Passive Trunk Exoskeleton Acceptability and Effects on Self-efficacy in Employees with Low-Back Pain: A Mixed Method Approach

Exoskeleton technology in nursing practice: assessing effectiveness, usability, and impact on nurses' quality of work life, a narrative review

The use of exoskeletons in nursing practice has gained attention as a potential solution to address the physical demands and risks associated with the profession. This narrative review examines the effectiveness, usability, and impact of exoskeleton technology on nurses' quality of work life. The review focuses on the reduction of physical strain and fatigue, improved posture and body mechanics, enhanced patient care, usability and acceptance factors, and the broader impact on work life. The effectiveness of exoskeletons in reducing physical strain and fatigue among nurses is supported by evidence showing decreased muscle activation and reduced forces exerted on the body. The usability and acceptance of exoskeletons are critical considerations, including device comfort and fit, ease of use and integration into workflows, user experience and training, compatibility with the work environment, and user feedback for iterative design improvements. The implementation of exoskeletons has the potential to positively impact nurses' work life by reducing work-related injuries, improving physical well-being, enhancing job satisfaction, and promoting psychological and psychosocial benefits. Additionally, the use of exoskeletons can lead to improved patient care outcomes. Challenges and future directions in the field of exoskeleton technology for nurses include cost and accessibility, adaptability to nursing specialties and tasks, long-term durability and maintenance, integration with personal protective equipment, and ethical considerations. Addressing these challenges and considering future research and development efforts are crucial for the successful integration of exoskeleton technology in nursing practice, ultimately improving nurses' quality of work life and patient care delivery.

[Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach : German version]

INTRODUCTION

Chronic low back pain (cLBP) is highly prevalent in the United States and globally, resulting in functional impairment and lowered quality of life. While many treatments are available for cLBP, clinicians have little information about which specific treatment(s) will work best for individual patients or subgroups of patients. The Back Pain Research Consortium, part of the National Institutes of Health Helping to End Addiction Long-termSM (HEAL) Initiative, will conduct a collaborative clinical trial, which seeks to develop a personalized medicine algorithm to optimize patient and provider treatment selection for patients with cLBP.

OBJECTIVE

The primary objective of this article is to provide an update on evidence-based cLBP interventions and describe the process of reviewing and selecting interventions for inclusion in the clinical trial.

METHODS

A working group of cLBP experts reviewed and selected interventions for inclusion in the clinical trial. The primary evaluation measures were strength of evidence and magnitude of treatment effect. When available in the literature, duration of effect, onset time, carryover effect, multimodal efficacy, responder subgroups, and evidence for the mechanism of treatment effect or biomarkers were considered.

CONCLUSION

The working group selected 4 leading, evidence-based treatments for cLBP to be tested in the clinical trial and for use in routine clinical treatment. These treatments include (1) duloxetine, (2) acceptance and commitment therapy, (3) a classification-based exercise and manual therapy intervention, and (4) a self-management approach. These interventions each had a moderate to high level of evidence to support a therapeutic effect and were from different therapeutic classes.

Mapping the conceptual structure of ergonomics, musculoskeletal disorders, treatment and return to work in manual jobs: A systematic review

BACKGROUND

Musculoskeletal disorders constitute one of the major health problems of workers exposed to manual work throughout the world. Nevertheless, there is no study that maps its conceptual structure based on a systematic methodology.

OBJECTIVE

To identify the conceptual structure of ergonomics, MSDs, treatment and return to work in manual jobs in the last 12 years by applying a systematic co-word network analysis methodology which describes the replicability of the search filters and emphasizes the rigor that has to be followed in the creation of the network.

METHODS

The search filter was customized for each bibliographic database, and followed the PRISMA 2020 flowchart for the screening process. For the creation of the network, the titles, abstracts, and keywords were used as the unit of analysis extracting the noun phrases of the first two units. In the normalization process, the terms of the search filter were deleted and their associated terms, and standardized the similar terms. Regarding the plotting of the network, Vosviewer was used applying the network settings based on content analysis.

RESULTS

The co-word network shows three communities: Ergonomic assessment and workplace intervention tools, factors related to rehabilitation and return to work, and physical and mental overload management. For each community, there is a framework that explains the relationship within terms.

