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VOLUME 7, ISSUE 1 

 2024 
 

REVIEW ARTICLE 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 

Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

 

https://jps.library.utoronto.ca/index.php/cpoj/index
mailto:cpoj@online-publication.com
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https://publicationethics.org/members/canadian-prosthetics-orthotics-journal
https://doi.org/10.33137/cpoj.v7i1.43827


 

1 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

 

 

REVIEW ARTICLE 

 

ACTIVE, ACTUATED, AND ASSISTIVE: A SCOPING REVIEW OF EXOSKELETONS FOR THE 

HANDS AND WRISTS 

Galbert A, Buis A*  

Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow, Scotland. 
 
  
 

 

 

 

  

 

 

 

 

 

 

 

 

 

 

INTRODUCTION   

Upper limb impairment, resulting from a range of factors 

such as injury, neurological disorders, diseases, conditions, 

and general comorbidities, can have a profound and 

detrimental impact on an individual's overall quality of life.1 

This impairment often leads to significant limitations in 

physical activity2,3 and can contribute to mental health 

challenges, due to the loss of independence and 

functionality.4 Symptoms such as muscle weakness, 

reduced muscle control, neurological issues, and 

prehension difficulties vary in severity and permanence.  

 

 

Due to this variability, a one-size-fits-all approach is 

inadequate. Tailored rehabilitation programs and assistive 

interventions must be designed to accommodate the 

specific requirements of individuals, enabling them to 

perform activities of daily living (ADLs) more effectively and 

improving their overall well-being. 

Spasticity, muscle weakness and prehension difficulties 

affect the upper limb differently. Spasticity is defined as 

velocity-dependent resistance,5 due to this muscle 

contracture, impaired control of voluntary hand-opening 

tasks and activities is seen.4 In contrast, muscle weakness 

affects hand-closing tasks such as grasping utensils and 

opening doors. The hands are the only prehensile organ in 

the human body.6 Prehension is required for feedback 

during tasks and coordination, therefore reduced 

prehension disrupts the balance between power and 

precision requirements of dexterous tasks.7 When a person 

receives no feedback during functional tasks, they may be 

 
OPEN  ACCESS 

ABSTRACT 

BACKGROUND: Assistive technology is often incorporated into rehabilitation and support for those impacted 

by upper limb impairments. When powered, these devices provide additional force to the joints of users with 

muscle weakness. Actuated devices allow dynamic movement compared to splints, therefore improving the 

ability to complete activities of daily living. However, these devices are not often prescribed and are 

underrepresented in research and clinical settings. 

OBJECTIVE: This review examined the existing literature on devices developed to support hand and wrist 

functionality in daily activities. Focusing on active, powered, and actuated devices, to gain a clearer 

understanding of the current limitations in their design and prescription. 

METHODOLOGY: The scoping review was conducted using the PRISMA-ScR guidelines. A systematic 

search was done on MEDLINE, EMBASE, Scopus, Web of Science, and NHS the Knowledge Network from 

inception to May 2023. Articles were included if the device was portable; supported the hands and wrist 

actively using an actuator; and could be used for assistive living during or post-rehabilitation period. 

FINDINGS: A total of 135 studies were included in the analysis of which 34 were clinical trials. The design 

and control methods of 121 devices were analyzed. Electrical stimulation and direct mechanical transmission 

were popular actuation methods. Electromyography (EMG) and joint movement detection were highly used 

control methods to translate user intentions to device actuation. A total of 226 validation methods were 

reported, of which 44% were clinically validated. Studies were often not conducted in operational 

environments with 69% at technology readiness levels ≤ 6, indicating that further development and testing is 

required.    

CONCLUSION: The existing literature on hand and wrist exoskeletons presents large variations in validation 

methods and technical requirements for user-specific characteristics. This suggests a need for well-defined 

testing protocols and refined reporting of device designs. This would improve the significance of clinical 

outcomes and new assistive technology.   

ARTICLE INFO 

Received: August 12, 2024 

Accepted: October 31, 2024 

Published: November 8, 2024 
 

CITATION 

Galbert A, Buis A. Active, 

actuated, and assistive: A scoping 

review of exoskeletons for the 

hands and wrists. Canadian 

Prosthetics & Orthotics Journal. 

2024; Volume 7, Issue 1, No.9. 

https://doi.org/10.33137/cpoj.v7i1

.43827 

KEYWORDS 

Upper Limbs, Exoskeletons, 

Assistive Devices, Wearable 

Devices, Design, Actuators, 

Outcome Measures, Systematic 

Review, Daily Activities, Wrist, 

Electromyography, Hand.  

Please refer to the end of the 

article for a list of Abbreviations. 

 

* CORRESPONDING AUTHOR: 

Professor Arjan Buis, PhD 

Department of Biomedical Engineering, Faculty of Engineering, University 
of Strathclyde, Glasgow, Scotland. 

