude increase and a frequency content decrease (Basmajian and DeLuca,
1985) is dramatically less in the case of prolonged repetitive lifting and lowering over 45 minutes
(Godwin et al. 2009, Lotz et al. 2009). Another effect that is mentioned are the lowered internal
forces on the lumbar spine when wearing PLAD, e.g. L4/L5 compression estimated to be 23-29%
lower (Abdoli-Eramaki et al. 2007). Finally, some other positive effects of PLAD, e.g. post-trial
endurance and maximal back strength, further support the above findings.
For the BNDR device, a reduction of muscle activity was also reported in dynamic lifting, but only for
those subjects not experiencing the flexion-relaxation phenomenon of the back muscles at deep
back flexion (Toussaint et al. 1995). The BNDR was also found to reduce torso flexion in stooped
lifting (Ulrey and Fathallah, 2013a). The reductions in back muscle activity when wearing BNDR were
attributed to the device’s ability to limit torso flexion rather than a transferring of loads (Ulrey and
Fathallah, 2013a and b).
The effects of passive exoskeletons in static trunk bending were investigated by Graham et al. 2009
and by Ulrey and Fathallah (2013a) for PLAD and BNDR, respectively. Both studies showed positive
effects on back muscle activity during static trunk bending (decrease ranging from 10-25%), spinal
loading (estimated lumbar compression force decreased by 12-13%) (Graham et al. 2009, Ulrey and
Fathallah 2013a).
In a short conference paper, Barret and Fathallah (2001) describe the effects of the BNDR,
HappyBack and Bendezy during static bending while holding loads. These three passive exoskeletons
differed with respect to materials and mechanism, but all showed positive effects, ranging from 21-
31% reduction in erector spinae activity when using the devices.

Beside the positive effects described above, some concerns should be mentioned. Depending on
lifting technique, reduced back muscle activity might be accompanied with increased activity of
other muscles (Frost et al. 2009). An increase in leg muscle activity (tibialis anterior) has been
reported for the HappyBack and Bendezy (Barrett and Fathallah 2001). The BNDR also showed a
significant increase in lower leg muscle activity (Ulrey and Fathallah, 2013a). The increase in leg
muscle activity could be explained by the fact that external forces applied by the equipment needs
to be counteracted to retain balance, both in static holding and in dynamic lifting activities. For the
PLAD, subjects were observed changing their lifting technique towards a more squat-like lifting
pattern (Sadler et al 2011), which might also may be an explanation for higher muscle activity in the
leg muscles when wearing a passive exoskeleton.

5
In prolonged lifting and lowering work, increased leg muscle activity could be expected to require
increase oxygen uptake. However, for PLAD, in prolonged repetitive lifting and lowering, oxygen
consumption was not affected (Whitfield et al. 2014). Whitfield et al. conclude that the
biomechanical advantage in terms of unloading the back was not accompanied by an increase in
energy consumption.
Other concerns relate to subjective reports of localised discomfort (e.g. shoulders or knees).
Exoskeletons need to apply pressure on the body to function. If not carefully designed these contact
areas may experience discomfort and possibly injury, which may lead to user reluctance to use the
exoskeleton.

