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In this article, we investigate the relation between gender and exoskeleton development through the lens of intersectionality theory. Exoskeleton users come in a wide variety of shapes, sizes, and genders. However, it is often the case that wearable robot engineers do not develop such devices primarily on the premise that the product should fit as many end users as possible. Instead, designers tend to use the one-size-fits-all approach-a design choice that seems legitimate from the return of an investment viewpoint but that may not do as much justice to end users. Intended users of exoskeletons have a series of user criteria, including height, weight, and health condition, in the case of rehabilitation. By having rigid inclusion criteria for whom the intended user of the technology can be, the exclusion criteria will grow in parallel. The implications and deep-rootedness of gender and diversity considerations in practices and structural systems have been largely disregarded. Mechanical and robot technology were historically seen as part of a distinct male sphere, and the criteria used today to develop new technology may reflect the biases that existed in another time that should no longer be valid. To make this technology available for all, we suggest some tools to designers and manufacturers to help them think beyond their target market and be more inclusive.
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Research Article
Roger Andre Søraa* and Eduard Fosch-Villaronga
Exoskeletons for all: The interplay between
exoskeletons, inclusion, gender, and
received November 28, 2019; accepted April 6, 2020
Abstract: In this article, we investigate the relation between
gender and exoskeleton development through the lens of
intersectionality theory. Exoskeleton users come in a wide
variety of shapes, sizes, and genders. However, it is often the
case that wearable robot engineers do not develop such
devices primarily on the premise that the product should t
as many end users as possible. Instead, designers tend to use
the one-size-ts-all approach a design choice that seems
legitimate from the return of an investment viewpoint but
that may not do as much justice to end users. Intended users
of exoskeletons have a series ofusercriteria,including
height, weight, and health condition, in the case of
rehabilitation. By having rigid inclusion criteria for whom
the intended user of the technology can be, the exclusion
criteria will grow in parallel. The implications and deep-
rootedness of gender and diversity considerations in practices
and structural systems have been largely disregarded.
Mechanical and robot technology were historically seen as
part of a distinct male sphere, and the criteria used today to
develop new technology may reect the biases that existed in
another time that should no longer be valid. To make this
technology available for all, we suggest some tools to
designers and manufacturers to help them think beyond
their target market and be more inclusive.
Keywords: exoskeletons, gender and technology, inter-
sectionality, inclusive design, exclusion, data bias, access,
1 Introduction
Robotic technology is increasingly present in the health-
care sector. Robots perform useful tasks for humans and
assist humans in performing tasks by processing and
acting upon the information collected by several sensors.
They can be a powerful tool for assisting people with
illnesses or disabilities because they can supplement the
work provided by the health-care professionals both in
medical treatment and in rehabilitation and support
people in prevention programs [1]. Robots may be helpful
in lessening the burden of care assistants by performing
automated tasks. In this respect, the European Parliament
[2]discuss how care robots might free caregivers from
tedious work and allow them to devote more time for
diagnosis and better-planned treatment optionsand thus
make doctorswork more ecient [3]. Recent ndings also
suggest that articial intelligence (AI)-powered diagnostic
tools in some cases can outperform physicians in the
diagnosis of probabilities for disease and conditional
interdependencies [4].
The use of technology in medical care is becoming
more prevalent. This includes devices, integrated platforms,
and services aimed at promoting the well-being of users,
patients, and formal and informal caregivers; and the use of
technology that allows people with health impairments to
be more independent, thus improving their quality of life
[5]. Robot-mediated gait training is one example of a
technology that helps patients with reduced gait function
[6]. In the 1990s, body weight-supported treadmill training
with manual assistance was developed to improve walking
function for patients with neurological impairments [7,8].
However, walk rehabilitation process was (and it is still)
very costly and labor intense it usually requires a team of
two to ve people. Robot technology has been proven to be
an eective method for rehabilitation, requiring only one
therapist to supervise a training session [9].
Despite the apparent benets of such technology,
research on care robot technologies suggests that their
* Corresponding author: Roger Andre Søraa, Department of
Interdisciplinary Studies of Culture & Department of Neuromedicine
and Movement Science, NTNU Norwegian University of Science and
Technology, Trondheim, Norway, e-mail:
Eduard Fosch-Villaronga: eLaw Center for Law and Digital
Technologies, Leiden University, Leiden, The Netherlands,
ORCID: Roger Andre Søraa 0000-0001-6800-0558;
Eduard Fosch-Villaronga 0000-0002-8325-5871
Paladyn, Journal of Behavioral Robotics 2020; 11: 217227
Open Access. © 2020 Roger Andre Søraa and Eduard Fosch-Villaronga, published by De Gruyter. This work is licensed under the Creative
Commons Attribution 4.0 Public License.
implementation is not straightforward, and new ethical,
legal, and social concerns arise from the humanrobot inter-
actions [1012]. Some authors argue that robot technology,
especially when coupled with AI, can be used to foster
human nature and its potentialities, thus creating opportu-
nities; underused, thus creating opportunity costs, or over-
used and misused, thus creating risks[13],suggestingthat
adoption is inevitable and that the current debate no longer
focuses on the question of whether robot technology has an
impact on society but on whether and to what extent this
impact is going to be positive or negative.
Seeing technology as a social construct and not a
natural force that arrives in society can help us under-
stand how technology is being produced, implemented,
and used in the social construction of technology[14].
It can also help illuminate the intricate relationship
between the user and producer and the potential
coproduction that happens in that relation [15,16]. For
instance, one essential concern is how dierent indivi-
dual usersattributes might lead to their exclusion from
technology. This critique has been around for decades,
thanks in particular to the feminist understanding of
technology, and remains quite unexplored in the context
of robot technology. In this sense, technology including
robots is not created in a vacuum. They arise as a result
of and reect human needs and ingenuity; they create
new relationships between humans and also transform
the way we see the world [17].
Disability studies seek to challenge the view that
disability is synonymous with human failing [18]by
creating space to explore the multitude of complexities of
people who are disabled [19]. Within disability studies,
exoskeletons are quite a new topic of inquiry, but they
have received some attention notably by Lajeunesse et al.
[20], who give an account of exoskeletons used for spinal
cord injury patients, and Goggin [21], who argues that
exoskeletons can lead to novel forms of mobility
opportunities for their users.