E-Mail: arjan.buis@strath.ac.uk 

ORCID ID: https://orcid.org/0000-0003-3947-293X 

Journal Homepage: https://jps.library.utoronto.ca/index.php/cpoj/index 

Volume 7, Issue 1, Article No.9. 2024 

 

 

https://doi.org/10.33137/cpoj.v7i1.43827
https://doi.org/10.33137/cpoj.v7i1.43827
https://doi.org/10.33137/cpoj.v7i1.43827
mailto:arjan.buis@strath.ac.uk
https://orcid.org/0000-0003-3947-293X
https://jps.library.utoronto.ca/index.php/cpoj/index


 

2 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 
unable to gauge if they have optimal hand orientation or 

enough strength to hold an item. Hand and wrist 

impairments of all types target a person’s ability to perform 

ADLs.   

In addition to performing ADLs, biopsychosocial factors are 

also impacted by hand impairment.8 The biopsychosocial 

model is a concept which allows for the classification of 

factors which may contribute to any individual’s mental and 

physical health.9-11 The psychological impact of hand 

impairment can be presented as distress, depression, and 

low self-efficacy. Persons with hand impairments have also 

shown a reduction of measures determining quality of life.2 

Sense of freedom, belonging and security are major social 

factors affected by having upper limb impairment.8 These 

people may also have reduced independence and may rely 

on family, caregivers, and allied health professionals for 

support. The biopsychosocial factors mentioned introduce a 

global burden on resources, cost, time and availability of 

support.12-14 Fortunately, assistive technology may reduce 

that burden while also attaining sustainable development 

goals for the future ageing population affected by these 

impairments.15,16  

To facilitate upper limb functional tasks, interventions such 

as rehabilitation and assistive technology may be provided. 

The objective of assistive technology is to ensure safety, 

and accessibility, promote independence and improve 

quality of life. To achieve these objectives, devices must be 

tailored to the user’s requirements. For users who require 

augmented strength and functionality to perform tasks, a 

powered and actuated device would be appropriate. 

Examples of active devices include exoskeletons and 

exosuits.17 The introduction of actuators makes the device 

active, compared to passive devices that use elastics, 

levers and springs to support user motion such as dynamic 

orthosis. These devices function by applying force from an 

actuator on segments of the upper limb. Actuators are 

devices which convert energy to motion; this energy may be 

electric such as DC motors. Depending on the position and 

power of the force applied to the upper limb, the device can 

assist in various functional tasks.  

The evolution of upper limb assistive devices has had rapid 

advancements in technology. It has grown in popularity 

within the commercial sector as workplace health and safety 

systems, and as stationary end-effector devices within 

physical rehabilitation settings.18 Despite the advantages of 

using these devices,16,19,20 the National Service Framework 

for Long-Term Conditions and Clinical Commissioning 

Groups (national to the United Kingdom) have minimal to 

absent policies for using these motorized devices.21 The 

rationale behind this regulatory stance is uncertain. 

However, global reports on assistive technology have 

postulated several factors for the general lack of 

prescription of assistive devices including limited-service 

provision, inadequate products, market shortcomings, 

governance and funding constraints, as well as 

sociodemographic barriers.16 These factors may apply to 

actuated devices, but these reports16,21 do not focus on 

actuated devices.  

Furthermore, literature reviewing the upper limb 

exoskeletons rarely discusses the hands and wrist 

segments,18 and of those which have, there is a lack of 

breadth on clinical utility and outcome measures.17, 20, 22, 23 

Based on the gaps in global reports and review literature, a 

study summarizing actuated devices would be appropriate.  

This scoping review aimed to explore the research question: 

What is known about active actuated and assistive devices 

for the hands and wrist? The secondary objectives include: 

1) Defining the intended populations of these devices, 2) 

Abstracting an overview of the device design: including 

modes of actuation, user intention methods and force 

transmission methods, 3) Summarize and categorize 

validation strategies used in the study of these devices. 

METHODOLOGY 

A scoping review summarizing the breadth of existing 

literature concerning active, actuated (powered and 

motorized) and assistive (provides support during functional 

tasks) devices designed for the hands and wrists was 

conducted. The scoping review offers a methodological 

approach to survey the evidence, key concepts, and 

analyze knowledge gaps.24-27 This may illuminate potential 

rationales for the underrepresentation of hand and wrist 

assistive devices in literature. It may also ascertain if the 

barriers outlined in the global report on assistive 

technology16 apply to actuated devices.  

A scoping review was chosen as it maps out the extent of 

existing research on a broad topic. For this study, it is active 

assistive devices for hand and wrist actuation. Scoping 

reviews have more inclusive eligibility criteria compared to 

systematic reviews. This encourages the use of larger 

sources of literature, more time-effective analysis, and 

provides evidence for future systematic reviews. 

This scoping review follows the Preferred Reporting Items 

for Systematic Reviews and meta-analysis extension for 

Scoping Reviews (PRISMA-ScR).28 This extension is an 

update from the PRISMA guidelines which is a validated 

systematic approach for evidence syntheses.24 The search 

criteria for the database were structured according to 

Population, Concept, Context (PCC) framework.29 The 

population was defined as individuals experiencing hand 

and/or wrist impairment. The concepts focused on devices 

with active actuation and power. The context encompassed 

devices which assist ADLs during and post-rehabilitation. 

The definition of post-rehabilitation in this study refers to the 

phase of recovery and support that follows an initial 

rehabilitation program.  