Effects of active exoskeletons on physical load

For several active exoskeletons, the effects in terms of physical load reduction have been evaluated,
but statistical comparison data has only been reported for the Muscle Suit (Muramutsu et al. 2011,
Kobayashi and Nozaki 2007). Originally the Muscle Suit was intended to aid the physically
challenged, but for reasons of ethics and safety, it was decided to deploy the device for use by
manual workers to help solve problems of work-related musculoskeletal disorders (Muramutsu et al.
2011). The Muscle Suit covers the thighs, trunk and upper extremities and includes three joints, at
waist, shoulder and elbow level. For the complex shoulder joints, a 4 degrees of freedom mechanism
was constructed allowing rotation around three orthogonal axes and transversal sliding of the centre
of rotation. The Muscle Suit was constructed to give support to shoulder flexion, elbow flexion and
trunk flexion in the sagittal plane. The McKibben artificial muscle (Chou and Hannaford 1996) was
selected as the Muscle Suit actuator because of its light weight.
Experiments including static holding and dynamic lifting showed positive effects of the Muscle Suit
for a large range of muscles in the upper extremities. Muscle activity reductions were reported in
the range of 20-35% for the Deltoideus Anterior in dynamic lifting and up to 40-65% for the Flexor
Carpi Radialis in dynamic lifting and static holding (Muramutsu et al. 2011). While holding a weight
above the head the suit resulted in a decrease in muscle activity for the Biceps Brachii (30-70%) and
the Trapezius pars transversa (40-70%). These results show the Muscle Suit’s potential for reducing
the physical load on the shoulder and arms for a large range of occupational activities including
dynamic lifting and carrying, static work in a forward bended posture and overhead work.
Aside from the Muscle Suit seven other active exoskeletons with potential effects on physical
loading were evaluated (see Table 3). However, these evaluations involved between one and three
participants, and thus, statistical tests have not been performed on the data. These exoskeletons
vary a lot with respect to body structures supported (either lower, upper or full body), the materials
used and the activation type. For the technical descriptions we refer to the individual papers shown
in Table 3. With regard to their effect on physical load, it can be concluded that these papers show
the potential of decreasing muscle activity in both the lower extremities (for instance in walking and
stairs climbing), the back (in lifting and static bending), and in the shoulders and upper extremities
(in various types of hand-arm work).

Practical implementation of exoskeletons

Despite the high interest for exoskeletons with an industrial application purpose, a large-scale
implementation of exoskeletons in industry has still a long way to go. Actually, for the exoskeletons
considered in this review, all evaluations took place in the laboratory, except for the study on PLAD

6
of Graham et al. (2009). The exoskeleton devices reviewed are largely at an experimental stage and
not ready yet to be used in practice. Technical issues need to be considered and solved first.
Even the more simple passive devices are not yet widely used in practice. One reason might be the
level of discomfort associated with wearing the exoskeleton. In a few studies, some concerns about
this aspect have been reported (e.g. Abdoli-Eramaki et al. 2007). With the biomechanical advantage
being established, the elimination of discomfort at the physical user interface with the equipment
could be the next challenge in the design of exoskeletons, bearing in mind that even a minimal level
of discomfort might hinder user’s acceptance. The latter might be different from the exoskeletons
aimed at supporting disabled people, where the exoskeleton could determine being able to walk or
grasp or not. Another concern with regard to the passive devices concerns the
potential increased activity of leg muscles. This aspect certainly needs consideration in further
developments towards final ready-to-be-used products.
Active exoskeletons may have a larger potential of reducing physical loads. While passive
exoskeletons mainly have a potential of unloading the back, the active devices may unload many
joints throughout the body. However, with increasing numbers of joints (each requiring actuators
and power supply) the weight of the exoskeleton will increase. For instance, an upper body
exoskeleton with lightweight actuators like the MuscleSuit, already has a total weight of 9 kg
(Muramutsu et al. 2011). To unload the worker from this constant weight burden, an extension of
the exoskeleton towards the ground would be beneficial, but this increases the complexity of the
design.
The exoskeletons reviewed in this paper were all anthropomorphic. That is, the exoskeleton has a
similar skeletal structure compared to the human body involving a series of many actuated joint. The
main advantage is that the footprint of the exoskeleton is relatively small as it adheres directly to the
body, and the movements should in theory be unrestricted. The movements of the worker are
copied by the exoskeleton, i.e. the limbs of the human and the exoskeleton are aligned during
motion. This necessitates detection of human movement intention to initiate the appropriate
responses of the exoskeleton’s actuators. Distinction of intended from unintended movements is
often difficult and results in systems with many different kinds of sensors and complex signal
processing. Yang et al. (2008) address the necessity for improved control strategies to enable
smooth movements at a normal to fast pace, but the cooperation and function allocation, man-
machine information exchange, real-time motion planning and safety control are the difficulties
faced by building such a control strategy.
It remains a challenge for anthropomorphic active exoskeletons to reflect the human anatomy,
kinematics and kinetics to enable natural and comfortable movements. We mentioned the shoulder
as a complex joint to incorporate in exoskeletons as it comprises three orthogonal axes of rotation
plus transversal sliding of the center of rotation. The knee may also form a challenge as the center of
rotation shifts during flexion. Moreover, rotational movement in any joint requires movement
between the skin and skeletal structure. To accommodate this during movement the exoskeleton
should ideally extend or shorten. This is a design feature that was not readily observed in the
exoskeletons observed.
The industrial use of passive and active exoskeletons requires consideration of several specific safety
issues. Varying risk scenarios can be defined for the worker wearing an actuated exoskeleton in the
occupational field, for example on the shop floors in production industry, in warehouses, in
hospitals, or outdoors in agriculture or construction. Exoskeletons used in the context of robots for
personal care are governed by ISO 13482. However, to date, international safety standards for