In this article, we investigate the interplay of inclusion
and gender perspectives and exoskeleton development
from the lens of intersectionality. Exoskeleton users come
with a wide variety of individual attributes, shapes, and
sizes. However, wearable robot engineers do not usually
develop such devices primarily on the premise that the
product should tasmanyendusersaspossible.Instead,
designers tend to rely on the one-size-ts-all approach
with some adjustment possible. Such a design choice
seems legitimate from a return of an investment view-
point, but it may not do as much justice to end users.
Intended users of exoskeletons have a series of user
criteria, including height, weight, and, in the case of
rehabilitation, health condition. When the inclusion
criteria for whom the intended user of the technology are
rigid, the exclusion criteria are necessarily just as rigid.
We draw on feminist scholarly understandings of gender
and technology to better understand how people adapt to
technologies such as exoskeletons. We use the concept of
intersectionality to see how people with disabilities are not
just disabledbut hold, as every human does, a wide
variety of other identities. Furthermore, we explore whether
being disabled can lead to double or multiple levels of
exclusion, disregard, or discrimination. The implications and
deep-rootedness of gender considerations in technology
practices have been disregarded in the development of
exoskeleton technology. Mechanical and robot technology
were historically seen as part of a distinct male sphere and
the criteria used today to develop new technology may
reect the biases that existed in another time that should
no longer be valid. To make exoskeletons available and
enabling for all, we suggest some tools to help designers
and manufacturers think beyond their target market, be
more inclusive, and avoid discrimination.
2 Gender, technology, and
intersectionality theory
Gender refers to psychological, social and cultural factors
that shape attitudes, behaviours, stereotypes, technolo-
gies and knowledge[22]. As a social construct, gender
relates to, but is not identical to, sex, which is biologically
and physiologically determined. Just as gender is in a
context ux and negotiation e.g., gendered understand-
ings of the body or who can drive a car so is technology.
To better understand how a technology such as exoske-
leton can be understood on the social, nontechnical
level for example, by zooming in on the inclusion and
exclusion of users gender perspectives can inform the
understanding of what exoskeletons can and cannot do for
dierent groups of people.
Feminist scholars stress that technology has for too
long been part of the male sphere and thus inevitably
reects inevitably certain biases, as discussed by
Wajcman [23], who argues that gendered power relations
mediate the development of technology because tech-
nology is always a form of social knowledge, practices,
and products. It is the result of conicts and compro-
mises, the outcome of which depends primarily on the
distribution of power and resources between dierent
groups in society. She argues that this could be achieved by
looking at how technology is being made and used by male
218 Roger Andre Søraa and Eduard Fosch-Villaronga
power and interests. Technology is not created in a vacuum,
as can be seen through the concept of situated knowledge
[24], which focuses on the interrelation of thinking with
both epistemologically, ontologically, ethically, and politi-
cally. In a semiotic materialist notion, situated knowledge
helpstogobeyondthegod trick god trick of seeing every-
thing from nowhere[24], showing how knowledge is not
neutral, but socially constructed. In her Cyborg Manifesto,
Haraway [25]takes the interweaving of technology and
gender on a slightly dierent perspective, by introducing the
cyborg concept into technofeminism:
A cyborg is a cybernetic organism, a hybrid of machine and
organism, a creature of social reality as well as a creature of
ction. Social reality is lived social relations, our most important
political construction, a world-changing ction []The cyborg
is a matter of ction and lived experience that changes what
counts as womens experience in the late twentieth century.
This is a struggle over life and death, but the boundary between
science ction and social reality is an optical illusion.
In contemporary society, the cyborg concept is so
commonly used that the theoretical conceptualization must
be explicitly mentioned when writing about cyborgs. People
using exoskeletons integrate their bodies with a robotic
device in a seamless manner, becoming in a way an actual
cyborg. Scholars like Berg and Lie [26]continued the
feminist technoinquiry by discussing the question, do
artifacts have a gender,continuously unwrapping the
black boxes of technology in a gendered framework, using
gender theories to understand technology.
One theory within gender studies that addresses how
people are made of a wide variety of personal attributes is
intersectionality theory, which can be used to give a
more comprehensive understanding of bias and direct
and indirect discrimination based on individual (and
sometimes clashing)identities. Intersectionality theory
illustrates how gender discrimination and other forms of
discriminating (e.g., racism, homophobia, xenophobia)
may interact and strengthen each other, as dened by
Crenshaw [27], who rst used it to describe the double-
discrimination Black women face:
Black women are regarded either as too much like women or
Blacks and the compounded nature of their experience is
absorbed into the collective experiences of either group or as
too dierent, in which case Black womens Blackness or
femaleness sometimes has placed their needs and perspectives
at the margin of the feminist and Black liberationist agenda.
Intersectionality can be dened as the interaction
between gender, race and other categories of dierence
in individual lives, social practices, institutional arrange-
ments, and cultural ideologies and the outcomes of these
interactions in terms of power[28].Intersectionality
perspectives have been included in a variety of topics on a
structural level, such as psychology [29]and mainstreaming
studies [30]. On a more individual level, McCall [31]discusses
how dierent personal attributes make us up as people and
individuals and makes each individual belong to multiple
societal subgroups. All of these together contribute to the
creation of identity politics [32].
This theory has also received criticism. Nash [33],for
example, problematizes: thelackofadened intersectional
methodology; the use of black women as quintessential
intersectional subjects; the vague denition of intersection-
ality; and the empirical validity of intersectionality.In our
contribution, we do not seek to remedy these four valid
criticisms regarding the theory, as we have found it to be a
useful theoretical perspective to show how several identities
overlap and create complex understandings of people
having more than just one identity, leading them to being
subject to systems of oppression and even discrimination.
There has, however, been scholarly attempts to justify/rene
intersectionality into a more operable theoretical tool [31,34].
We draw on the abovementioned feminist scholarly under-
standings of gender and technology to better understand
how we as humans adapt to and are made to better or worse
use technologies such as exoskeletons.
3 Methods and typology of
The use of exoskeletons in rehabilitation is a relatively
new research eld, with the most important technological
developments happening within this past decade. How-
ever, several research groups and clinics across the world
have made notable advances inunderstanding the benets
that patients have when using this novel technology.
Exoskeletons have the potential to revolutionize the
rehabilitation context completely. Exoskeletons provide
health benets, including improvements in gait function,
body composition, aerobic capacity, bone density, spasti-
city, bowel function, and quality of life [6,35]. Moreover,
exoskeletons allow a freer and more natural movement
while walking than that provided by body weight-
supported treadmill training. Exoskeletons oer much
independence in a variety of everyday settings such as
shopping malls, local parks, and movie theaters [6].
Exoskeletons also provide excellent help in repetitive
intensive gait training interventions [36]and help patients
combat several chronic health-related consequences that
are likely to aect persons with a spinal cord injury [37].