CONCLUSION

This study is aligned with the replicability, robustness, and relevance recommendations in the implementation of rigorous scientometric studies. The occupational health community is encouraged to implement scientometric studies following a rigorous methodology and working in interdisciplinary team.

Understanding contributing factors to exoskeleton use-intention in construction: a decision tree approach using results from an online survey

Work-related musculoskeletal disorders (WMSDs) are a major health concern in the construction industry. Occupational exoskeletons (EXOs) are a promising ergonomic intervention to help reduce WMSD risk. Their adoption, however, has been low in construction. To understand the contributing factors to EXO use-intention and assist in future decision-making, we built decision trees to predict responses to each of three EXO use-intention questions (Try, Voluntary Use, and Behavioural Intention), using online survey responses. Variable selection and hyperparameter tuning were used respectively to reduce the number of potential predictors and improve prediction performance. The importance of variables in each final tree was calculated to understand which variables had a greater influence. The final trees had moderate prediction performance. The root node of each tree included EXOs becoming standard equipment, fatigue reduction, or performance increase. Important variables were found to be quite specific to different decision trees. Practical implications of the findings are discussed.Practitioner summary: This study used decision trees to identify key factors influencing the use-intention of occupational exoskeletons (EXOs) in construction, using online survey data. Key factors identified included EXOs becoming standard equipment, fatigue reduction, and performance improvement. Final trees provide intuitive visual representations of the decision-making process for workers to use EXOs.

Objective and subjective evaluation of a passive low-back exoskeleton during simulated logistics tasks

Musculoskeletal disorders remain the most common work-related health problem in the European Union. The most common work-related musculoskeletal disorder reported by workers is backache, especially in the logistics sector. Thus, this article aims to evaluate the effects of a commercial passive low-back exoskeleton during simulated logistics tasks. Thirty participants were recruited for this study. Typical logistics tasks were simulated in a laboratory environment. Cross-over research design was utilized to assess the effects of the exoskeleton on heart rate, trunk inclination, trunk acceleration, throughput, and perceived exertion. Also, usability and acceptance were obtained using a custom questionnaire. We found mostly non-significant differences. Effects on throughput varied widely between workplaces. Usability ratings were poor and acceptance moderate. The study suggests that a holistic evaluation and implementation approach for industrial exoskeletons is necessary. Further, prior to exoskeleton implementation, workplace adaptation might be required.

The Dynamic Adoption Journey: A Typology for Users and Non-Users of Occupational Exoskeletons

Various barriers prevent the adoption of occupational exoskeletons. It is therefore important to understand why some people are willing to use occupational exoskeletons, while others are not. To identify why people use or do not use exoskeletons, we created a typology describing different types of users and non-users. These types were created based on existing literature on internet adoption and social robots. Next, literature and empirical data were used to identify reasons why some people use exoskeletons and others do not use them (yet). The typology includes users with pain and users without work-related musculoskeletal disorders, but also non-users: resisters, rejecters, discontinuers, excluded or expelled non-users. It can be used by companies interested in implementing exoskeletons to identify possible early adopters. For exoskeleton designers, it can be used as a tool to identify non-users and focus on design strategies to enable non-users to become users (such as making exoskeletons that would fit people with a wide range of body shapes). Future research can use these types to identify users and non-users in field trials or pilot projects.

Reducing Back Exertion and Improving Confidence of Individuals with Low Back Pain with a Back Exosuit: A Feasibility Study for Use in BACPAC

OBJECTIVE

Low back pain (LBP) is hallmarked by activity limitations, especially for tasks involving bending. Back exosuit technology reduces low back discomfort and improves self-efficacy of individuals with LBP during bending and lifting tasks. However, the biomechanical efficacy of these devices in individuals with LBP is unknown. This study sought to determine biomechanical and perceptual effects of a soft active back exosuit designed to assist individuals with LBP sagittal plane bending. To understand patient-reported usability and use cases for this device.

METHODS

Fifteen individuals with LBP performed two experimental lifting blocks once with and without an exosuit. Trunk biomechanics were measured by muscle activation amplitudes, and whole-body kinematics and kinetics. To evaluate device perception, participants rated task effort, low back discomfort, and their level of concern completing daily activities.