7
industrial application of exoskeletons does not yet exist and this is a significant barrier to their
adoption.
A final concern has been raised earlier by Eisinger et al. (1996) with regard to lumbar orthoses (i.e.
close fitting rigid lumbar supports). They reported that prolonged use of orthoses could be
associated with deconditioning of trunk muscles. Therefore they recommend either to limit the
duration of their use or to combine the use with strengthening exercises. The same phenomenon
and recommendation may hold for exoskeletons used in industry.

Conclusions
This review shows a wide interest in passive and active exoskeletons for industrial purposes, but
most developments are at an early stage of technology development with many concepts not tested
beyond the lab.
Passive industrial exoskeletons are aimed at supporting or unloading the lower back region and
appear to be quite successful herein for both dynamic lifting or static holding activities. Some
concerns have been raised regarding the potentially negative effects associated with increasing leg
muscle activity, high levels of discomfort and muscle deconditioning.
The potential effect in reducing physical loads seems to be even higher for active exoskeletons. Both
lower body, trunk and upper body regions could benefit from large reductions in loading.
Exoskeletons thus have the potential to considerably reduce the underlying factors associated with
developing work-related musculoskeletal injuries. The true impact on potentially reducing injury
prevalence however, still needs to be determined, as until now significant technical challenges and a
lack of specific safety standards stands in the way of large-scale implementation in workplaces.

Acknowledgments
This research was supported by the European shared cost project Robo-Mate, funded under the
Seventh Framework Program (FP7-2013-NMP-ICT-FOF)

8
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Table 1. Overview of retrieved exoskeletons, references, aimed type of industrial application, and type of exoskeleton