Exoskeletons for all 219
Over the years, these devices are becoming less and less
bulky. See an example in Figure 1.
Evidence concerning the rehabilitation of stroke
patients is somewhat weaker, with fewer extensive studies
to provide evidence. A recent scoping review found only
seven pre-post clinical studies and four controlled trials,
although it concluded that exoskeleton-based gait training
in patients with subacute stroke had meaningful improve-
ment when compared to traditional therapy [36].These
studies show that exoskeletons can be used safely in gait
training in a clinical environment [38]. However, there is
still a lack of research in certain key areas, including their
use outside of a clinical setting [39]and especially relating
to social science and humanities perspectives, on their
impact on the daily life of the user from a nonmedical point of
view. Although tests on exoskeletons show the potential for
signicant medical, technological, and social improvements
for patients, there is still little understanding of how this
technology will be implemented eciently.
Several types of exoskeletons exist in the market and in
research settings to date, with a varying degree of com-
plexity, weight, and applications. The Lokomat (Hocoma,
Switzerland)involves patients using body weight support on a
treadmill. Motorized braces move the patientslegs through
trajectories that imitate standard gait patterns. Other robot
devices include stepping machines like the Gait Trainer
(RehaStim, Germany)and the G-EO, which uses movements
similar to those of elliptical machines (Reha Technology AG,
Switzerland). Another example is KineAssist (HDT Global,
USA), which uses body weight support around the pelvis and a
treadmill reacting to the patients movements [40].
connected with the H2020 Cost Action 16116 on Wearable
Robots,¹ that is, on physical assistant robots that physically
assist a user to perform required tasks by providing supple-
mentation or augmentation of personal capabilities[41].
Although there is confusion whether or not these devices can
be considered medical devices [12],aprescription device
that is composed of an external, powered, motorized orthosis
Figure 1: Indego therapy; photo courtesy of Parker Hannin Corporation, USA.
220 Roger Andre Søraa and Eduard Fosch-Villaronga
that is placed over a persons paralyzed or weakened lower
extremity limb(s)for medical purposesis recognized as a
medical device by the FDA. Moreover, what matters is the
intended purpose of the device, something reinforced by art.
Section 1.3 of the European Union Regulation of Medical
non-medicalintendedpurposeshallfull cumulatively
the requirements applicable to devices with an intended
medical purpose and those applicable to devices without an
intended medical purpose[42].
In the following section, we compile several examples of
exoskeletons available in the market and analyze their
dierent results. For our selection, we combined a nonsyste-
matic online search with the Google search engine, using the
key words: “‘marketedAND exoskeleton’”;“‘exoskeletons
AND forAND sale’”;“‘buyAND anAND exoskeleton’” to
seek companies currently selling exoskeletons. This showed
that lower limb (as opposed to upper limb)products from
large, respected companies dominated the online presence.
The results were varied and lacked consistency in the amount
of information freely available online, making the compilation
and visualization of these products in a single chart dicult.
The majority of companies did not have technical information
online, forcing potential clients to contact them for further
inquiries. Although this is a good strategy for marketing
purposes, it presented a signicant obstacle in our research
and data collection.
As a second step, therefore, we sought further details by
directly contacting the companies using their online contact
forms. Unfortunately, the majority of the companies did not
reply. After careful thought, we present the information we
found online from mid-/large-sized companies (Table 1).
Although our sample is limited, it is rich in results; it
identies and illustrates a trend that seems to replicate in
dierent domains. In this regard, we included EksoWorks
in the chart to complement our understanding of the impact
that the physical embodiment of current exoskeletons has on
constraining the access to technology by design.
4 Results
The section below includes three available commercial
products: the US-based Ekso Bionics,² Indego,³ and
Cyberdyne from Japan.Considering the available informa-
tion online, we focused on EksoHealth for gait training,
Indego for therapy, and HAL for well-being. Rewalkis a
major player in the market; however, they do not have any
technical information online and did not respond to our
requests for information, so they are excluded. Other
excluded robots include Twiice from Switzerlandand
MarsiBionics from Spain,both of which have yet to begin
mass production of exoskeletons. In Table 1, we look at some
specic technical information concerning the device and the
We can deduce some results from Table 1. The
majority of the companies have both physically impaired
patients and people without a medical condition as
intended users (e.g., workers who perform physically
demanding labor). Concerning the weight parameter, we
see that the upper weight limit from HAL and Ekso is
100 kg. The average body weight for an American male is
91 kg.While fully clothed, which adds another kilo or
two, many users on the heavier side would be excluded
from the possibility of using the exoskeletons. Indego
allows for slightly more, with 113 kg as the maximum
weight. Similarly, the minimum limit for weight can also
cause a problem, as HAL requires users to weigh at least
40 kg. This could be problematic in countries like
Madagascar or Bangladesh, where the average weight of
women is about 49 kg [43].
Concerning the height parameter, we observe that
Japanese Cyberdyne starts at 150 cm, followed by Ekso
Bionics at 152 cm and Indego at 155 cm. The World
Population Review [44]reports that the country with the
shortest average human height (Indonesia)has an average
height of 62.2 inches (157 cm). This implies that many
Indonesians would be too short to use these devices. There
are many other populations such as Filipino women
[45]who could likely be prevented from using the
devices. There are also categories other than nationality
e.g., individuals with dwarsm that would similarly
exclude potential users. Although some companies are
investigating pediatric orthoses (Hocoma,for instance,
2 Although its website is not forth-
coming about its headquarters, it is a US-based company that
additionally has a signicant presence in the EU and Asia. https://
8See Froehlich-Grobe et al. [46]for data on self-reported height and
weight of the average wheelchair user. The reason why American
males were chosen in the example here is because they represent one
of the most overweight and richest countries in the world.
Exoskeletons for all 221
oers pediatric orthoses for persons with femurs between 21
and 35 cm), there are not currently any mainstream items,
further excluding children and youth. Even in such situa-
tions, age is not a common or a specic parameter that
companies take into account. They focus more on femur
length or hip width. Populations can also be excluded for
being too tall menintheNetherlandshaveanaverage
height of 183 cm, suggesting that Cyberdynes device, which
can accommodate a maximum height of 200 cm, would be
the only device that is broadly available to many Dutch users.
Concerning the weight of the device, Ekso Bionics proves
to be the most massive (25 kg); but on their website, the
company stresses that patients bear only their weight. Indego
is 12 kg for personal use and a bit heavier for medical
purposes (18 kg). HAL reports being in between, with a
device weight of 14 kg. (We are not considering the 9 kg
single-legged device because the others are double legged.)