 

https://doi.org/10.33137/cpoj.v7i1.43827


 

3 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 
Database Search 

Five databases were searched from inception to the date of 

search (May 25th, 2023). The databases selected were 

MEDLINE (Ovid), EMBASE (Ovid), Scopus, Web of 

Science, and NHS the Knowledge Network. No limitations 

or filters were applied to the results during the systematic 

database search. These databases were chosen based on 

their optimal combination, and collectively satisfy the 

minimum requirement of databases necessary to ensure 

adequate and efficient coverage of studies.30,31 Search 

terms were combined with Boolean logic ((Hand OR hands 

OR extremity) AND (Wrist OR wrists OR carpus) AND 

(Device OR devices OR assistive devices OR actuated 

devices OR powered devices OR exoskeleton OR glove OR 

dynamic) AND (Functional OR function OR assist OR 

assistive OR assistance OR aid OR aiding OR support)). 

Database search results were imported to Endnote v20 in 

an RIS file format. Duplicates and retractions were removed 

using Endnote v20 software.  

Selection Criteria  

Two screening processes were used: The first examined 

titles and abstracts for all papers on Microsoft Excel 2018 

Version 2409. The inclusion criteria were “Is this an active, 

actuated, and assistive device for the hands and wrist?”. 

Papers were marked “include”, “exclude”, “duplicate” and 

“maybe”. The process of tagging studies was conducted by 

2 reviewers with 86.9% agreement, and any disagreements 

were resolved with consensus. All studies tagged as 

duplicates were checked to ensure a version was kept 

within the dataset. The second screening process examined 

the full paper against the inclusion criteria shown in Table 1. 

The studies were tagged with include or exclude using these 

criteria.  

Data Extraction 

A total of 24 data items were charted independently by 

researcher AG. The full list of data charting items collected, 

and their definitions can be found in Table 2. Records from 

the same research group were considered individually if the 

devices described were mechanically different from each 

other, whereas articles regarding different iterations of the 

same device were grouped with the latest prototype 

iteration considered. For records using the same device, the 

most representative across all papers was chosen. 

The data charting items provided a comprehensive 

summary of participants demographic features, 

interventions, validations, and technology readiness levels 

(TRLs) of the included studies. Participants demographics 

include country, the sum of participants, gender, age, and 

patient conditions (if applicable). The intervention 

comprises device name, weight, degree of freedom (DoF), 

mechanical transmission, user intent/detection methods, 

and limb segment the device supports. The synthesis of 

validation includes both clinical outcome measures and 

non-clinical. TRLs were also part of the data extraction and 

can be analyzed against all data items to investigate 

potential trends in technological advancements. 

RESULTS 

Overview 

A total of 5,588 records were identified from the initial 

database search conducted in May 2023, of which 135 

studies were included in the scoping review dataset.32 The 

selected studies were published between 1995 to 2023  

(m = 2016, SD = 6.64), with 54% (73/135) studies published 

in the last 5 years. The selection process is provided in 

Figure 1. Two publications were identified and retracted 

using EndNote software.  

The most popular methodology used an experimental 

design (25%, 34/135), followed by feasibility studies (21%, 

28/135). Clinical methodologies, such as RCTs 

(Randomized Control Trials, n = 12) and single group trials  

(n = 12), made up 34% (46/135) of the dataset.  

Thirty-one countries contributed to the field of hand and 

wrist exoskeletons. Of which, the USA (20%, 27/135), China 

(16%, 21/135), Japan (12%, 16/135), Italy (8%, 11/135) and 

South Korea (6%, 8/135) produced the highest number of 

studies.  

 

Table 1: Exclusions Criteria for Second Screening. 

Decision Tag  Exclusion Criteria  Additional Notes  

Reason 1:  Is the device mobile?   
Devices grounded to static tables are excluded, but devices mounted to wheelchairs are included as it is 
mobile.  

Reason 2:  
Does the device actively support 
hand and/or wrist movement?  

Devices which immobilize joints are excluded. Devices which support the wrist in a static position and do 
not support hand movement are also excluded. 

Reason 3:  Is this a complete system?  A complete system must include hardware and software.  

Reason 4:  Does the device support ADLs?   
If the hand and wrist are put in a static position, it can be assumed ADLs are not being completed and 
therefore excluded. Devices which train the hand/wrist for ADLs are included.  

Reason 5:  
Is the study primary research and 
not a review?  

Excludes all reviews; examples include systematic, scoping, narrative, and state-of-the-art reviews.   

Miscellaneous: Access to full paper in English   
Excludes research posters, published abstracts, and conference abstracts. Excludes papers not provided 
with English translation.   

 

https://doi.org/10.33137/cpoj.v7i1.43827


 

4 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 

 

Table 2: List of all data items collected, and their definitions. 

Data Item  Definition  

Title  Title of the article as found in the database. 

Reference ID Reference number linked to list of all referenced in the dataset. 

Author  List of all authors. 

Year  The year the article was published.  

Country of Study   The country of study is either given based on the institution or location of the clinic of the affiliated author. 

Study Type  
The study type was defined by the publisher. Options cited include articles, research papers, case reports, letters, and pilot 
studies.  

Method  Methodology of the study.  

