Exoskeletons: Game-Changer or the New Back Belt? What the Research Actually Says

Exoskeletons are showing up in warehouses, distribution centres, construction sites, and surgical suites and the marketing behind them is compelling. But before your clients start outfitting their workforce in wearable tech, there's a question that isn't being asked loudly enough: are we solving the ergonomic problem, or just covering it up?

We dive into a direct parallel between the exoskeleton boom and the back belt era of the 1990s, a time when an intuitively appealing device was adopted widely, rapidly, and without adequate evidence, creating a false sense of protection while the underlying ergonomic hazards went unaddressed. NIOSH eventually concluded that back belts should not be recommended for occupational use. Are we heading down the same road?

We dive into including a 2024 systematic review of 49 studies, CCOHS guidance on overreliance, and peer-reviewed evidence on risk transfer, deconditioning, adoption barriers, and the donning and doffing problem to give you a clear-eyed, evidence-based framework for when exoskeletons make sense and, more importantly, when they don't.

What you'll take away from this episode:

•       The back belt history and what the science said, what the industry did anyway, and why it matters now

•       The superman effect and deconditioning: what happens when a device makes workers feel more protected than they are

•       What the research actually shows about exoskeleton effectiveness, including the lab vs. real-world gap

•       Five critical concerns: risk transfer, overreliance, donning/doffing time, the enthusiasm drop, and long-term compliance

•       Where exoskeletons belong in the hierarchy of controls, and why they're often being deployed at the wrong level

•       High-impact, low-cost alternatives that should come first

•       The specific conditions where exoskeletons genuinely add value

If you're an ergonomics consultant advising clients on technology decisions, or a practitioner trying to make the case for doing the ergonomic work properly before reaching for expensive tools, this episode is required listening.

Are you a healthcare professional curious about how office ergonomics assessments could fit into your services? I’ve got you covered with some valuable (and free!) resources at www.ergonomicshelp.com/free-training.

Transcript

Darcie J's video recording 0:00

Why, hey there. Today on the show, we're gonna be diving into the world of exoskeletons, specifically what the research actually says if they are a game changer as they're representing themselves as being, or in reality, are they actually the new back belt? We'll dive into all of this, what the research is saying, and if this is something that we should be recommending as ergonomists.

0:30

Welcome to the Business of Ergonomics Podcast. I'm your host, Darcy Jeremy. I'm a board-certified professional ergonomist with over 15 years of experience delivering ergonomics programs to employers of all different types. In this podcast, I share what other healthcare professionals are already doing and being with ergonomics assessments and how to land those clients that you dream of. Without further ado, let's jump into this episode right now.