RESULTS

The back exosuit reduced peak back extensor: moments by 9%, and muscle amplitudes by 16% when lifting. There were no changes in abdominal co-activation and small reductions maximum trunk flexion compared to lifting without an exosuit. Participants reported lower task effort, back discomfort, and concern about bending and lifting with an exosuit compared to without.

CONCLUSIONS

This study demonstrates a back exosuit not only imparts perceptual benefits of reduced task effort, discomfort, and increased confidence in individuals with LBP but that it achieves these benefits through measurable biomechanical reductions in back extensor effort. The combined effect of these benefits implies back exosuits might be a potential therapeutic aid to augment physical therapy, exercises, or daily activities.

Evidence-based interventions to treat chronic low back pain: treatment selection for a personalized medicine approach

Literature on current treatments for chronic low back pain (cLBP) were reviewed and 4 interventions were recommended for inclusion in a multisite cLBP clinical trial.

Introduction:

Objective:

Methods:

Conclusion:

A Systematic Review on Evaluation Strategies for Field Assessment of Upper-Body Industrial Exoskeletons: Current Practices and Future Trends

With rising manual work demands, physical assistance at the workplace is crucial, wherein the use of industrial exoskeletons (i-EXOs) could be advantageous. However, outcomes of numerous laboratory studies may not be directly translated to field environments. To explore this discrepancy, we conducted a systematic review including 31 studies to identify and compare the approaches, techniques, and outcomes within field assessments of shoulder and back support i-EXOs. Findings revealed that the subjective approaches [i.e., discomfort (23), usability (22), acceptance/perspectives (21), risk of injury (8), posture (3), perceived workload (2)] were reported more common (27) compared to objective (15) approaches [muscular demand (14), kinematics (8), metabolic costs (5)]. High variability was also observed in the experimental methodologies, including control over activity, task physics/duration, sample size, and reported metrics/measures. In the current study, the detailed approaches, their subject-related factors, and observed trends have been discussed. In sum, a new guideline, including tools/technologies has been proposed that could be utilized for field evaluation of i-EXOs. Lastly, we discussed some of the common technical challenges experimenters face in evaluating i-EXOs in field environments. Efforts presented in this study seek to improve the generalizability in testing and implementing i-EXOs.

An industrial exoskeleton user acceptance framework based on a literature review of empirical studies

Studying the acceptance of exoskeletons in industry has gained increased attention. Exoskeletons (wearable support devices) are envisioned to alleviate heavy work. Examining what factors influence the use of exoskeletons is important, because influencing these factors could positively contribute to the adoption of industrial exoskeletons. The factors identified in this paper have been systematically derived from empirical research with (potential future) end users, most of whom have tried on an exoskeleton. Our framework with factors influencing the acceptance of industrial exoskeletons can be used during the (ideally iterative) design, (re)development and evaluation phase of new or existing exoskeletons. This could improve the quality of exoskeletons since this allows designers to already consider acceptance factors early in the design process instead of finding out what is important late in the design process during (field) testing. In turn, this might accelerate the adoption of exoskeletons. Also, our framework can be used to study the ongoing introduction of exoskeletons at work since it also addresses policy decisions companies interested in implementing exoskeletons should consider.

Assoziation, Erwartungen und Barrieren eines Exoskeletteinsatzes in kleinen mittelständischen Unternehmen

Hintergrund

Arbeitsbedingte Muskel-Skelett-Erkrankungen (MSE) führen in der herstellenden Industrie zu Krankheitstagen und haben erhebliche wirtschaftliche Folgen für die Unternehmen und die Volkswirtschaft. Exoskelette können den Körper im Umgang mit schwerer Last oder in Zwangshaltungen unterstützen. Besonders in großen Unternehmen der Automobilindustrie werden Exoskelette pilotiert. In kleinen und mittelständischen Unternehmen (KMU) werden Exoskelette bisher jedoch wenig eingesetzt, und ihre Anwendung dort wurde wissenschaftlich bisher kaum untersucht. Ziel dieser Arbeit war es, die Barrieren der Exoskelett-Implementierung und die Erwartungen an deren Einsatz im produzierenden Gewerbe zu ermitteln.

Methode

In sechs produzierenden Unternehmen wurden teilstrukturierte Leitfadeninterviews durchgeführt und analysiert.