Sum of Participants  The sum of the participants in the study.   

Male  The sum of male participants (when provided).  

Female  The sum of female participants (when provided).  

Age Range  Based on the participants, the youngest to oldest participants make the age range.   

Target Population  The intended population/user group for the device.  

Grouped Target  
Population  

To reduce variations in a target population, the grouped target was separated into 22 subgroups with 13 unique groups that 
were often combined:   

• Autoimmune Disease  

• Cardiovascular Disease (CVD)/Stroke 

• Entrapment Neuropathy  

• Healthy  

• Joint Disorder 

• Muscular Dystrophy  

• Musculoskeletal Impairment  

• Musculoskeletal Injury  

• Neurological Disorder 

• Sarcopenia 

• Spinal Cord Injury (SCI) 

• Traumatic Brain Injury (TBI)  

• Tremor 

Study Population  The condition of the participants in the study.   

Device  Name of the device if provided.   

Weight of Device (g)  Weight of the device on the upper limb unless specified otherwise.  

DoF (Degree of  
Freedom)  

DoF of the entire device refers to the number of independent ways the mechanical transmission can move joints in the 
hand/wrist.   

Mechanical  
Transmission  

Method of applying active force from an actuator to the joint of the user.  

Grouped Mechanical 
Transmission 

To reduce variations in mechanical transmissions, sub-classes were  
Grouped into 6: 

• Cable-Conduit: These systems use cables or flexile wires inside a conduit. They transmit force in push or pull 
motions, like a brake cable on a bicycle. 

• Direct: These systems transfer force directly to the joint segment, for instance, a linear actuator may push the 
wrist into flexion. 

• Fluidic Transmission: Commonly hydraulic or pneumatic, these systems use pressurized fluids in a tube to 
control movement. 

• Muscle Contraction: To induce movement, electrical stimulation is used to contract (shorten) the muscle. The 
placement of electrical stimulation triggers various joint movements. 

• Pulley: As a motor turns, the pulley system amplifies the force and moves the joint segment attached to the 
system.  

• Supernumerary: These systems include extra robotic limbs such as fingers or hands. These devices aid in 
functional tasks by providing additional force.   

Hand/Wrist  Is the device aimed to support the hand, the wrist, or the hand and wrist together? 

User Intent/Detection 
Methods  

The user intent/detection methods are how the device is controlled. The user will actively trigger the device, this can be by 
using a joystick, by contracting muscles, and many more.  

Outcome Measures   All outcome measures and outcome measurement tools that were used in the study.  

Technology Readiness 
Level (TRL) 

The TRL was assigned according to the TRL definition provided by the HORIZON 2020 - Work Program 2014-2015 defined 

in Table 4. The TRL is a scale used to measure how developed and ready a technology is for practical use. 

Outcome Measure  
Field  

The outcome measures were separated into clinical, technical, or clinical and technical measures. Clinical outcomes focus on 
the patient’s health and quality of life, technical outcomes focus on the functionality and performance of the device. 

Classification of outcome measures was aided by the WHO ICF Model.11 

 

https://doi.org/10.33137/cpoj.v7i1.43827


 

5 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 

Following the World Development Indicators for income 

classification,33 3 studies were completed in Low-Middle 

Income Economies,34-36 31 in Upper-Middle Income and 

101 in High Income. The correlation (r) between the number 

of studies published per country and the sum of participants 

was foreseeably high (r=0.867). An outlier to this trend is 

one study from Russia by Abramovich et al,37 which 

included 96 participants. This was also the second largest 

sum of participants in one study, with the largest sum of 

participants in a study conducted by Takebayashi et al with 

115 participants.38 

Participants 

The sum of participants within the dataset totaled 1310. Of 

the 1310 participants (female: male 39%:61%), 46% 

(597/1310) had upper limb impairment due to stroke, 28% 

(371/1310) have been affected by Spinal Cord Injury (SCI) 

in the form of tetraplegia, hemiparesis, or hemiplegia, and 

11% (140/1310) were considered healthy. The least 

reported conditions for support included persons with 

Cerebral palsy40 with 19 participants, upper limb tremors34,41 

with 20 participants, Parkinson's disease36 with 10 

participants, and support post-burns42 with 20 participants.  

Of the 39 studies which recruited healthy participants solely, 

two devices43,44 were intended for human augmentation in 

healthy user groups. Age of participants ranged from 12-83 

years old: two studies45,46  included a device for non-adults.  

Intervention 

In all, 121 devices were presented within the studies. A 

summary of the devices is presented in Table 3. Devices 

were categorized by their Weight (g), Degree of Freedom 

(DoF), Power Transmission, Mechanical Transmission, 

segment of support (Hand and or Wrist) and User intent. Of 

the target support joint, 37% (45/121) of devices supported 

hand actuation, 36% (44/121) supported both the hand and 

wrist and 26% (32/121) supported wrist actuation only.  