Other results suggest that HAL from Cyberdyne is the only
company oering the possibility to adjust the shoe size. The
same company also has a gender specication, that of the
hip width. For men, the size is 2836 cm, whereas for women
it is 3240 cm. Pricewise, the majority of the companies do
not have their prices online and force potential buyers to
contact them directly for more information.
Table 1: User and device characteristics for some commercially available exoskeletons from Ekso Bionics, Indego, and Cyberdyne
Parameter Exoskeletons
Ekso Bionics Indego HAL, Cyberdyne
Intended user/
health condition
EksoHealth is for patients, and
EksoWorks is for workers
Indego personal oers users with
spinal cord injury a new level of
independence at home and in the
community. Indego therapy is a
lower limb powered exoskeleton
which enables therapists to oer
task-specic and intensive gait
HAL for Well-Being Lower Limb type
Pro is a wearable robot designed
for inducing the improvement in
physical function in the lower limb,
for the wearer with chronic
User height range 5′–64(152193 cm)Height range: 51″–63
(155191 cm)Maximum hip width:
16.6(42.2 cm)Femur length:
14″–18.5(3547 cm)
S size: 150165 cm, upper leg
length 3638 cm, lower leg length
3538 cm M size: 160175 cm,
upper leg length 3841 cm, lower
leg length 3741 cm L size:
170190 cm, upper leg length
4045 cm, lower leg length
3945 cm XL size: 180200 cm,
upper leg length 4348 cm, lower
leg length 4248 cm
Supported weight Maximum weight: 220 pounds
(100 kg)
Maximum weight: 250 lb (113 kg)Minimum weight: 40 kg Maximum
weight: 100 kg
User age N/A N/A N/A
Intended use EksoHealth is to gait train.
EksoWorks is for workers for fatigue
reduction for overhead
manufacturing, assembly, and
Personal or medical Personal
Device size Adjustable hip width and abduction Hip width range: 13.3″–16.6
(3442 cm)Upper leg length range:
14.6″–19.3(3749 cm)Lower leg
length range: 16.5″–21.7
(4255 cm)
Device weight 55 lbs. (25 kg), but patients bear
only their own weight
Personal: 26 lbs. (12 kg)Medical: 39
lbs. (18 kg)
Double-leg model: 14 kg Single-leg
model: 9 kg
Shoe size N/A N/A 23.0, 24.0, 25.0, 26.0, 27.0, 28.0,
29.0, 30.0 cm
N/A N/A Hip width: male size: 2836 cm
and female size: 3240 cm
Price Not available for personal use To be consulted To be consulted
222 Roger Andre Søraa and Eduard Fosch-Villaronga
5 Discussion
In this section, we apply a feminist critique through an
intersectional lens in order to better understand the social
context of the individual relating to exoskeleton tech-
nology. Based on the results, we have selected three
individual attributes height, weight, and age that
aect how a user may be included or excluded from using
exoskeleton technologies. We also include discussion of
matters of socioeconomic status (relating to the price of
the exoskeletons)as critical inclusion/exclusion criteria.
5.1 Exoskeletons for all?
Height and weight are the two most important para-
meters for exoskeleton use, but the technological t for
the standard user might also lead to exclusion. As
Wajcman [23]writes on the topic of hay bales which
require workers to be able to lift precisely 50 kg in the
particular weight of the standard hay bale: male
workers use their bodily and technical eectivity to
design machinery and machine tasks to constitute
themselves as the capable workers and women as
inadequate.Similarly, exoskeletons have been given a
certain standard measure at one point in their design
and development history. As we can see, devices may
support from 100 to 113 kg of maximum weight. This
excludes users who have a weight under or over the
weight limits. Intended users of exoskeletons have a
series of user attributes that developers need to bear in
mind for eective development and implementation.
Most important of those is the health condition of the
user, which excludes a large number of users who do not
have the body strength required to use the exoskeleton.
In an industry, this would exclude those workers
required to use these devices for work; in a rehabilita-
tion context, this could impede patients from accessing a
technology that may benet them. Although health
condition-oriented exoskeletons seem to help realize
the goals of personalized medicine, they also seem to
highlight the need to develop exoskeletons for the other
conditions, whichever those may be, pressuring devel-
opers and health-care systems to provide an equal and
fair access to health-care technological solutions.
It is not only the weight of the technology but also the
embodied technological adoption through the usersbody
weight that matters for successful domestication of
exoskeleton technology. As seen in the comparison, users
of these exoskeletons can never weigh less than 40 kg, nor
more than 113 kg. If they do so, they are excluded from
use. This is problematic, as there are several issues with
weight in contemporary societies. Malnourishment and
starvation are causing massive health pandemics in the
global south, and the global north faces the opposite
problem of obesity and overeating. Both of these global
demographic weight trends are increasing at both ends of
the spectrum and causing multiple health issues. In turn,
this can make gait treatment and rehabilitation dicult as
the users might not be within the weight limits of the
technology. The weight limit is both a social construct and
a result of technological constraints. To build an
exoskeleton that supports heavier patients would lead to
having heavier, clunkier, and more cumbersome devices
which could then be in conict with users of decreased
arm strength (some of whom might be barely able to use
the current system now).
Another aspect that seems to be highly problematic
on a structural level is the price of exoskeletons. We did
not nd the exact price of the exoskeletons of the
companies we analyzed due to the lack of the companies
transparency. However, some articles suggest that the
price range of exoskeletons varies between US$30,000
and US$200,000, which suggests that patients in emer-
ging and developed countries cannot aord to obtain such
a solution for their condition [47]. Although there may be
many exoskeleton solutions out in the market, their use
largely remains limited to the rehabilitation center or
wealthy patients. It is an undeniable fact that disadvan-
taged people are recurrently excluded from the benets of
technological development. At an extreme, in some
capitalist economies only the rich can aord to live
when contracting a severe disease, whereas the poor who,
due to their socioeconomic situation, cannot aord
medicines would die in a worst-case scenario. In more
egalitarian societies like the Nordic European countries, it
is the states responsibility to provide good minimal equal
health care for all citizens. However, exoskeletons
currently are not seen as necessary enoughfor patients
to have their own, due primarily to the high cost of the
technology. Also, there is little evidence on the social
impact of using the technology.