name or description of references industrial activity to be power supply part of

exoskeleton supported mechanism body
1 PLAD Abdoli-Eramaki et al. 2006 lifting/lowering passive upper
Personal Augmentive Lifting Abdoli-Eramaki et al. 2007 static holding elastic straps
Device Abdoli-Eramaki et al. 2008
Frost et al. 2009
Godwin et al. 2009
Graham et al. 2009
Lotz et al. 2009
Sadler et al. 2011
Whitfield et al. 2014
2 Muscle Suit Kobayashi et al. 2009 lifting active upper
Kobayashi and Nozaki 2008 static holding McKibben artificial muscle
Kobayashi and Nozaki 2007
Muramatsu et al. 2011a
Muramatsu et al. 2011b
3 ‘quasi-active exoskeleton’ Kim et al. 2009 carrying (quasi-)active lower
Kim et al. 2013 lifting electric motors for knee only
4 PARM Kadota et al. 2009 lifting active upper
Power Assisted Robot Arm pneumatic artificial rubber muscle
5 SRL Davenport et al. 2012 static holding active upper
Supernumerary Robotic Limbs electric motor and viscoelastic
elements
6 ‘strengthen upper limb Deng et al. 2013 lifting active upper
exoskeleton’ hydraulic actuators
7 HAL Kawabata et al. 2009 heavy lifting active full
Hybrid Assistive Limb carrying
8 ‘power assist wear’ Li t al. 2013 lifting active upper
static holding pneumatic actuators
9 IKO Martinez et al. 2008 static holding active, upper
IKerlan’s Orthosis cable-drive transmission, electric
motor, pneumatic muscles
10 ‘myosignal-based powered Rosen 2001 static holding active upper
exoskeleton’ electric servo motor
11 ‘human-robot integrated Ryu 2012 heavy lifting active full
exoskeleton’ (mechanism not mentioned)
12 ESA EXARM Schiele 2009 static holding active upper
(mechanism not mentioned)
13 PAS Toyama and Yonetake 2007 patient lifting active full
Power-assisted Suit patient transfer ultrasonic motors
14 ‘wearable agrirobot’ Toyama and Yamamoto 2010 farming: kneeling, arm active full
lifting, stooped work electric motors
15 Skil Mate Umetani et al. 1999 construction work active upper
McKibben artificial muscle
16 EXO-UL7 Yu and Rosen 2010 static holding active upper
electric servo-motor
17 ‘power assist suit’ Tsuzura et al. 2013 patient lifting passive upper
patient transfer torsion springs
18 ‘lower limb assistive device’ Hasegawa and Muramutsu patient lifting passive lower
2013 patient transfer gas spring
19 ‘wearable robot’ Naito et al. 2007 carpentry overhead work active upper
motor and springs
20 ‘exoskeleton power assis Naruse et al. 2003 lifting active upper
system’ lowering motor and cables
21 ‘exoskeleton’robot’ Lee et al. 2012b static holding active upper
(mechanism not mentioned)
22 ‘wearable moment restoring Wehner et al. 2009 lifting passive upper
device’ springs
23 WSAD Luo and Yu 2013 stooped work active upper
Wearable Stooping-Assist servo-motor
Device
24 BNDR Ulrey and Fathallah 2013a lifting passive upper
Bending Non-Demand Return Ulrey and Fathallah 2013b stooped work springs
Barret and Fathallah 2001
25 Happyback Barret and Fathallah 2001 stooped work passive upper
bungee cords
26 Bendezy Barret and Fathallah 2001 stooped work passive upper
springs

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Table 2. Effects of passive exoskeletons in terms of physical load reductions