 

Figure 1: PRISMA Flowchart of database search, inspired by PRISMA2020.39 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Identification of studies via databases 

D
a

ta
b

a
s
e

s
 

S
c
re

e
n

in
g

 

Records identified: 

MEDLINE (n   1   1) 

EMBASE (n   1 2 2) 

Scopus (n   1   4) 

Web of Science (n   1 211) 

NHS (n   200) 

Records removed before screening: 

Duplicate records (n   1   1) 

Records retracted (n   2) 

Records excluded (n     201) 

Records not retrieved (n   11 ) 

Records screened (n   4 0  ) 

Records sought for retrieval  

(n     4) 

Records assessed for 

eligibility  

(n      ) 

Studies included in review (n   1  ) 

Records e cluded: 

Reason 1: Not wearable and portable (n      ) 

Reason 2: Not a hand and/or wrist device (n     ) 

Reason 3: Not a complete system (n   1  ) 

Reason 4: Does not support ADLs (n   1 ) 

Reason 5: Review (n   2 ) 

In
c
lu

d
e

d
 

https://doi.org/10.33137/cpoj.v7i1.43827


 

6 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 

 

Table 3: Summary of devices analyzed. 

Device name Reference 
Weight of 
Device on 
Arm (g) 

DoF 
Power 

Transmission 
Mechanical 

Transmission 
Hand/ Wrist User Intent 

2-channel portable battery-
47operated FES system 

47 - 3 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

3-CRP 48 2700 3 DC motors Direct 
Hand and 

wrist 
Concurrent 
movement 

4-DOF wheelchair 
exoskeleton and Carbon 
hand 

49 4000 4 
Maxon DC 

motor 
Cable and gear 

Hand and 
wrist 

Joint position 
and tactile 

A5 hand function training 
system 

42 - 6 Linear actuator Bar linkage 
Hand and 

wrist 
Muscle torque 

Anthropomimetic upper limb 
assistive device 

35 - 12 DC motors Pulley 
Hand and 

wrist 
Manual 

selection 

Armeo Power II 50 205000* 7 Motors Gears Wrist Joint torque 

Attention-controlled wrist 
rehabilitation method 

51 415 2 Linear actuator Push-pull cable Wrist EEG signal 

BOTAS 52 - 6 
Electrical 

stimulation 
Direct 

Hand and 
wrist 

EMG signal 
and EEG signal 

BRIDGE EMPATIA 53 - 5 Stepper motor Bar linkage Wrist 
Manual 

selection 
(joystick) 

DiaDENS-PKM 54 350 - 
Electrical 

stimulation 
Muscle 

contraction 
Wrist EMG signal 

Distributed FES and 
Assessment System 

55 - 2 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 

Concurrent 
EMG signal 
and finger 

angle 

DTF Splint 56 - 1 
Pneumatic 
actuator 

Pneumatic Hand 
Manual 

selection 

DTSaM Orthosis 57 - 2 
Pneumatic 
actuator 

Pneumatic Wrist Joint angle 

DULEX-II 58 504 3 
pneumatic and 
linear actuator 

Pneumatic 
Hand and 

wrist 
concurrent 

EMG 

Electrical stimulation 59 - - 
Electrical 

stimulation 
Muscle 

contraction 
Wrist 

Manual 
selection 

Electromechanical orthosis 
and MyoSystem BrI system 

60 - 2 DC motors Pulley 
Hand and 

wrist 
EMG 

EMG-driven 
exoneuromusculoskeleton 

61 368 - 
Pneumatic 
actuator 

Pneumatic Hand Muscle torque 

EMG-driven NMES-robotic 
arm 

62 - - 
DC servo 
motors 

Direct Wrist EMG signal 

EMG-Driven NMES-Robotic 
Hand 

63 - 4 Linear actuator Bar linkage Hand EMG 

EMG-driven WH-ENMS 64 - 5 
Pneumatic 
actuator 

Pneumatic 
Hand and 

wrist 
EMG 

Emotiv EPOC and 
Rehastim 

65 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EEG signal 

Empi FOCUS 66 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
Manual 

selection 

EMS 400 and Ultraflex 40 - 2 
Electrical 

stimulation 
Muscle 

contraction 
Wrist 

Manual 
selection 

Energy-efficient wrist 
exoskeleton 

67 - 1 
Pneumatic 
actuator 

Pneumatic Wrist Joint angle 

ETS-MARSE 68 7072 7 
Brushless DC 

motors 
Gears Wrist Muscle torque 

eWrist 69 556 1 
Brushless DC 

motors 
Gears Wrist 

Joint angle and 
EMG signal 

ExoFinger 70 - 2 
DC servo 
motors 

Bar linkage Hand 

EMG signal, 
Finger 

temperature 
and Joint angle 

EXOTIC upper limb 
exoskeleton and ITCI and 
Carbon hand 

71 6000 4 
Maxon DC 

motor 
Cable and gear 

Hand and 
wrist 

Manual tongue 

Exo-Wrist 72 1003 2 Rotary encoder Pulley Wrist Muscle torque 

EXTEND exoskeleton 73 105 3 Linear actuator Bowden cable Hand 
Manual 

selection 

Fesia grasp Device 74 91 8 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

FESMATE CE1230 75 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG 

 

 

https://doi.org/10.33137/cpoj.v7i1.43827


 

7 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 

 

Table 3 (continued): Summary of devices analyzed. 