One essential unaddressed issue is whether there is
enough competition to cover all market needs at
aordable prices. At the moment, providers try to suit
as many users as possible from a cost perspective, not
specializing in specic minority targeted audiences. If
some companies created exoskeletons just for children,
while in healthy competition with other providers,
would that create more aordable solutions? For some
other considerations, private actors might not be in a
position to aord developing technologies that cover the
Exoskeletons for all 223
whole market, thus prompting the question of public
support or mandatory requirements for certain features
e.g., language support for indigenous people who might
not speak the ocial/majority state language but whose
developers might not have the resources (or protability)
to include in their original design.
5.2 Technological bias as user exclusion
Technological biases reect how technology embodies
social knowledge, practices, and products. Although we
cannot claim to know if the exoskeletons in question are
being made and used by male power and interests[23],
there are certain gender biases that can be seen through
target users. Going back to Berg and Lies[26]feminist
techno-inquiry of artifactsgenders, we can likewise
prompt the question: do exoskeletons have a gender?
By this, we do not mean the physical exoskeleton itself,
as it is not gendered in the same way as a social robot or a
chat program that may be given male/female design
choices [48]. Instead, we wonder what the design script
of the exoskeleton implies symbolically for the intended
user. Here gender theories can help better understand
user exclusion, and especially intersectionality can be
To give an intersectional account of the user of
exoskeletons, we need to look at who the intended user
is, but, more importantly, who she is not. By looking at
the technology user criteria, there are specic attributes a
user must t within. She cannot be too tall or too short,
and she cannot be too overweight or underweight. She
must be healthy enough to be able to strap on the
technology if she is to use it by herself. These choices will
necessarily exclude many users who could, for example,
nd themselves being too young and healthy normally be
required to use a wheelchair for life but too tall to be able
to walk with an exoskeleton. Disabled people already a
minority in society are not just disabledbut hold, as
every human does, a wide variety of other identities. How
can this, especially in regard to disabled people, lead to
double or multiple levels of exclusion, discrimination, or
disregard? Are exoskeleton users more in control of their
life when using exoskeletons? And, revisiting the concept
of coproduction [16], are the users involved in coproduc-
tion processes of the technology?
As Haraway [25]prompts with her Cyborg concept,
one novel way of thinking about the exoskeleton user is
precisely as a cyborg where humans and machines merge
as cybernetic organisms; and although this sounds quite
futuristic, we already see the start of this through
exoskeleton use. Through active inclusion, by under-
standing and eliminating exclusion criteria, more people
could and should have the opportunity to walk again if
that is their wish and the technology allows it. By looking
at the rigid inclusion criteria for whom the intended user
of the technology can be, we can thus also see whom the
intended user is not meant to be.
5.3 Intersectional users of exoskeletons
For a better understanding of the exoskeleton users, we
argue that it is imperative to see the users as unique and
actively engage with their multiple identities. People
come from all walks of life, have diverse genders, ages,
socioeconomic backgrounds, upper arm strength, weight,
and height. For a good development and implementation
usage of exoskeleton technology, it is important that
producers, health-care technology providers, health-care
sta, and formal and informal caregivers be aware of
patientsunique individuality. As of now, technology
seems to treat users as black boxes: the input and the
output are known, but not what happens in the black box.
We propose that, instead, technology should understand
the user attributes and the eects it has on them.
Unboxing the user-as-a-black-boxcan serve as an
argument for a better sociotechnical understanding of
the user as a technologyhuman hybrid as people using
exoskeletons integrate their bodies with a robotic device
become a sort of cyborg. Making developers and designers
aware of the eect technology has on users may confront
them with the responsibility they have. The following
chart provides a list of inclusive design choices that
designers and manufacturers could consider when de-
signing exoskeletons, which we term inclusive design
choices for exoskeleton design(Table 2).
By considering these and other related issues when
building, testing, and receiving feedback on the tech-
nology, creators, designers, and technology developers
can increase the usability of their technology by better
including a myriad of users not only those who t
within the relatively high threshold standards. This may
also help realize the dignity of the users, which should
be central to how manufacturers design and build these
robotic devices [50]. Going back to Haraways[24]
situated knowledge, she describes how bodies as
objects of knowledge are material-semiotic nodes. Their
boundaries materialize in social interaction.In this
case, this relates to how the producersway of selecting
and excluding which bodies that matter.The ones
that need the technology the most could risk being the
224 Roger Andre Søraa and Eduard Fosch-Villaronga
ones that are not able to use it due to, for example,
being a couple of kilos or centimeters over or under the
limits. Since the technology and the knowledge put
into development and redevelopment is situational,
and sociomaterially constructed, inclusive criteria can
better inform the production and also the use of exo-
5.4 Limitations and further studies
The limited public availability of information concerning
exoskeletons limited this study. The majority of large,
international companies do not have specicinformation
online. Additionally, given that there are currently only a
few companies developing exoskeletons, the data were
dependent on a few selected available companies that could
provide the data. Following Nashs(2008)critique of
intersectionality, the lack of a specic, dened intersectional
methodology is also a potential issue, but here we have
used it more as a conceptual tool. Additionally, we do not
seek to give an empirical validity of intersectionality, as our
data material does not include user studies. However, this
could be a focus on further studies. Future studies may also
cover a growing area of application, i.e., exoskeletons for
work purposes. Exoskeletons may improve and support the
working conditions of staperforming demanding physical
tasks, such as lifting patients. Overall, exoskeletons may
help reduce fatigue in dicult jobs, such as manufacturing,
assembly, and construction. More in-depth studies are also
needed to investigate the coproduction that producers have
with end users regarding exoskeletons.
6 Conclusion and further
By having rigid inclusion criteria for whom the intended
user of the technology can be, exclusion criteria will grow
in parallel. This holds for exoskeletons and may lead to
discriminatory scenarios. By integrating a deeper under-
standing of how users of exoskeleton come in a wide
variety of attributes, shapes, sizes, gender, and wealth,
and that there is no general one-size ts all,exoskeleton
technology holds the potential for being more inclusive.
