Assessing the Effects of Exoskeleton Use on Balance and Postural Stability

There is emerging evidence for the potential of occupational back-support exoskeletons (BSEs) to reduce physical demands, and thereby help control/prevent the risk of overexertion injuries associated with manual material handling. However, it is important to understand whether BSEs also introduce any unintended safety challenges. One potential risk associated with BSE use is increased risk of falls, since their extra weight, rigid structure, and external hip extension torque may increase demands on the postural control system. However, there is currently limited evidence on whether, and to what extent, BSE use alters postural stability and/or fall risk. The primary goal of this work was to understand the effects of exoskeleton use, and quantify the effects of exoskeleton design parameters, on balance and postural stability, with a focus on passive BSEs used for repetitive lifting work. A comprehensive evaluation of BSE use was performed under controlled laboratory conditions, focusing on three classes of human activity that form the basis of maintaining postural balance in diverse real-life scenarios: maintenance of a specified posture, voluntary movement, and reaction to an external perturbation.

The first study demonstrated that during quiet bipedal stance, BSE use increased median frequency and velocity of the center of pressure in the anterior-posterior direction. In the second study on level walking, BSE use caused an increase in gait step width and gait variability, and decrease in the margin of stability. BSE use with high supportive torque led to adapted gait patterns in early-stance phase. Hip range of motion and peak hip flexion velocity also decreased, and participants exhibited different strategies to increase mechanical energy for propelling the leg in late-stance phase: these effects increased with increasing torque applied by the exoskeleton. In the final study, BSE use did not alter the maximal lean angle from which individuals could successfully execute single step balance recovery, following a forward loss of balance. However, several recovery responses were negatively affected by BSE use, including increased reaction time, impeded hip flexion, and reduced margin of stability in the high-torque condition.

This is the first systematical investigation to quantify the effects of passive BSEs with multiple supportive torque levels on balance and postural stability. While exoskeleton effects on static balance were minimal, more substantial changes in gait spatiotemporal parameters, hip joint kinematics, and dynamic margins of stability were observed in the later studies. Our results indicate that postural stability deteriorated with exoskeleton use in dynamic conditions, and provide mechanistic insight into how stability is altered by different exoskeleton design factors such as added mass, restricted range of motion, and external hip extension torque. While our results are suggestive of increased fall risk, especially in the high-torque condition, fall risk in real life is moderated by a complex combination of individual and environmental conditions. Future work should consider more complex, realistic tasks and also include a more diverse sample that is studied under longer exposure durations, to further elucidate these findings. Our characterizations of a wide variety of postural responses as a function of exoskeleton torque settings are expected to contribute to improving both design and practice guidelines to facilitate the safe adoption of BSEs in the workplace.