Device name Reference 
Weight of 

device on arm 
(g) 

DoF 
Power 

Transmission 
Mechanical 

Transmission 
Hand/ Wrist User intent 

FESMED 4050 device 76 200 - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
Manual 

selection 

Five-digit 3D printed 
battery-powered and force 
augmenting orthotic 
exoskeleton 

77 - - Linear actuator Cable Hand Muscle torque 

Five-fingered exoskeleton 
hand 

78,79 2000 3 DC motors Bar linkage 
Hand and 

wrist 
EMG and wrist 

joint angle 

Flexohand 80 280 6 
DC servo 
motors 

Bowden cable Hand 
Manual 

selection 

Foot-controlled 
hand/forearm exoskeleton 

81 - 4 
DC servo 
motors 

Pulley 
Hand and 

wrist 
Manual Foot 

selection 

GBBAs 82 95 3 
Pneumatic 
actuator 

Pneumatic Hand 
Joint angle and 
muscle torque 

Gloreha lite glove 83 80 5 
Pneumatic 
actuator 

Pneumatic Hand 
Manual 

selection 

Glove-based assistive 
device 

84 - 2 
Pneumatic 
actuator 

Pneumatic Wrist 
Wrist 

movement 

GraspyGlove 85 340 4 
Maxon DC 

motor 
Push-pull cable Hand 

Sensor 
proximity 

Hand assistive device 86 - 1 Linear actuator Bowden cable Hand 
Muscle torque 

(index) 

Hand exoskeleton 87 114 3 DC motors Bowden cable Hand 
Joint angle and 
muscle torque 

Hand exoskeleton system 
HES 

88 350 2 
DC servo 
motors 

Bar linkage Hand Manual hand 

Hand function rehabilitation 
robot 

89 450 2 Linear actuator Bar linkage Hand 
Manual hand 

(touch screen) 

Hand/Wrist exoskeleton 90 1815 7 
DC Torque 

motor 
Bar linkage Hand 

EMG and joint 
motion 

HANDS therapy 91,92 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

Hybrid system 93 402 5 Linear actuator Bar linkage Hand 
EMG signal 

and EEG signal 

Hybrid-driven compliant 
hand exoskeleton 

94 147 - 
DC Torque 

motor 
Cable Hand Finger torque 

Implanted sensor-controlled 
microstimulator system 

95 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

INTFES 96 170 - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

intracortical MEA-BCI-FES 97 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EEG signal 
(Implant) 

IOTA 98 230 2 
DC servo 
motors 

Cable Hand Manual hand 

Layer jamming-based soft 
Tremor Suppression Glove 

34 30 6 
DC servo 
motors 

Hydraulic Hand Tremor 

MAH system 99 580 6 
DC servo 
motors 

Supernumerary Hand Wrist angle 

MAHI Exo-II 100,101 340 4 DC motors Bar linkage Wrist 
Manual 

selection 

MeCFES 102 - 2 
Electrical 

stimulation 
Muscle 

contraction 
Hand EMG wrist 

MeFES 103 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

Mirror hand HS 001 104 800 5 Motors Bar linkage Hand 
Mirrored 
motion 

Mirror-image motion device 
with an exoskeleton 

105 1800 3 
Brushless DC 

motors 
Cable Wrist 

Mirrored 
motion 

Motor orthotic device 106 - 1 
Ultrasonic 

motor 
Gears Wrist EMG signal 

MWDO 107 330 2 DC motors Bar linkage 
Hand and 

wrist 
Wrist torque 

 

 

https://doi.org/10.33137/cpoj.v7i1.43827


 

8 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 

 

Table 3 (continued): Summary of devices analyzed. 

Device name Reference 
Weight of 

device on arm 
(g) 

DoF 
Power 

Transmission 
Mechanical 

Transmission 
Hand/ Wrist User intent 

Myoelectric control 108 - 2 
Electrical 

stimulation 
Muscle 

contraction 
Wrist EMG 

MyoPro 109-112 1814 2 Motors Direct 
Hand and 

wrist 
EMG signal 

NESM and 5-DOF wrist-
hand exoskeleton 

113 - 9 DC motors Bar linkage 
Hand and 

wrist 
Joint position 

NESS handmaster system 114-116 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand 

Manual 
selection 

Neuro-orthosis 117,118 - 2 
Electrical 

stimulation 
Muscle 

contraction 
Wrist Joint angle 

NMES-robot arm 119 895 2 
DC Torque 

motor 

Muscle 
contraction and 

direct 
Wrist 

EMG signal 
and NMES 

signal 

Odstock 2-channel 
Programmable Stimulator 

120 200 - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

Paediatric hand 
exoskeleton PEXO 

45 107 1 Linear actuator Cable 
Hand and 

wrist 

Manual hand 
OR hands-free 
voice control 

based on 
keyword 
detection 

Pinch assistant 121 580 5 
DC servo 
motors 

Pulley Hand 
Index and 

thumb torque 

Pinotti portable robotic 
exoskeleton PPRE 

122 1600 2 DC motors Gears 
Hand and 

wrist 
Manual hand 

PneuGlove 123 - 2 
Pneumatic 
actuator 

Pneumatic Hand Joint angle 

Pneumatic-controlled finger 
extension system 

43 2000* 1 
Pneumatic 
actuator 

Pneumatic Hand EEG signal 

Power augmentation soft 
glove 

124 120 4 
Pneumatic 
actuator 

McKibben Hand 
Joint torque 

(index) 