To make this technology available for all who need it,
designers and producers must also think beyond their
target market. However, how this extra mile of inclusive
Table 2: Inclusive design choices for exoskeleton design
Human feature Technology solution
Height considerations Make exoskeletons that can accommodate very tall people as well as short people, e.g., children,
or persons with dwarsm
Weight considerations Make sure exoskeletons can support overweight and underweight people. This is especially
important since a disproportionate amount of people in wheelchairs are overweight because of
their more sedentary life
Correlated condition
Make buttons in dierent patterns, so that green-red color-blind people can easily operate them
without the fear of pushing the wrong-colored button. Create buttons with dierent textures for
blind people and add auditory response sensors
Capability considerations Make the exoskeleton as easy as possible to put on and operate with minimal upper body
strength required, so that the users who are also minorly impaired in their upper body but
severely impaired in their lower body can benet from the technology
Gender and sex considerations Be aware of bodily dierences between men and women and ensure that the exoskeleton design
is not a result of a man-only team, designing for men. A diverse group of employees or users
should be involved at all levels and also be included in the target user group
Cultural considerations People from dierent sociocultural backgrounds might relate to robotic technology in widely
dierent manners. Acceptance rate and levels of trust dier, and what might work well in one
region might not be ideal in others. Therefore, be sure to include a robust sociotechnical
perspective in the development and testing of the technology to better understand how to adhere
to dierent cultural values
Inclusivity considerations Think about the importance of including typically marginalized communities such as the LGBTQ+
in the development of technology to avoid discrimination and reinforcing the existing biases [49].
Be inclusive-by-design and remember that any inclusion criteria may represent exclusion criteria
for other communities. Careful reection on these aspects when developing
technology including exoskeletons can benet both society and the individual
Exoskeletons for all 225
design should be implemented is not within the scope of
this article. Some potential solutions could be to give
incentives for technology producers to also include users
who do not t the standard frames of the technology, thus
realizing and providing exoskeletons for all.
Acknowledgments: This article has been partially funded
by the LIFEBOTS Exchange project funded by the
European Unions Horizon 2020 research and innovation
program under the Grant Agreement No. 824047 and by
the LEaDing Fellows Marie Curie COFUND fellowship, a
project that received funding from the European Unions
Horizon 2020 research and innovation program under the
Marie Skłodowska-Curie Grant Agreement No. 707404.
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Exoskeletons for all 227
... Because robotic exoskeletons operate intimately with users' bodies [61], ignoring those conditions in robot design, test beds, policies, and technical standards might introduce dissimilarities in human-robot interaction, ultimately compromising user safety as it may hide important distinctions and risks excluding specific users (something highlighted theoretically by [98]. Following these lines of thought, our paper touches upon a mutual flaw in legal, engineering, and clinical settings: the accounting for gender and sex considerations in medicine, human-robot interaction, and the law. ...
... On top of that, the standard lacks safeguards for specific categories of users, such as children, pregnant women, and older adults (as highlighted in the introduction of ISO 13482:2014). However, recognizing individuals' unique characteristics and providing adequate safeguards is essential for not only wearable robots' correct functioning but also for ensuring user safety and universal access [18,36,63,67,98,113]. ...
... Our efforts culminated in finding a wide array of areas for improvement, particularly concerning the role of psychological factors [91], gender and intersectionality considerations, and protective stops that play a crucial role in ensuring user safety [61,70]. Diversity, inclusion, and intersectional considerations have been identified in the literature as potential access and discriminatory problems for 'non-average' body sizes, genders, and pediatric populations [18,36,42,54,98]. Persons differ considerably in size and body form, so accommodating robots to each potential user is a complicated task, yet there seems to be no alternative to embracing complexity and Fig. 2 Subjects' reported sex and gender (Please, note that different scholars are pointing to many more gender identities, which we did not account for them all) spurring developers to construct suitable alternatives. ...
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... Apart from an unclear scope, ISO 13482:2014 lacks specific requirements for different categories of people, like children and women [10]. It is thus uncertain whether devices designed in compliance with the standard are suitable for particular subjects and questions how and to what extent diversity and inclusion as concepts are considered. ...
... In this contribution, we identify the need to revise ISO 13482:2014 to include novel hazards and safeguarding alternatives to cover risk steaming, such as psychological aspects, sex, and gender considerations [10]. This is particularly relevant considering that the standard had remained virtually untouched in the latest revision in 2020. ...
Despite the growing body of literature highlighting the legal and ethical questions robots raise, robot developers struggle to incorporate other aspects than mere physical safety into robot design to make them comprehensively safe. The chemical, food, and pharmaceutical industries established years ago use evidence-based frameworks that ensure the safety of these products EU-wide. However, these evidence-based frameworks have yet to be seen for robot technology. As a result, current robot technology raises many legal and ethical issues. The PROPELLING project aims to investigate how robot testbeds can be harnessed as data generators for standard-makers. To this end, the project focuses on testing safety requirements for lower-limb exoskeletons to understand whether standards, particularly ISO 13482:2014, address safety sufficiently and comprehensively and use the H2020 Eurobench testing beds and data as a means for appraising the standard. We suggest that linking experimentation settings with standard-making processes could speed up the creation, revision, or discontinuation of norms governing robot technology.
... We recognize that those with less social power in terms of social identity and physical characteristics laden with social values are underrepresented and marginalized [12,21,26]. People at the intersections of these population slices experience greater disenfranchisement [18,22]. Part of the workshop aims to highlight this issue and take action on rectifying it. ...
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... This may be because, as Carr (2011) highlights, technology developers are so focused on solving a problem that they are oblivious to the broader consequences of their technology. Also, technology developers often times initially focus on creating a product and successfully bringing it to market, before they take into consideration the wider ethical and legal concerns-including, for instance, privacy and data protection, and diversity and inclusion consideration-that their creations may raise (Fosch- Villaronga and Drukarch, 2020;Søraa and Fosch-Villaronga, 2020). Even where clear policies are in place to prevent or mitigate any such risks, technology developers experience difficulties in translating these oftentimes abstract codes of conduct into development decisions or they fail to incorporate other aspects than mere physical safety into their robot design to ensure their devices are comprehensively safe. ...
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... However, it may not be as beneficial to end-users. Thus, wearable chair exoskeleton designers and manufacturers must be more inclusive when thinking about their target market and must meet several requirements, including gender, age, income, location, and even health status of users in order to make this technology available to everyone who needs it (Soraa and Fosch-Villaronga, 2020). ...
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... Even in a perspective more referring to legal aspects, it emerges how the context of reference can be the key aspect in order not to replicate, in reference to robots as well, inequalities that affect humans (Karnouskos 2022). Inequalities that, for example, are evident in the production of exoskeletons, for which it is blatant that the production process is based on masculine perspectives and does not consider the intersection of the different identity dimensions of patients (not only gender dimensions) that will have to enter into symbiosis with those technologies (Søraa and Fosch-Villaronga 2020). ...