exo-skelet publication type of study subj. effect on muscle activation effect of on biomechanical parameters other effects
PLAD Abdoli-Eramaki laboratory 9♂ Erector Spinae T9 AMP ▼14.4% lumbar flexion, pelvis flexion NS
et al. 2006 asymmetric lifting of 5, 15, 25 kg, three Erector Spinae L4 AMP ▼ 27.6% trunk acceleration ▼
lifting styles External Oblique, Rectus Abdominus AMP NS
Abdoli-Eramaki laboratory 9♂ compression L4/L5 ▼23%-29% all subjects reported the feeling of PLAD assisting
et al. 2007 symmetric lifting of 5, 15, 25 kg, three lifting shear L4/L5 ▼8-9% them in the up phase of lift
styles moment L4/L5 ▼ 22-26%
Abdoli-Eramaki laboratory 9♂ Erector Spinae T9 contralat. AMP ▼15.9% lateral bending moment L4/L5 ▼30% all subjects felt supported in down and up phase,
et al. 2008 asymmetric lifting of 5, 15, 25 kg, three Erector Spinae L4 contralat. AMP ▼22.6% rotational moment L4/L5 ▼24% 10% of all subjects complained about shoulder
lifting styles Erector Spinae T9 ipsilat. AMP ▼24.4% flexion/extension moment L4/L5 ▼19.5% discomfort and 40% about knee discomfort when
Erector Spinae L4 ipsilat. AMP ▼23.9% wearing PLAD
Frost et al. laboratory 13 ♂ Erector Spinae T9 AMP ▼11-43% moment L4/L5 ▼17-19%
2009 symmetric lifting of 15kg, three lifting styles Erector Spinae L4 AMP ▼ 10-40%
Godwin et al. laboratory 12 ♀ Erector Spinae T9 AMP increase ▼96% maximal isometric back strength (post-trials) ▲
2009 lifting/lowering for 45 min, load 20% of max. Erector Spinae T9 MPF decrease▼81% endurance (post-trials) NS
back extensor strength Erector Spinae L3 AMP increase ▼84% heart rate, perceived exertion, NS
Erector Spinae L3 MPF decrease▼56%
Graham et al. field 2♀ Erector Spinae T9 AMP ▼25% compression T9 ▼ 18% RPE ▼ 16%
2009 automotive assembly activities 8♂ Erector Spinae L3 AMP ▼15% compression L3▼ 12% Subjective estimate of 52% off-loading of the low back
Rectus Abdominis AMP NS
Lotz et al. laboratory 10 ♂ Erector Spinae T9 AMP increase ▼78% heart rate, endurance NS
2009 lifting/lowering for 45 min, load 20% of max. Erector Spinae T9 MPF decrease▼70% perceived exertion increase ▼(25%)
back extensor strength. Erector Spinae L3 AMP increase ▼97% max. back extension strength (post-trials) NS
Erector Spinae L3 MPF decrease▼98% endurance (post-trials) ▲20%
Whitfield et al laboratory 15 ♂ Biceps Femoris AMP ▼10% (lifting pase) oxygen consumption NS
2014 lifting/lowering of 10 kg for 15 min Erector Spinae T9 AMP ▼24% (lowering)
Rectus Femoris, Erector Spinae T9, Erector
Spinae L3, Gluteus Maximus AMP NS
‘lower limb Hasegawa and laboratory 2♂ ground reaction force ▼67-80%
assist. dev.’ Muramutsu patient transfer 2♀
2013
‘wearable Wehner et al. laboratory 5♂ 4.5 kg: Erector Spinae (lumbar) ▼44% 4.5 kg: compression force L5/S1▼60%
moment 2009 repetitive lifting of 4.5 and 13.5 kg 1♀ 13.5 kg: Erector Spinae (lumbar) ▼54% 13.5 kg: compression force L5/S1 ▼36%
restoring
device’
BNDR Ulrey and laboratory 11 ♂ Erector Spinae (lumbar) AMP ▼13.7% L5/S1 compression force ▼13.5%
Fathallah2013a static bending in 0-100% trunk flexion 7♀ Erector Spinae (thoracic) AMP ▼10.3% L5/S1 shear force ▼12.1%
postures Rectus Abdominis NS L5/S1 medio-lateral force NS
Biceps Femoris AMP ▼13.6% L5/S1 active extensor moment ▼15.0%
Tibialis Anterior AMP ▲73% Ankle axial moment ▼30.9%
Knee axial moment ▼31.1%
Ulrey and laboratory 11 ♂ Static bending Static bending
Fathallah2013b static bending and lifting of 0, 4 and 9 kg 7♀ Erector Spinae (lumbar) AMP NS Total torso angle ▼17.4%
Erector Spinae (thoracic) AMP NS
Rectus Abdominis AMP NS Lifting (flexion movement)

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 Biceps Femoris AMP ▼17% Total torso angle ▼16.7%
Tibialis Anterior AMP NS Lifting extension movement)
Lifting Total torso angle ▼17.1%
Erector Spinae (lumbar) AMP ▼15.2%
Erector Spinae (thoracic) AMP ▼10.0%
Rectus Abdominis AMP NS
Biceps Femoris AMP ▼9.5%
Tibialis Anterior AMP NS
Barret and Laboratory 4♂ Erector Spinae (lumbar) ▼31%
Fathallah 2001 static bending and holding of 0, 4 and 9 kg 5♀
Happyback Barret and Laboratory 4♂ Erector Spinae (lumbar) ▼23%
Fathallah 2001 static bending and holding of 0, 4 and 9 kg 5♀
Bendezy Barret and Laboratory 4♂ Erector Spinae (lumbar) ▼21%
Fathallah 2001 static bending and holding of 0, 4 and 9 kg 5♀

▼and ▲= significantly lower and higher value respectively, for condition with exoskeleton vs. without exoskeleton
▼and ▲= not statistically evaluated differences between conditions with vs. without exoskeleton
± = estimated effects based on figures
AMP = amplitude of EMG signal
MPF = mean power frequency of EMG signal