Power-assisted FES 125 - 3 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

REHA 2030 126 - 1 DC motors Bar linkage Wrist 
Wrist angle and 

velocity 

ReIn-hand system (Empi 
300 and EMG collection 
unit) 

127,128 227 - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

RELab tenoexo 129,130 148 3 
Maxon DC 

motor 
Bowden cable Hand 

Finger torque 
and bend 

ReoGo-J 38 79000* 3 Motors Direct Wrist 
Manual 

selection 

Rope-driven flexible robot 131 - - Linear actuator Pulley Hand 
Manual 

selection 
(touch screen) 

RUPERT IV 132,133 - 5 
Pneumatic 
actuator 

Pneumatic Wrist 
Joint position 

and tactile 

SaeboFlex and BMR 
Neurotech electrical 
stimulator unit 

134 1587 5 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
Muscle torque 

SaeboMAS and 
accelerometer-triggered 
FES 

135 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
Joint position 

SCRIPT Active orthosis 
SAO-i3 

136 - 3 DC motors Bar linkage 
Hand and 

wrist 
Joint angle 

SCRIPT1 Project 137 - - Elastic torque Pulley 
Hand and 

wrist 

Wrist motion 
and muscle 

torque 

SEM Glove 138 700 3 
Brushless DC 

motors 
Bowden cable Hand Fingertip tactile 

Semi-soft assistive glove 
SAG 

139 - 2 DC motors Cable Hand 
Wrist motion 

and EMG 

SETS system 41 255 3 
Flexible semi-
active actuator 

Direct Wrist Tremor 

SMA muscle 140 300 2 SMA Hydraulic Wrist 
Manual 

selection 

 

 

https://doi.org/10.33137/cpoj.v7i1.43827


 

9 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 

 

Table 3 (continued): Summary of devices analyzed. 

Device name Reference 
Weight of 

device on arm 
(g) 

DoF 
Power 

Transmission 
Mechanical 

Transmission 
Hand/ Wrist User intent 

SNU Exo-glove 141 - 3 
Brushless DC 

motors 
Cable Hand 

Joint velocity 
and joint tensile 

Soft glove 142 237 6 
Pneumatic 
actuator 

Pneumatic 
Hand and 

wrist 
Manual 

selection 

Soft modular elbow-wrist 
rehabilitation exoskeleton 
driven by PAMs 

143 - 2 
Pneumatic 
actuator 

Pneumatic Wrist Joint position 

Soft robotic rehabilitation 
glove 

144 - - 
Pneumatic 
actuator 

Pneumatic Hand 
Manual 

selection 

Soft sixth finger 145,146 140 1 
DC servo 
motors 

Supernumerary Hand EMG 

SoftHand X system 147 500 - 
Maxon DC 

motor 
Supernumerary Wrist 

Joint angle 
(finger) 

SR Fingers 148 750 6 
DC servo 
motors 

Supernumerary Hand Hand position 

SSVEP-BCI controlled soft 
robotic glove rehabilitation 
system 

149 - 2 
Pneumatic 

actuator 
Pneumatic Hand EEG signal 

Super stim ZZAEV906 46 - 3 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

Supernumerary robotic 
finger SRF 

44 650 6 
DC servo 
motors 

Supernumerary Hand Joint angle 

TCAMs-Exo 150 135 2 DC motors Artificial muscle Wrist 
EMG and wrist 

joint angle 

tDCS 151 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG signal 

TDS-HM the hand mentor 
and tongue drive system 

152 - 2 
Pneumatic 
actuator 

Pneumatic 
Hand and 

wrist 
Tongue 
position 

TENS Stimulator N604 153 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EMG 

T-GRIP exoskeleton 154 50 1 Linear actuator Bar linkage Hand 
Joint angle 

(wrist) 

The Bionic glove 155 - - 
Electrical 

stimulation 
Muscle 

contraction 
Hand Wrist position 

The Hand exoskeleton 156 1800 15 Linear actuator Push-pull cable Hand 
Mirrored 
motion 

TIGER 157,158 420 2 
Brushless DC 

motors 
Bar linkage 

Hand and 
wrist 

Manual hand 
(touch screen) 

Upper limb rehabilitation 
robot 

159 - 6 DC Motors Gears Wrist 
Manual 

selection 

Utah microelectrode array 
and NMES 

160 - 6 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 
EEG signal 

WDFHO 161 - 1 Linear actuator Gears Hand 
Joint angle 

(wrist) 

Wearable glove with 
incorporated compliant 
mechanical transmission 

162 - 2 
Pneumatic 
actuator 

Pneumatic Hand 
Manual 

selection 
(touch screen) 

Wearable mechanism to 
suppress axial vibration 

36 268 3 DC motors Direct Wrist Tremor 

WearME Glove 163 500 3 
Brushless DC 

motors 
Pulley 

Hand and 
wrist 

Joint angle 

W-EXOS 164 1900 3 DC motors Gears Wrist 
Muscle torque 

and EMG 
signal 

WHOs 165 - 1 Motors Bar linkage Hand 
Joint angle 

(wrist) 