Ergebnisse

In den Unternehmen werden vielfältige Tätigkeiten bis an die Belastungsgrenze ausgeführt. Allgemein erwartet man durch die Anwendung von Exoskeletten Arbeitserleichterungen sowie wirtschaftliche Vorteile. Bedenken bestehen hinsichtlich des Einsatzes aufgrund des Kostenfaktors, eines ungewissen Nutzens und mangelnden Tragekomforts. Insbesondere werden mangelnde Kenntnisse über den Effekt eines Exoskeletts deutlich.

Fazit

Die vorgestellten Interviewergebnisse sind ein Schritt im interdisziplinären Prozess der Weiterentwicklung und Implementierung von Exoskeletten in der herstellenden Industrie. Bedenken und Unwissenheit potenzieller Unternehmen und Anwender müssen adressiert werden, auch um eine hohe Nutzerakzeptanz zu schaffen. Folgestudien, die die Ermittlung des Bedarfs mit einer besseren Trennschärfe erheben, könnten weitere Erkenntnisse liefern.

Benchmarking occupational exoskeletons: An evidence mapping systematic review

OBJECTIVES

To provide an overview of protocols assessing the effect of occupational exoskeletons on users and to formulate recommendations towards a literature-based assessment framework to benchmark the effect of occupational exoskeletons on the user.

METHODS

PubMed (MEDLINE), Web of Science database and Scopus were searched (March 2, 2021). Studies were included if they investigated the effect of one or more occupational exoskeletons on the user.

RESULTS

In total, 139 eligible studies were identified, encompassing 33, 25 and 18 unique back, shoulder and other exoskeletons, respectively. Device validation was most frequently conducted using controlled tasks while collecting muscle activity and biomechanical data. As the exoskeleton concept matures, tasks became more applied and the experimental design more representative. With that change towards realistic testing environments came a trade-off with experimental control, and user experience data became more valuable.

DISCUSSION

This evidence mapping systematic review reveals that the assessment of occupational exoskeletons is a dynamic process, and provides literature-based assessment recommendations. The homogeneity and repeatability of future exoskeleton assessment experiments will increase following these recommendations. The current review recognises the value of variability in evaluation protocols in order to obtain an overall overview of the effect of exoskeletons on the users, but the presented framework strives to facilitate benchmarking the effect of occupational exoskeletons on the users across this variety of assessment protocols.

Challenges and solutions for application and wider adoption of wearable robots

The science and technology of wearable robots are steadily advancing, and the use of such robots in our everyday life appears to be within reach. Nevertheless, widespread adoption of wearable robots should not be taken for granted, especially since many recent attempts to bring them to real-life applications resulted in mixed outcomes. The aim of this article is to address the current challenges that are limiting the application and wider adoption of wearable robots that are typically worn over the human body. We categorized the challenges into mechanical layout, actuation, sensing, body interface, control, human-robot interfacing and coadaptation, and benchmarking. For each category, we discuss specific challenges and the rationale for why solving them is important, followed by an overview of relevant recent works. We conclude with an opinion that summarizes possible solutions that could contribute to the wider adoption of wearable robots.

Occupational exoskeletons: A roadmap toward large-scale adoption. Methodology and challenges of bringing exoskeletons to workplaces

The large-scale adoption of occupational exoskeletons (OEs) will only happen if clear evidence of effectiveness of the devices is available. Performing product-specific field validation studies would allow the stakeholders and decision-makers (e.g., employers, ergonomists, health, and safety departments) to assess OEs' effectiveness in their specific work contexts and with experienced workers, who could further provide useful insights on practical issues related to exoskeleton daily use. This paper reviews present-day scientific methods for assessing the effectiveness of OEs in laboratory and field studies, and presents the vision of the authors on a roadmap that could lead to large-scale adoption of this technology. The analysis of the state-of-the-art shows methodological differences between laboratory and field studies. While the former are more extensively reported in scientific papers, they exhibit limited generalizability of the findings to real-world scenarios. On the contrary, field studies are limited in sample sizes and frequently focused only on subjective metrics. We propose a roadmap to promote large-scale knowledge-based adoption of OEs. It details that the analysis of the costs and benefits of this technology should be communicated to all stakeholders to facilitate informed decision making, so that each stakeholder can develop their specific role regarding this innovation. Large-scale field studies can help identify and monitor the possible side-effects related to exoskeleton use in real work situations, as well as provide a comprehensive scientific knowledge base to support the revision of ergonomics risk-assessment methods, safety standards and regulations, and the definition of guidelines and practices for the selection and use of OEs.