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Table 3. Effects of active exoskeletons in terms of physical load reductions

exo-skelet publication type of study subj. effect on muscle activation effect of on biomechanical parameters other effects
MUSCLE Kobayashi et laboratory: holding 10 kg while bending 2♂ holding:
SUIT al. 2009 field: tire assembly 1♂ Erector Spinae AMP▼40%, Trapezius AMP ▼
laboratory: lifting 12.5 kg 2♂ 80%, Biceps Brachii AMP▼70%
tire assembly:
Erector Spinae AMP ▼31%, Trapezius AMP▼
37%, Biceps Brachii AMP ▼69%
lifting:
Erector spinae AMP ▼41%
Kobayashi and laboratory 3♂ Erector Spinae AMP ▼30-60%
Nozaki 2008 holding of 0, 5, 10 and 15 kg while bended
Kobayashi and laboratory 5♂ Biceps Brachii AMP ▼30-75%
Nozaki 2007 holding load of 10 kg above head Trapezius AMP ▼40-70%
Erector Spinae AMP NS
Muramatsu et laboratory 10 ♂ holding: ‘subject felt less fatigued when wearing MUSCLE
al. 2011a holding 20 kg while bended Flexor Carpi Radialis AMP ▼±50-60% SUIT’
lifting/lowering/carrying of 20 kg Flexor Carpi Ulnaris AMP ▼±30-45
Biceps Brachii AMP ▼±30-60%
Deltoid Ant. AMP ▼±25%
Deltoid Post. AMP ▼±45-50%
lifting/lowering/carrying:
Flexor Carpi Radialis AMP ▼±45-65%
Flexor Carpi Ulnaris AMP ▼±30-45%
Biceps Brachii AMP ▼±20-55%
Deltoid ant. AMP ▼±20-35%
Deltoid post. AMP ▼±30-55%
‘quasi-act. Kim et al. 2013 laboratory 1♂ Quadriceps, Gastrocnemius AMP ▼32-49% (flat)
exo- walking flat and stairs with 20 kg and 30 kg and ▼11-24% (stairs)
skeleton’
PARM Kadota et al. laboratory 1♂ Biceps Brachhii, Brachioradialis AMP ▼(not
2009 lifting and lowering 10 kg quantified)
‘power Li et al. 2013 laboratory 1♂ holding:
assist wear’ stooped posture (no load) Erector Spinae AMP ▼19%
lifting 12.6 kg. lifting:
Erector Spinae AMP ▼29-38%
‘wearable Naito et al. laboratory 3♂ Forearm Flexors AMP ▼56%
robot’ 2007 upper arm holding of 3 kg Biceps Bracchii AMP ▼29%
standing upright with load at shoulder level Deltoid muscle AMP ▼77%
‘exo- Lee et al. laboratory 1♂ Biceps brachii AMP ▼46% (elbow); ▼86%
skeleton 2012b holding of 10 kg in elbow flex/extension and (shoulder)
robot’ shoulder flex/extension. Triceps brachii AMP ▼64%(elbow); ▼87%
(shoulder)
Deltoid post AMP ▼49% (elbow); ▼67%
(shoulder)
Deltoid ant ▼23% (elbow); ▼45% (shoulder)

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WSAD Luo and Yu laboratory, 1♂ at 30º Erector Spinae (thoracic) AMP ▼30%,
2013 stooped postures for 5 min with trunk flexion Erector Spinae (lumbar) AMP ▼34%
at 30º, 60º and 90º Latissimus Dorsi AMP ▼18%
Rectus Abdominis AMP ▼4%
at 60º Erector Spinae (thoracic)AMP ▼35%,
Erector Spinae (lumbar) AMP ▼40%
Latissimus Dorsi AMP ▼22%
Rectus Abdominis AMP ▼6%
at 90º Erector Spinae (thoracic) AMP ▼42%,
Erector Spinae (lumbar) AMP ▼47%
Latissimus Dorsi AMP ▼28%
Rectus Abdominis AMP ▼9%

▼and ▲= significantly lower and higher value respectively, for condition with exoskeleton vs. without exoskeleton
▼and ▲= not statistically evaluated differences between conditions with vs. without exoskeleton
± = estimated effects based on figures
AMP = amplitude of EMG signal
MPF = mean power frequency of EMG signal

17