Research on gender role stereotypes activated in interactions with humanoid robots has yet to produce conclusive knowledge. To analyse how much, and in which way, gender role stereotypes used in interactions with humans are also called into play in interactions with humanoid robots, a study was conducted with 240 participants. The study was an online survey in which a scale was used for determining the appropriateness for performing four stereotypically masculine and four feminine by humans and robots. Overall, eight humanoid robots – four judged feminine and four masculine – were considered. Results showed that gender role stereotypes are activated for both genders, but men most strongly activate those pertaining to male roles. These stereotypes are also adopted in reference to humanoid robots, though robots are generally considered less suitable for performing female roles. Furthermore, an increased degree of similarity of robots to humans has a positive effect in assessing the appropriateness to perform female roles only for female robots. The same does not happen with male robots. These results suggest that male and female robots are not categorised in the same way. Robots are essentially perceived as male entities, a particularly relevant hypothesis for the gender-sensitive design of humanoid robots.
... • Reflection encourages researchers to think about their work mindfully to identify prevailing assumptions to identify biases and frame issues and problems constructively. Multidisciplinary R&I teams could create room for more inclusive intersectional reflections ( Søraa and Fosch-Villaronga, 2020 ). • Responsiveness refers to the possibility to reshape R&I processes in response to events that no longer align with the continually evolving needs of society. ...
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In healthcare, gender and sex considerations are crucial because they affect individuals' health and disease differences. Yet, most algorithms deployed in the healthcare context do not consider these aspects and do not account for bias detection. Missing these dimensions in algorithms used in medicine is a huge point of concern, as neglecting these aspects will inevitably produce far from optimal results and generate errors that may lead to misdiagnosis and potential discrimination. This paper explores how current algorithmic-based systems may reinforce gender biases and affect marginalized communities in healthcare-related applications. To do so, we bring together notions and reflections from computer science, queer media studies, and legal insights to better understand the magnitude of failing to consider gender and sex difference in the use of algorithms for medical purposes. Our goal is to illustrate the potential impact that algorithmic bias may have on inadvertent discriminatory, safety, and privacy-related concerns for patients in increasingly automated medicine. This is necessary because by rushing the deployment of AI technologies that do not account for diversity, we risk having an even more unsafe and inadequate healthcare delivery. By promoting the account for privacy, safety, diversity, and inclusion in algorithmic developments with health-related outcomes, we ultimately aim to inform the Artificial Intelligence (AI) global governance landscape and practice on the importance of integrating gender and sex considerations in the development of algorithms to avoid exacerbating existing or new prejudices.
... As long as ISO 13482:2014 does not consider any special safety requirements for different types of users, it could be that a personal care robot is certified under the standard with disregard as to its safety or accessibility. This gap brings about uncertainty regarding the protected scope of the framework for different types of users and questions to what extent diversity and inclusion as concepts are sufficiently considered and how they are (Søraa and Fosch-Villaronga, 2020). ...
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From exoskeletons to lightweight robotic suits, wearable robots are changing dynamically and rapidly, challenging the timeliness of laws and regulatory standards that were not prepared for robots that would help wheelchair users walk again. In this context, equipping regulators with technical knowledge on technologies could solve information asymmetries among developers and policymakers and avoid the problem of regulatory disconnection. This article introduces pushing robot development for lawmaking (PROPELLING), an financial support to third parties from the Horizon 2020 EUROBENCH project that explores how robot testing facilities could generate policy-relevant knowledge and support optimized regulations for robot technologies. With ISO 13482:2014 as a case study, PROPELLING investigates how robot testbeds could be used as data generators to improve the regulation for lower-limb exoskeletons. Specifically, the article discusses how robot testbeds could help regulators tackle hazards like fear of falling, instability in collisions, or define the safe scenarios for avoiding any adverse consequences generated by abrupt protective stops. The article’s central point is that testbeds offer a promising setting to bring policymakers closer to research and development to make policies more attuned to societal needs. In this way, these approximations can be harnessed to unravel an optimal regulatory framework for emerging technologies, such as robots and artificial intelligence, based on science and evidence.
... However, if they are not familiar with the context of the application and do not have direct access to the necessary information, they unintentionally create user configurations: these do not correspond to the actual needs, preferences, competencies, and motives of future users, but nevertheless shape future application situations [15][16] [17]. Observations show that exoskeleton development mostly adopts a one-size-fits-all approach and ignores the diversity of user characteristics [18]. In addition, there are promises of increased safety and health, which are obviously not achievable by the exoskeleton alone. ...
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The timber prefabrication industry (TPFI) requires that workers deal with challenges such as customized products or changing materials. Physical stress is unavoidable and causes work-related musculoskeletal disorders. Preventive exoskeletons are new devices for physical support of workers. However, widespread implementation of exoskeletons within construction is missing due to various barriers. We describe current challenges for adopting exoskeletons in construction work and present four aspects that hinder adoption so far. We draw on motion analysis and sociological reflections on human–exoskeleton configurations. These findings call for an interdisciplinary action plan for future studies on exoskeletons for TPFI.
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Robots and AI are no longer confined to industry but can be found in healthcare, education and retail environments. However, the insertion of robots into society raises ethical, legal and societal concerns. Discrimination and bias are known to be inherent problems of many AI applications and we wonder what this means for the LGBTQ+ community and whether they are considered at all in the development and use of robotics and AI.
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Healthcare robots enable practices that seemed far-fetched in the past. Robots might be the solution to bridge the loneliness that the elderly often experience; they may help wheelchair users walk again, or may help navigate the blind. European Institutions, however, acknowledge that human contact is an essential aspect of personal care and that the insertion of robots could dehumanize caring practices. Such instances of human–robot interactions raise the question to what extent the use and development of robots for healthcare applications can challenge the dignity of users. In this article, therefore, we explore how different robot applications in the healthcare domain support individuals in achieving ‘dignity’ or pressure it. We argue that since healthcare robot applications are novel, their associated risks and impacts may be unprecedented and unknown, thus triggering the need for a conceptual instrument that is binding and remains flexible at the same time. In this respect, as safety rules and data protection are often criticized to lack flexibility, and technology ethics to lack enforceability, we suggest human dignity as the overarching governance instrument for robotics, which is the inviolable value upon which all fundamental rights are grounded.
