Exoskeletons In Healthcare: The Era Of Great Advancements

Science fiction has for long fantasized about ways to augment fragile humans’ power and endurance through mechanical means. In Edge of Tomorrow, Tom Cruise’s abilities are enhanced via a combat jacket. Humans in Avatar board the AMP suit to tread the deadly environment on Pandora. Such depictions of exoskeletons – or wearable mechanical structures that attach to joints to assist and/or enhance strength and endurance for motion – have left the realm of science fiction and have become part of our reality.

Back in 2014, a paraplegic man suited in a robotic exoskeleton made the symbolic kick-off for the World Cup in Brazil. In 2019, news emerged of a man who could move all of his four paralyzed limbs thanks to a mind-controlled exoskeleton.

But nothing stands as powerful a statement as the example of Kevin Piette, a French para-athlete, who became an Olympic torchbearer wearing a self-balancing exoskeleton developed by France’s Wandercraft – a company that already has regulatory-approved robotic structures.

Although we have seen significant advances in the past decade, the exoskeleton market is still gaining steam, with models even targeted at the general consumer and healthcare workers. 

Meanwhile, exoskeletons started finding their place in healthcare systems. In 2023 ReWalk (now called Lifeward) announced that Centers for Medicare & Medicaid Services (CMS) finalized a rule for reinbursing their exoskeleton technology, which was followed by another similar announcement from Ekso Bionics.

We can expect further announcements to come, as there are over a dozen approved exoskeletons on the FDA’s list.

So let’s take a closer look at where those once sci-fi robotic structures stand today.

Exoskeletons’ assistance in healthcare

Robotic assistants are no stranger in healthcare, but while they are also robotic structures, exoskeletons provide a different type of assistance. Rather than move around independently to clean surfaces or handle deliveries, exoskeletons wrap around the user’s limbs to support them physically. This offers tremendous assistance to those with disabled limbs, and rehabilitation is where exoskeletons initially made much progress in healthcare.

California-based Ekso Bionics is one of the best-known companies that develop bionic suits to provide power to the upper and lower body of patients with spinal cord injury, stroke, and acquired brain injuries. 

“It is really interesting that we had over 3000 different individuals in our database in less than 2 years,” Russ Angold, Chief Technology Officer of Ekso Bionics, told The Medical Futurist. “The device is helping a lot of people who otherwise could not work, or their therapy would take a long time. Our job is giving them the technology that allows them to stay healthy and live a full life.” 

Working along the same vein is LifeWard (formerly called ReWalk). Dr. Amit Goffer, a quadriplegic himself, founded the company as he wanted to help individuals with lower-limb paralysis to walk again. Their ReWalk Personal System received FDA clearance in 2014 for at-home or community use.

Throughout the years, other exoskeleton manufacturer’s products like the HAL from Cyberdyne and SuitX’s Phoenix received FDA approvals of their own. Clinical trials for Wandercraft’s Atalante exoskeleton began in 2017 and received the CE mark in 2019. With more options for patients with limb impairments getting approved by healthcare authorities and becoming available, the market is steadily growing and is also pivoting towards other demographics. 

Interesting new development directions are also present. A wearable robot developed by researchers at Chung-Ang University in South Korea targets the frontal plane, emphasizing hip abduction to improve lateral stability and balance. What makes this wearable robot particularly special is its focus on enhancing walking efficiency by helping lateral movements, which are crucial for maintaining balance and stability. This design not only improves gait efficiency but also offers the potential for broader applications, such as supporting older adults and patients recovering from leg or hip surgeries in their daily activities.

Marching into a growing industry

While still relatively niche, the exoskeleton market has expanded in recent years. The Exoskeleton Report last updated its report in 2021, which listed 118 companies worldwide working on 172 exoskeletons that were on sale or soon to be commercialised. Their directory listed 67 medical exoskeleton companies in 2024, some definitely surprising.

There have been further signs of the industry’s maturity recently. Earlier this year, Paris-based exoskeleton developer Wandercraft raised €25 million in financing from EIB; following a €40 million C-round two years ago, showing a keen interest from investors. Ottobock, a developer of prosthetics and exoskeletons, acquired SuitX, a fellow exoskeleton maker, in late 2021. While it was not the first acquisition of its kind, it showed that the work of smaller companies is being recognized by larger ones, which find potential in their technology.