Darcie J's video recording 1:02

This is something that I have genuinely been wanting to talk about for a while. Before we dive in today's episode, I wanna take a moment to thank the sponsor of today's show, the Ergonomics Blueprint Program. If you've been listening to this podcast for any amount of time, you know that the Ergonomics Blueprint is my signature program for healthcare professionals who want to learn how to deliver office ergonomics assessments and build a service into their practice. Whether you're a physiotherapist, a physical therapist, an occupational therapist, a kinesiologist, a chiropractor, any healthcare professional who wants to add ergonomics consulting to what you do, the blueprint gives you the clinical framework, the assessment tools, the report templates, and the business foundation to do it with confidence, and we're talking about office ergonomics assessments. And late-breaking news, we just got approval for the Ergonomics Blueprint to be pre-approved for CEUs from the AOTA. So if you're looking for CEUs and make sure that you are on the ball with that, then look no further than the Ergonomics Blueprint to give you the start that you need for office ergonomics assessments. Okay? So let's get into this. Today, we are talking about exoskeletons, and specifically, we're asking a question that I don't think gets asked loudly enough in our field. Are exoskeletons genuinely solving ergonomic problems, or are they the latest shiny tool that lets organizations feel like they've done something without actually addressing what's causing the injury in the first place? I'm going to push on this. I'm going to look at the science, and I'm going to draw a comparison that might make some of you uncomfortable because I think there's a real parallel between- What we're seeing with exoskeletons today and what happened with back belts in the 1990s. And if we learned anything from the back belt era, it's that a tool that feels protective isn't always a tool that's protective. Let's start there. If you've ever walked through a Home Depot, and I mean in North America, this is still happening. You might have noticed employees wearing those elastic lumbar support belts, the thick ones, usually orange, worn around the lower back. Maybe you've seen them at other retail or warehouse environments too. They've been around for decades, and they're still showing up. Back belts, also called lumbar support belts, abdominal belts, or weightlifting belts in their original form, started in medical rehab. Clinicians used them to support patients with existing low back injuries. Weightlifters then adopted them to increase what's called intra-abdominal pressure during heavy lifts. Essentially, this creates a kind of internal bracing mechanism that can support the spine under extreme load. For competitive powerlifters moving hundreds of pounds, there is an argument to be made for this, right? But somewhere in the 1980s and into the 1990s, these belts migrated from the gym and the clinic into manual material handling workplaces. Whether it was distribution centers, retail floors, or warehouses, the logic seemed intuitive here. If a belt supports the spine during extreme lifting in a gym, it must protect workers during lifting at work, right? The problem is that intuition is not evidence, and the evidence when it came in was very concerning. In 1994, NIOSH, the National Institute for Occupational Safety and Health, published a formal review concluding that there was insufficient evidence to recommend back belt use as a back injury prevention measure in the workplace. They even went further than this. In the largest study of its kind, a prospective cohort study conducted from 1996 to 1998 among material handling workers in a large retail setting, NIOSH found that back belt use was not associated with any reduction in back injury claims or, get this, low back pain. That study was published in the Journal of American Medical Association in two thousand. JAMA, not a fringe journal here. This is the most widely read medical journals in the world. NIOSH's formal conclusions was that back belts should not be considered personal protective equipment. Back belts should not be recommended for use in occupational situations, and that the use of back belts may create a false sense of security, increasing the risk of lifting excessive loads. Now, here's the part that really matters for today's conversation. One of NIOSH's core concerns, and the CCOHNS echoed this too, was that back belts may limit mobility and reduce the suppleness and elasticity of muscles and tendons over time. And they may create what researchers described as a false sense of security, meaning workers wearing back belts might attempt to lift heavier loads than they would without one because they felt protected. the belt creates a perceived capability that isn't matched by actual physiological protection. This is what some research called the Superman effect. The belt makes you feel invincible, so you lift heavier, right? And when the belt comes off, or when you encounter a load or a posture outside of the belt's range of assistance, you are potentially at greater risk than if you've never worn it at all. That's huge. Not only that, let's talk about the deconditioning argument. My hypothesis here is that when external support consistently does work that your muscles would otherwise do, stabilizing the trunk, managing spinal load, those muscles may become less trained over time. You're offloading the work to a device, and the device doesn't build capacity. it potentially reduces it. This is contested in the literature too. Some studies found minimal deconditioning effects from lumbar belts, but the concern is real enough that it has been a consistent thread in research for 30 years. And yet, after the NIOSH findings in 1994 and confirmed again in 2000, almost 4 million back belts were purchased in 1995 alone. The year after the first study was published. And you can still find them at Home Depot today. So why am I telling you all of this? Because I think we are at a risk of repeating this pattern. Exactly. With exoskeletons. And as ergonomics professionals, I think it's our job to pump the brakes and ask the hard questions before this technology becomes as entrenched as the back belt was. And before organizations start using it as a substitute for actually fixing the