The use of exoskeletons in the occupational context for primary, secondary, and tertiary prevention of work-related musculoskeletal complaints

OCCUPATIONAL APPLICATIONS

This guideline includes 20 recommendations and four key statements that achieved consensus or strong consensus regarding the application of exoskeletons in the workplace for the prevention of musculoskeletal complaints and diseases, the general use and implementation of exoskeletons, and recommendations for risk assessment. The guideline is intended for company physicians, occupational physicians, ergonomists, occupational safety specialists, and employers, and serves as information for all other actors in practical occupational safety. Due to the lack of evidence from the scientific literature, the recommendations and key statements are the result of expert discussions that were conducted at a consensus conference in accordance with the Regulations of the Association of the Scientific Medical Societies in Germany, moderated by an external consultant.

TECHNICAL ABSTRACT

Background

The prevention of work-related musculoskeletal complaints and diseases has high priority, considering the prevalence of musculoskeletal complaints and diseases and the associated high burden on health care systems, the economy, and the people affected. Purpose: This guideline provided recommendations for potential applications of exoskeletons in the workplace for the primary, secondary, and tertiary prevention of musculoskeletal complaints and diseases, general recommendations on the use and implementation of exoskeletons, and recommendations on risk assessment. Methods: A systematic literature search, a survey among exoskeleton manufacturers and companies using exoskeletons, and expert discussions formed the basis of the formulated recommendations and key statements. For reaching consensus on the recommendations and key statements, we applied the Nominal Group and Delphi Techniques under the supervision of an external, independent moderator. Results: We formulated 20 recommendations and four key statements, all of which reached consensus or strong consensus. Conclusion: No answers could be found in the current scientific literature to the central questions in this guideline about primary, secondary, and tertiary prevention. We outline five main directions for future research on exoskeletons in occupational settings. First, using exoskeletons for prevention should be investigated using randomized controlled trials. Second, the effects of exoskeletons on work-related musculoskeletal stress and strain should be investigated both in the body region intended to be supported by the exoskeleton as well as in other non-supported body regions. Third, the effects of exoskeletons should be investigated in samples varying in age, gender, and health status, as well as during different occupational activities. Fourth, a specific risk assessment tool for exoskeletons in occupational settings should be developed and implemented to meet and evaluate the applicable occupational health and safety standards. Fifth, there is a need to expand upon the very limited social science research on the impacts of exoskeletons on employee professional understanding, social role understanding, or diversity.

Keywords:

• Literature review
• musculoskeletal disorders
• workload
• musculoskeletal stress
• musculoskeletal strain
• assistive device

Acknowledgements

We would like to thank Dr. Susanne Blödt, consultant from the Association of the Scientific Medical Societies in Germany (“Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.”; AWMF), for providing methodological support during the preparation of the guideline, in particular for providing information on the guideline procedure and for moderating the Nominal Group Technique during the consensus conference.

Conflict of Interest

All authors of the current guideline provided their declarations for conflict of interest in written form by a standard form provided by the Association of the Scientific Medical Societies in Germany (“Arbeitsgemeinschaft der Wissenschaftlichen Medizinischen Fachgesellschaften e.V.”; AWMF). The declarations were summarized by the guideline coordinators (BS, TL), jointly reviewed during the consensus conference (October 1, 2019) and classified according to the criteria of the AWMF as low, moderate or high. This process was guided by a representative of the AWMF (Dr. Susanne Blödt). A moderate or high conflict of interest meant exclusion from voting on the guideline’s recommendations and key statements. Twice a moderate conflict of interest was identified; however, both mandate holders concerned were not present when the recommendations and key statements were voted on. The conflicts of interest are summarized and provided in the original German Guideline to ensure a high degree of transparency (Steinhilber et al., 2020).

Funding

The work of the mandate holders and consultants was done on a voluntary basis or at the expense of the respective professional association, institution or the respective employer. The financial resources for the moderation (1^st physical guideline meeting at July 24, 2018 and consensus conference at October 1, 2019) as well as the personnel resources for the guideline coordination (BS, TL) were provided by the Institute for Occupational and Social Medicine and Health Services Research of the University Hospital Tübingen, Germany. The rooms and catering were provided by the Institute for Occupational and Social Medicine and Health Services Research of the University Hospital Tübingen in Tübingen, Germany (1^st physical guideline meeting), the German Social Accident Insurance Institution for the Trade and Logistics Industry in Mannheim, Germany (2^nd physical guideline meeting), the German Social Accident Insurance Institution for the Woodworking and Metalworking Industries in Mainz, Germany (3^rd physical guideline meeting) and the BG University Hospital Bergmannsheil GmbH in Bochum, Germany (consensus conference).