Exoskeleton acceptance and its relationship to self-efficacy enhancement, perceived usefulness, and physical relief: A field study among logistics workers

Objective

This field study aimed to explore the effects of exoskeleton use on task-specific self-efficacy beliefs of logistics workers and to relate these effects to usefulness perceptions and technology acceptance.

Background

A growing number of industrial companies have shown interest in having employees wearing exoskeletons to support their physical health. However, psychological consequences of exoskeleton use and mechanisms associated with workers' acceptance or rejection of exoskeletons are not yet sufficiently understood.

Methods

A total of 31 logistics workers of a vehicle manufacturing company reported on their work-related self-efficacy, that is, how capable they felt of performing tasks related to their job well, before partaking in half-hour trials of a passive lift-assistive exoskeleton (Laevo V2.5) during their normal work. Afterward, they completed a questionnaire on their exoskeleton-supported self-efficacy and indicated how useful they found the exoskeleton, how much physical relief they felt from wearing it, and how willing they were to continue with its use.

Results

Overall, wearing the exoskeleton did not lead to increased work-specific self-efficacy. However, indications of interaction effects were found between baseline self-efficacy, perceived physical relief, and perceived usefulness in such a way that workers who experienced the exoskeleton as more strain-relieving or more useful were also more likely to report a post-trial growth in their self-efficacy beliefs. A positive change in self-efficacy, in turn, was associated with a greater willingness to further use the exoskeleton at the workplace.

The effectivity of a passive arm support exoskeleton in reducing muscle activation and perceived exertion during plastering activities

The supportive effect of arm-support exoskeletons has been mainly studied for single postures or movements. The aim of this study is to analyse the effect of such an exoskeleton on shoulder muscle activity and perceived exertion, in six tasks of plasterers, each including multiple arm movements. The tasks of 'applying gypsum', 'screeding' and 'finishing' were performed at a ceiling and a wall, with exoskeleton (Exo) and without (NoExo). EMG was recorded of six muscles involved in upper arm elevation, four agonists and two antagonists, and plasterers rated their perceived exertion (RPE). In all tasks, the EMG amplitudes of three agonist muscles, Trapezius and Medial Deltoid, and Biceps Brachii, were lower in Exo vs NoExo, while the agonist, Anterior Deltoid, showed lower EMG values in Exo in most tasks. None of the antagonists (Triceps Brachii, Pectoralis Major) showed increased EMG values in the Exo condition. RPE's were lower in Exo condition for all tasks, except for 'applying gypsum to the wall'. Overall, the exoskeleton seems to reduce loads in realistic plastering tasks. Practitioner summary: Exoskeletons are an emerging technology in the field of ergonomics. Passive arm support exoskeletons have mainly been tested in lab studies using continuous overhead work, involving one posture or movement. However, in reality, working tasks generally involve multiple movements. This study investigates the effectiveness of an arm support exoskeleton in work that requires multiple arm movements, specifically in plastering. Muscle activity, as well as perceived exertion were both reduced when working with an exoskeleton. Abbreviations: Exo: with exoskeleton; NoExo: without exoskeleton; RPE: rated perceived exertion; EMG: electromyography; Trap: upper trapezius; AD: anterior deltoid; MD: medial deltoid; BB: biceps brachii; TB: triceps brachii; PM: pectoralis major; RPD: rated perceived discomfort; p50: 50th percentile; p90: 90th percentile; MVC: maximum voluntary contraction; GEE: generalised estimated equations.