ergonomic problem. Okay, let's make sure we're all working from the same definition. Because exoskeleton is being used to describe a pretty wide range of devices right now, and lumping them all together isn't helpful. It's not going to help the case. It's not going to help you as an ergonomist. In occupational settings, exoskeletons are wearable devices that are designated to augment, assist, or reduce the physical demands on the worker's body during specific tasks. There are two broad categories. don't have a motor or power source. They use springs, elastic bands, or counterbalance mechanisms to redistribute the load. They're lighter, cheaper, and don't require charging. They provide support during specific movements, typically bending, lifting, or sustained overhead work, by storing and releasing mechanical energy. exoskeletons have motors and actuators. They're powered, which means they require charging. They're heavier, and they're significantly more expensive. But they can provide dynamic support that responds to movement in real time, which passive devices can't do. The body parts these devices target vary. Back support exoskeletons are the most common in industrial settings. Shoulder support exoskeletons are used for overhead tasks. Lower limb exoskeletons support workers who need to sustain awkward postures or carry heavy loads across distances. A comprehensive systematic review published in the International Journal of Environmental Research and Public Health in December 2024, covering 49 studies from 2014 to 2024, found that passive exoskeletons are by far the most studied in occupational settings, with back and upper limb support being the most common applications. Laboratory settings dominated the research landscape, which is an important caveat we'll come back to. A 2023 study published in the International Journal of Environmental Research and Public Health found that active exoskeletons reduced muscle activity in the erector spinae, latissimus dorsi, and gluteus maximus by seven to 62% compared to no exoskeletons, and 10 to 52% compared to passive exoskeletons Across lifting and static tasks. So the muscle offloading effect is real, particularly With active devices. The EMG data, and that stands for the electromyographic data, does show reductions in muscle activation during tasks when exoskeletons are used. In the right context, for the right task, with the right worker, This can be genuinely helpful. One study found that wearing a lower back assistive exoskeleton during manual material handling reduced the perceived weight of a handled object by a factor of almost 38%. So a 20 kilogram box was perceived as equivalent to about 12.5 kilograms. And that's not nothing, especially when you consider the frequency and duration that this item could be handled during a shift Surgeons in surgical suites reported up to a seventy percent reduction in shoulder pain and fatigue during prolonged procedures. ICU staff using exoskeletons during patient positioning tasks showed measurable lower back relief supported by EMG data. In nursing contexts, eighty-six percent of users in one study reported reduced back pain and fatigue. So there is a signal here. This technology is not a fraud. But here's where I want to slow down. because the existence of measurable benefit under controlled conditions does not mean we should be deploying these devices broadly as a first-time ergonomic intervention without deeply evaluating the ergonomic risk factors that created the need in the first place. and the research has some significant things to say about why. The first problem that we're gonna be looking into is that most of the research is from the lab, not the real world. The twenty twenty-four systematic review I mentioned, that's forty-nine studies published in a peer-reviewed journal, noted that laboratory-based studies dominated the research landscape. The most common sample size across the studies was ten participants. Ten. That's a significant limitation when you're trying to generalize findings to an industrial population. Lab conditions are controlled. Even the participants are relatively controlled. Workers are performing standardized tasks. There's no production pressure. There's no unexpected loads. There's no multitask environment where a worker is bending, twisting, reaching, and carrying in rapid succession across an eight-hour shift. Real workplaces are messy, and the research that tells us how exoskeletons perform across a shift, across diverse task profiles in real production environments is still sparse. We need more long-term data before we can make confident claims about long-term effectiveness and safety at scale. Let's move into the second problem here Donning and doffing time is a real barrier. Here's one that doesn't get talked about enough in the promotional materials for these devices. How long does it actually take to put on an exoskeleton? Manufacturers often cite 30 to 60 seconds for donning, which sounds fast, but consider the reality of a production environment. A worker arrives at a task, puts the device on, completes the task, needs to switch to a different type of task that requires a different movement, takes the device off, and then moves on. Multiply that across a full shift, across a full workforce with varying task types and task frequencies. Research published in Applied Ergonomics and several other journals has identified donning and doffing time as a consistent and reoccurring barrier to exoskeleton adoption. In construction environments specifically, the additional time required for donning and doffing requires productivity work time, which creates real pressure on workers to either skip the device or wear it for tasks it wasn't designed for. The research says that barriers to occupational exoskeleton adoption consistently identified in the research include incompatibility with required tasks, poor fit, discomfort, time to don and doff, thermal burden, and limited usability in dynamic task environments. A 2022 systematic scoping review also flagged hygiene and infection control concerns in healthcare settings. Shared devices in clinical environments raise real sanitation questions that aren't simple to resolve. Let's move into the third problem, shall we? The enthusiasm effect and what happens after. This one is subtle but important. Research from the Frontiers in Public Health Journal