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The integration of robotic systems and artificial intelligence into healthcare settings is accelerating. As these technological developments interact socially with children, the elderly, or the disabled, they may raise concerns besides mere physical safety; concerns that include data protection, inappropriate use of emotions, invasion of privacy, autonomy suppression, decrease in human interaction, and cognitive safety. Given the novelty of these technologies and the uncertainties surrounding the impact of care automation, it is unclear how the law should respond. This book investigates the legal and regulatory implications of the growing use of personal care robots for healthcare purposes. It explores the interplay between various aspects of the law, including safety, data protection, responsibility, transparency, autonomy, and dignity; and it examines different robotic and AI systems, such as social therapy robots, physical assistant robots for rehabilitation, and wheeled passenger carriers. Highlighting specific problems and challenges in regulating complex cyber-physical systems in concrete healthcare applications, it critically assesses the adequacy of current industry standards and emerging regulatory initiatives for robots and AI. After analyzing the potential legal and ethical issues associated with personal care robots, it concludes that the primarily principle-based approach of recent law and robotics studies is too abstract to be as effective as required by the personal care context. Instead, it recommends bridging the gap between general legal principles and their applicability in concrete robotic and AI technologies with a risk-based approach using impact assessments. As the first book to compile both legal and regulatory aspects of personal care robots, this book will be a valuable addition to the literature on robotics, artificial intelligence, human–robot interaction, law, and philosophy of technology.
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Improving walking function is a desirable outcome in rehabilitation and of high importance for social and vocational reintegration for persons with neurologic-related gait impairment. Robots for lower limb gait rehabilitation are designed principally to help automate repetitive labor-intensive training during neurorehabilitation. These include tethered exoskeletons, end-effector devices, untethered exoskeletons, and patient-guided suspension systems. This article reviews the first 3 categories and briefly mentions the fourth. Research is needed to further define the therapeutic applications of these devices. Additional technical improvements are expected regarding device size, controls, and battery life for untethered devices.
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The adoption of robot technology is accelerating in healthcare settings. Care robots can support and extend the work of caregivers in assisting patients, elderly or children. Typical examples of such systems are ‘cognitive therapeutic robots,’ ‘physical rehabilitation robots,’ ‘assistive and lifting robots.’ Although these robots might reduce the workload of care workers, and be a cost-efficient solution against healthcare system cuts, the insertion of such technologies may also raise ethical, legal and societal concerns concerning users. In this article, we describe some of these concerns, including cognitive safety, prospective liability, and privacy. We argue that the current regulatory framework for care robot technology is ill-prepared to address such multidisciplinary concerns because it only focuses on physical safety requirements, whereas it disregards other issues arising from the human–robot interaction. We support the idea that design plays a significant role in shaping the technology to meet the needs of the users and the goals set by the regulation. To illustrate practical challenges, in this article we consider as an example the case of lower-limb exoskeletons. This example helps illuminate the overarching idea of the article, that is, that regulation, design, and human needs need to intertwine and mutually shape each other to serve the solutions these technologies proclaim.
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This article sheds light on the design and control of a lower limb exoskeleton system named NOD-P developed to assist paralyzed children with neurological diseases such as spinal cord injury (SCI) to move their lower limb and perform a gait motion. The device consists of a powered robotic device capable to operate effectively and synchronously with the human muscle-skeletal system. First, the mechatronic design presented and detailed. Second, a closed loop control system for exoskeleton developed and simulated using Matlab-Simulink. In the end, a novel human machine interface presented to ensure an interactive interface between the patient and the exoskeleton.
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This article reports the findings of AI4People, an Atomium—EISMD initiative designed to lay the foundations for a “Good AI Society”. We introduce the core opportunities and risks of AI for society; present a synthesis of five ethical principles that should undergird its development and adoption; and offer 20 concrete recommendations—to assess, to develop, to incentivise, and to support good AI—which in some cases may be undertaken directly by national or supranational policy makers, while in others may be led by other stakeholders. If adopted, these recommendations would serve as a firm foundation for the establishment of a Good AI Society.
This chapter reviews recent technologic advances to counteract the immobility and negative comorbidities that are associated with the lack of ambulation after spinal cord injury (SCI). A historical background of the progression of robotics in the medical field is reviewed to describe their evolution in rehabilitation medicine. Exoskeletal devices are a new robotic technology that has the potential to revolutionize therapeutic exercise after SCI. Different brands of exoskeletons have been introduced for rehabilitation and community ambulation with different designs and features. The use of exoskeletons may ameliorate several of the chronic health-related consequences that are likely to affect persons with SCI. Existing research is limited but suggests some health benefits of exoskeletons, including improvements in gait function, body composition, aerobic capacity, bone density, spasticity, bowel function, and quality of life. Clinical trials are underway to confirm these benefits and determine the underlying mechanisms that lead to such improvements. Maximizing the application of robotics in rehabilitation environments may be accomplished by providing hybrid protocols with other established techniques such as exercise, gait training, and functional electrical stimulation (FES). Future recommendations may include using FES and brain computer interfaces in conjunction with an exoskeleton to improve rehabilitation outcomes and quality of life after SCI. Further research is warranted to demonstrate the health and quality-of-life benefits of robotic exoskeletons in outpatient and home settings.
The goal of sex and gender analysis is to promote rigorous, reproducible and responsible science. Incorporating sex and gender analysis into experimental design has enabled advancements across many disciplines, such as improved treatment of heart disease and insights into the societal impact of algorithmic bias. Here we discuss the potential for sex and gender analysis to foster scientific discovery, improve experimental efficiency and enable social equality. We provide a roadmap for sex and gender analysis across scientific disciplines and call on researchers, funding agencies, peer-reviewed journals and universities to coordinate efforts to implement robust methods of sex and gender analysis.
Objective: To explore changes in pain, spasticity, range of motion, activities of daily living, bowel and lower urinary tract function and quality of life of individuals with spinal cord injury following robotic exoskeleton gait training. Design: Prospective, observational, open-label multicentre study. Methods: Three training sessions per week for 8 weeks using an Ekso™ GT robotic exoskeleton (EKSO Bionics). Included were individuals with recent (<1 year) or chronic (>1 year) injury, paraplegia and tetraplegia, complete and incomplete injury, men and women. Results: Fifty-two participants completed the training protocol. Pain was reported by 52% of participants during the week prior to training and 17% during training, but no change occurred longitudinally. Spasticity decreased after a training session compared with before the training session (p < 0.001), but not longitudinally. Chronically injured participants increased Spinal Cord Independence Measure (SCIM III) from 73 to 74 (p = 0.008) and improved life satisfaction (p = 0.036) over 8 weeks of training. Recently injured participants increased SCIM III from 62 to 70 (p < 0.001), but no significant change occurred in life satisfaction. Range of motion, bowel and lower urinary function did not change over time. Conclusion: Training seemed not to provoke new pain. Spasticity decreased after a single training session. SCIM III and quality of life increased longitudinally for subsets of participants.