Indeed, it seems that the exoskeleton will not be available only for therapeutic purposes but will also expand to other markets. Browsing the pages of the Exoskeleton Report, you’ll find over a hundred models designed for industrial use, listing 65 different products for back support only! This is because, in addition to assisting in rehabilitation, exoskeletons can well be applied for injury prevention.

Preventive equipment to limit worker injury and fatigue

Indeed, beyond rehabilitation, a trend seems to be forming to equip workers with exoskeletons. A small-scale pilot experience of about 40 exosuit-assisted workers found promising results. Those workers reported that the exoskeletons provided a reduction of 73% in lower back discomfort, and lowered work effort by 30%. Moreover, 80% felt that these mechanical add-ons could prevent injuries of the lower back. With some $100 billion in medical bills attributed to worker injuries in the U. S., it makes sense for employers to explore new methods to assist workers and limit healthcare hazards.

With this in mind, companies are developing exoskeleton solutions to assist workers and prevent injury. For example, the exoskeletons from German Bionic allow a worker to easily carry around weights of up to 36 kg, while they also help prevent common lifting injuries. 

This approach also applies to the healthcare setting, given the association of long working hours. “With back pain being the cause of one in every four medical leaves in Japan, some of the largest hospitals and manufacturers now use our Archelis suits as a form of PPE, or personal protective equipment,” said Hideyuki Fujisawa, CEO of Japanese exoskeleton startup Archelis. 

The extra weight of robotic add-ons

While the exoskeleton market is maturing, there are still hurdles that developers of that equipment must overcome before achieving wider adoption. For one, the cost of exoskeletons can be a barrier to entry; like Wandercraft’s Atalante exoskeleton, which amounts to around €220,000. 

Then there’s the weight of the device itself which could be a hindrance. German Bionic’s apogee comes in the form of an 8kg backpack, which might not be totally comfortable to wear all day long. They also need charging; meaning the workplace will need additional batteries or exoskeletons as substitutes when the batteries need recharging.

Given the novelty of such devices, there might be unforeseen challenges as well as new research has found. Researchers investigated the neurocognitive ‘cost’ to exoskeleton users, and concluded that the exoskeleton’s advantages were offset when a user was tasked with a cognitively-demanding task. 

“While exoskeletons hold great promise in alleviating physical loads in the workplace, these findings can guide the development of decision support tools for ergonomists to determine when/how and during what tasks exoskeletons should be used on the factory floor to maximise worker safety,” the researchers said.

Will exoskeletons be our next wearable?

Nevertheless, some of these challenges are being taken into consideration already. For example, the Archelis suits do not rely on electricity and are thus lighter and do not need recharging. Tokyo-based Innophys has also deployed non-powered exoskeletons to assist workers with minimal hindrance.

For battery-powered models, a battery hot-swap feature would help alleviate the hindrances of depleted batteries. The now retired Cray X from Bionic had such a feature. “You can pull out the [spent battery] for a new one, place the old one on the charger […] and then you can just move on,” Marius Kiss, Head of Mechanical R&D at German Bionic, told Engadget. “You could potentially work like eight hours without having to take off the exoskeleton.”

As for the cost, with a larger production scale, it will go down with time. Wandercraft is working on an at-home exoskeleton, which it expects to cost much less than their clinical models. “They will also be cheaper because, unlike the rehabilitation version, they will be individualized,” explained Jean-Louis Constanza, Wandercaft’s Chief Business and Clinical Officer. “Exoskeletons used in hospitals have to be fully adjustable for an array of sizes.” This video from 2021 also features Kevin Piette, who, by the way, works for the company as an exoskeleton pilot, helping with product development and testing.

So does this mean that in the future, we can expect to see exoskeletons become as common as our current wearables? Eric Eitel, German Bionic’s Head of Communications, surely thinks so. “I really see everyone on the street wearing an exoskeleton in one form or another,” Eitel said. “But I think that the exoskeletons that we are looking for in the future are the active ones. I see them being a lot slimmer, smarter, and connected.” 

He might be onto something since Hong Kong startup Enhanced Robotics had its Kickstarter campaign funded and promised to bring its consumer-oriented exoskeleton to the market. Weighing 2.5kg, it was supposed to assist wearers in their fitness activities whether it’s for walking or strength training – but based on the angry comments from their backers on Kickstarter, the project is not going as promised.

But as we’ve seen there are over 200 devices in the product catalog of Exoskeleton report, with many companies being in business for over a decade now. Maybe this is the beginning of our exoskeleton-powered future…

Written by Dr. Bertalan Meskó & Dr. Pranavsingh Dhunnoo

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