noted something interesting. When subjective experience of exoskeleton use was measured over time, the ratings decreased after an initial enthusiastic evaluation. So, and this is something I see across the board when adapting to new technology. In this case, workers were excited about technology at the beginning of the trial. Novelty is a real psychological driver But as time went on, when the novelty wore off, when the fit issues became apparent, when the thermal discomfort during sustained use built up, when the donning and doffing became just another thing to manage, the enthusiasm dropped and so did the compliance. This is a challenge for long-term program sustainability. If compliance decreases over time, the protective effect decreases with it, and you've potentially built an ergonomics solution into your program that isn't actually being used. Let's move into problem four, risk transfer, not risk elimination. Here's one that concerns me most from a purely ergonomic standpoint. Exoskeletons are designed to offload specific muscle groups during specific movement patterns. Back support exoskeletons reduce erector spinae activation during forward bending. Shoulder exoskeletons reduce deltoid and trapezius activation during overhead work. That's just what they do. But the body is a system. When you reduce load on one structure, you can shift it to another. Research has noted that lower limb exoskeletons can increase knee muscle activity when the device positions the body in certain ways. The 2024 Applied Sciences review noted findings suggesting the sustained use with the knees in an excessively extended position may shift health risk from the back to the knees. In other words, you may solve the back problem and create a knee problem. There's a risk transfer. This is exactly the kind of unintended consequences that a thorough ergonomic risk assessment done before the device is ever employed and deployed would be designed to identify and anticipate. But if the exoskeleton is being used instead of a proper ergonomic assessment, you never find out until someone's knees start going. Let's jump into problem five, shall we? The over-reliance problem. This is the back belt situation. And This brings me to the similar situation I've been building towards. The CCOHS, the Canadian Center for Occupational Health and Safety, has published guidance on exoskeletons that explicitly address over-reliance. And I want to read a piece of this guidance directly because I think it's important. CCOHS guidance on exoskeleton state, Consider the potential for over-reliance on exoskeleton technology. One way to address this risk is developing policies stating that exoskeleton use is not an opportunity for increasing workload or productivity. And it is also important not to neglect other levels of hazard control. Exoskeletons should not be the only control measure used to create ergonomic work environments." And that's from twenty twenty-two. The second sentence is key here. Exoskeletons should not be the only control measure. They are not a substitute for engineering controls, for administrative controls, for job redesign. They are at best one layer in a multi-layered approach. But here's what I see happening. An organization has a lifting task with high MSD risk. Instead of evaluating whether the lift height can be adjusted, whether a mechanical assist is feasible, whether the load can be reduced or the frequency decreased, there's so many options here, right? As an ergonomist, you know you've implemented something like handle design or any sort of factor here. The issue is that someone, some company might buy exoskeletons instead. They check a box. They feel like they've done something, and they-- and the underlying ergonomic problem, the thing that actually causes the injury, goes unevaluated and unaddressed. The exoskeleton becomes the Band-Aid. And just like the back belt before it, it may create a false sense of protection that discourages the more thorough ergonomic intervention that the situation actually requires. In the nineteen nineties, back belts were adopted widely, quickly, without strong evidence because they felt like a logical solution. NIOSH told us they didn't work as injury prevention And we kept buying them anyway, millions per year, and many workplaces are still using them today. Are we about to do the same thing with exoskeletons? Are we going to spend the next decade deploying expensive technology that doesn't address root causes, while the underlying ergonomic problems accumulate, and then discover in 2035 that we needed to fix the job, not augment the worker? Am I right here? Let me know. Reach out to me and let's talk about this, because I sincerely hope not, but I think we need to be honest about the risk. I wanna be very clear about something. I am not anti-exoskeleton. I am pro-evidence, and I am pro doing the ergonomic work before you reach for the technology. Because here's the thing, most organizations that are considering exoskeletons have not exhausted, or in many cases even started, the basic ergonomic intervention hierarchy. And the basic hierarchy gives us tools that are often more effective, more durable, cheaper, and don't require charging. So let's talk about that. Let's dive into the hierarchy of controls, where exoskeletons actually fit. In occupational health and safety, we use the hierarchy of controls as a framework for evaluating and prioritizing interventions. From the most effective to least effective include engineering controls, administrative controls, behavioral controls, and personal protective equipment. Exoskeletons are functionally at the PPE end of this hierarchy, and probably some of the behavior as well,'cause you gotta remember to put those dang things on, right? They augment the worker. They do not change the job, the environment, or the hazard. They are the last lines of defense when we're talking about PPE, yet they are increasingly being deployed as a first response. Before any organization reaches for an exoskeleton, they should be asking,"Can we eliminate the lift entirely? Can it be automated? Can we substitute the task?" Like the use of a mechanical lift assist, a conveyor, a pallet jack with a lift table, anything like that. Can we engineer the hazard out? It could be adjust the height so that we're not lifting from the floor or pushing above shoulder height. Can