Effects of industrial back-support exoskeletons on body loading and user experience: an updated systematic review

This study is an updated systematic review of papers published in the last 5 years on industrial back-support exoskeletons. The research questions were aimed at addressing the recent findings regarding objective (e.g. body loading, user performance) and subjective evaluations (e.g. user satisfaction), potential side effects, and methodological aspects of usability testing. Thirteen studies of active and twenty of passive exoskeletons were identified. The exoskeletons were tested during lifting and bending tasks, predominantly in laboratory settings and among healthy young men. In general, decreases in participants' back-muscle activity, peak L5/S1 moments and spinal compression forces were reported. User endurance during lifting and static bending improved, but performance declined during tasks that required increased agility. The overall user satisfaction was moderate. Some side effects were observed, including increased abdominal/lower-limb muscle activity and changes in joint angles. A need was identified for further field studies, involving industrial workers, and reflecting actual work situations. Practitioner summary: Due to increased research activity in the field, a systematic review was performed of recent studies on industrial back-support exoskeletons, addressing objective and subjective evaluations, side effects, and methodological aspects of usability testing. The results indicate the efficiency of exoskeletons in back-load reduction and a need for further studies in real work situations. Abbrevaitions: BB: biceps brachii; BF: biceps femoris; CoM: centre of mass; DA: deltoideus anterior; EMG: electromyography; ES: erector spinae; ES-C: erector spinae-cervical; ESI: erector spinae iliocostalis; ESI-L: erector spinae iliocostalis-lumborum; ESL: erector spinae longissimus; ES-L: erector spinae-lumbar; ESL-L: erector spinae longissimus-lumborum; ESL-T: erector spinae longissimus-thoracis; ES-T: erector spinae-thoracic; GM: glutaeus maximus; LBP: low back pain; LD: latissimus dorsi; LPD: local perceived discomfort scale; LPP: local perceived pressure scale; MS: multifidus spinae; MSD: musculoskeletal disorder; M-SFS: modified spinal function sort; NMV: no mean value provided; OA: obliquus abdominis (internus and externus); OEA: obliquus externus abdominis; OIA : obliquus internus abdominis; RA: rectus abdominis; RF: rectus femoris; RoM: range of motion; SUS: system usability scale; T: trapezius (pars Ascendens and Descendens); TA: trapezius pars ascendens; TC: mid-cervical trapezius; TD: trapezius pars descendens; VAS: visual analog scale; VL: vastus lateralis; VM: vastus medialis.

Towards a Functional Performance Validation Standard for Industrial Low-Back Exoskeletons: State of the Art Review

While the research interest for exoskeletons has been rising in the last decades, missing standards for their rigorous evaluation are potentially limiting their adoption in the industrial field. In this context, exoskeletons for worker support have the aim to reduce the physical effort required by humans, with dramatic social and economic impact. Indeed, exoskeletons can reduce the occurrence and the entity of work-related musculoskeletal disorders that often cause absence from work, resulting in an eventual productivity loss. This very urgent and multifaceted issue is starting to be acknowledged by researchers. This article provides a systematic review of the state of the art for functional performance evaluation of low-back exoskeletons for industrial workers. We report the state-of-the-art evaluation criteria and metrics used for such a purpose, highlighting the lack of a standard for this practice. Very few studies carried out a rigorous evaluation of the assistance provided by the device. To address also this topic, the article ends with a proposed framework for the functional validation of low-back exoskeletons for the industry, with the aim to pave the way for the definition of rigorous industrial standards.

Comparison of Subjective Responses of Low Back Pain Patients and Asymptomatic Controls to Use of Spinal Exoskeleton during Simple Load Lifting Tasks: A Pilot Study

Spinal exoskeletons have been suggested as an approach for the prevention and rehabilitation of occupational low back pain (LBP). While the state-of-the-art exoskeletons were shown to substantially unload the back, user acceptance is still limited. Perceived discomfort and restriction of freedom of movement are commonly reported. In this pilot study, we explored the differences in subjective responses and user impressions to using passive spinal exoskeleton during a set of simple lifting tasks between LBP patients (n = 12) and asymptomatic individuals (n = 10). Visual analog scales (0-10) were used for all assessments. Overall, the results showed mostly similar responses or slightly more positive responses to the exoskeleton from LBP patients. Most notably, the LBP patients reported a statistically significant (p = 0.048) higher willingness to use the device daily (5.36 ± 4.05) compared to the control group (2.00 ± 1.85) and also gave the device a higher overall grade (6.58 ± 1.98 vs. 4.30 ± 2.26; p = 0.021). This study has demonstrated that individuals with current LBP responded more favorably to the use of the spinal exoskeleton for simple lifting tasks. This implies that current exoskeletons could be appropriate for LBP rehabilitation, but not preventions, as pain-free individuals are less willing to use such devices. Future studies should explore whether different exoskeleton designs could be more appropriate for people with no LBP issues.