we reduce the load weight? Can we change the carrying distance? There's so much opportunity there. Maybe we can administer it differently. Can we rotate workers? Can we reduce the frequency or build in recovery time? Or maybe train the proper technique, and I know that's like a worker behavior, but using the right technique is important, too. These interventions are significantly cheaper than an exoskeleton fleet, significantly more effective at reducing the root cause risk, and don't carry the concerns around compliance, donning time, risk transfer, or long-term deconditioning. A lift table that costs$2,000 and raises a pallet to a working height eliminates the hazardous lift zone entirely. An exoskeleton costing 4 to$8,000 per unit still requires the worker to perform the lift, just with some muscle offloading. Which of those is a better ergonomic intervention? In most cases, it's the lift table every time. So let's talk about the discomfort survey as your starting point. And if you're an ergonomist consultant working with an organization that is eyeing exoskeletons, I want to encourage you to slow them down and start with a proper needs assessment. That discomfort survey is one of the most powerful, yet underused tools we have. And before you decide what intervention to deploy, you need to know where the risk actually lives. Which body parts? Which tasks? How much risk? Which departments? Which shifts? A discomfort survey is a really good starting point However, you still have to do a thorough ergonomics risk assessment. That will give you a clear direction forward about which intervention will be the most valuable for that organization. If you implement an exoskeleton without a baseline, without a pre-intervention score with regards to ergonomics risk or a thorough assessment with discomfort or even an evaluation of the previous injury rates and near-miss rates in that area, you absolutely have no way to know whether it worked or not. And when the contract comes up for renewal, you might have nothing to show here. So I want to encourage you to do the assessment first. If you need help with walking through an industrial ergonomic assessment, reach out to me. I'm more than willing to help you. I've been pushing on the limitations and the risks for most of this episode, so I want to be clear about where I think exoskeletons genuinely add value, because there are contexts here. Exoskeletons make the most sense in environments where the ergonomic risk has been thoroughly assessed and engineering and administrative controls have been genuinely exhausted, not just considered and dismissed, but actually evaluated and found to be infeasible. The task is highly repetitive, sustained, and involves specific body regions that can be effectively supported by an available device. Sustained overhead work and shoulder fatigue is a good example where a shoulder exoskeleton can provide real relief for tasks like wiring, painting, or assembly where the elevation requirement is genuinely fixed. The task profile is consistent enough that the device can be worn for meaningful periods without needing to be removed for task switching. The donning and doffing burden needs to be manageable for the device to actually be used. The workforce population fits the anthropometric range of the device and can be properly fitted. A device that doesn't fit properly is not just ineffective, it's potentially a hazard in itself. There's a full evaluation and follow-up plan in place. Discomfort surveys, before and after assessment scores compliance tracking, adverse event monitoring, and a defined review point to assess whether the device is working. I think about certain surgical environments, highly specialized industrial tasks, specific rehabilitation contexts. These are places where exoskeletons can be genuinely valuable. I think about them much less when a company has a high volume picking operation with variable load weights, multiple task types, production pressure that creates time stress, and hasn't yet evaluated whether the pick heights can be adjusted or whether some of the heaviest picks can be mechanically assisted. In that situation, an exoskeleton is not the answer. A proper ergonomic assessment is the answer. So here's where I land on this. Exoskeletons are an interesting technology with real but context-dependent benefits. The research shows measurable muscle offloading in specific tasks. The research also shows meaningful barriers to adoption concerning risk transfer patterns, a growing concern about long-term reliance, and a body of evidence that is still heavily dominated by short-term, small sample size, and laboratory-based studies. We are not yet at the point where we can say exoskeletons are a proven, generalizable, first-line intervention for workplace MSD prevention. What we can say is that they may be a useful component of a layered ergonomics program for specific tasks and environments when they follow, not replace, a proper ergonomic risk assessment. The back belt story should be a warning, not because exoskeletons are the same device, they're not, but because the pattern is the same. Intuitive feeling technology, rapid adoption, limited evidence, and a tendency to use them as a substitute for the harder, more substantive work of actually fixing the job. As ergonomic professionals, our job is to advocate for that harder work, the risk assessment work. Not because we're anti-technology, because we're pro-evidence, and because the worker who goes home without a back injury deserves an intervention that was based on a thorough evaluation of their actual work, not on what was available in the procurement catalog. I wanna highlight again to fix that job first. Then, if the job has been as fixed as it can be, bring in technology. That's what I've got for you today. if this episode sparked some thinking, some questions about how you're approaching assessments in your own practice, or how you're advising clients on specific decisions, I'd love to hear from you. And if you're ready to learn how to make office ergonomics work and how to build an ergonomic assessment service that is grounded on proper clinical reasoning and sound ergonomic science, the Ergonomics Blueprint is where to start. Head to ergonomicshelp.com. I'll have the details in the show notes for more. Thank you so much for listening. I'll see you in the next one.