Wireless distributed FES 
system 

166 45 - 
Electrical 

stimulation 
Muscle 

contraction 
Hand 

EMG and joint 
movement 

Wireless wearable device 167 - 2 
Electrical 

stimulation 
Muscle 

contraction 
Hand and 

wrist 

Joint position 
and movement 

(wrist) 

Wrist exoskeleton 168 288 2 Linear actuator Push-pull cable Wrist 
Manual 

selection 

Wrist exoskeleton 169 728 1 DC motors Gears Wrist 
Mirrored 
motion 

X-Glove 170 - 5 Linear actuator Cable Hand 
Manual 

selection 

 

 

https://doi.org/10.33137/cpoj.v7i1.43827


 

10 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 

Recordings on the weight of the device were poor in the 

literature with only 52% (63/121) mentioning weight. Weight 

spanned from 30g (Layer jamming-based soft Tremor 

Suppression Glove34) to 205kg (Armeo Power II50). From 

the limited reported data, there were indications that the 

weight of the device on the upper limb was reduced each 

year on average. The degrees of freedom (DoF) were 

reported in 62% (84/135) of studies and tended to be low, 

with many devices actuating one (11%, 13/121) or two DoF 

(24%, 29/121). Assistive devices which actuated 1 DoF had 

the lowest weight on average at 285g, followed by 6 DoF at 

422g. Devices with higher levels of DoF tended to be 

designed for the hands: Average hand device DoF was 3.6, 

whereas wrist devices were 2.8 DoF. 

The categories of mechanical transmission described in 

Table 2, were inspired by Bos et al structured overview of 

dynamic hand orthoses.17 However, this study included 

muscle contraction and supernumerary devices. This 

improves the inclusivity of unconventional actuation 

methods; muscle contraction due to electrical stimulation 

acts as an internally applied active force, and 

supernumerary devices use indirect mechanical force to 

attain ADLs. Muscle contraction (26%, 31/121), bar linkage 

 

Figure 2: Distribution of studies based on the field of outcome measures. 

0

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10

15

20

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1990 1995 2000 2005 2010 2015 2020 2025

Study Outcome Measures

All Clinical Clinical and Technical Technical

 

 

Figure 3: Count of outcome measures. Blue indicates clinical outcomes; orange indicates technical outcomes. The outcome measures in 

order: ROM (Range of Motion), EMG, Joint angle, MAS (Motor Assessment Scale),  FMA (Fugl-Meyer Assessment), Grasp, ARAT (Action 

Research Arm Test), Force, RMSE (Root Mean Square Error), Joint motion, Tasks, Grip, Torque, PGT (Pinch Grip Test), ANOVA (Analysis 

of variance), AROM (Active ROM), PROM (Passive ROM), BBT (Box and Blocks Test). 

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https://doi.org/10.33137/cpoj.v7i1.43827


 

11 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 
(15%, 18/121) and pneumatic devices (15%, 18/121) were 

among the most popular mechanical transmission methods 

across all applications.  

To apply the active force, a command signal must be sent 

to a control unit. This command signal was charted as the 

“user intent” defined in Table 2, results are shown in Table 3. 

The user’s intention to control the device was detected 

predominantly with Electromyography (EMG) (30%, 36/121) 

and users’ joint movement (30%, 37/121). The placement of 

electrodes for EMG varied widely and most EMG intention 

methods were combined with muscle contraction to actuate 

the upper limb (61%, 22/36), this is the foundation of 

Functional Electrical Stimulation (FES).171 Other user 

intention methods include detecting a force applied by the 

joint typically the fingertips, by manually selecting how and 

when the actuator moves using a touchscreen or joystick, 

and EEG systems such as the Emotiv.65 

Outcome measures  

A total of 226 unique outcome measures were extracted 

from the 765 tests completed in the data set. From the 226 

outcome measures extracted, 100 were considered clinical 

tools using the WHO-ICF Model of functional outcomes 

alongside additional validated sources.10,11,172,173 Therefore, 

126 outcome measures were considered technical or non-

clinical. A dip in the number of clinical-based outcome 

measures used was found in 2020. While testing of devices 

on patients had decreased, the past 10 years have seen an 

exponential increase in research publications on upper limb 

devices seen in Figure 2. 

The frequency of outcome measures repeated between 

studies tended to be low (8%, 18/226). The majority of 

outcome measures appeared in less than 10 studies (92%, 

208/226); Figure 3 presents the outcome measures most 

regularly used (outcome measures used in ≥10 studies). 

The clinical outcome measures trended towards 

observational ordinal scales inspecting mobility (MAS, FMA, 

and BBT) and movement functions (ROM, ARAT and 

functional tasks). The technical and non-clinical outcome 

measures were either statistical analysis methods (RMSE, 

ANOVA and kinematic analysis) or usability tests (EMG, 

joint angle, and grasp force of device). Patient-reported 

outcome measures such as the Motor Activity Log (MAL), 

ABILHAND, Disabilities of the Arm, Shoulder, and Hand 

Scale (DASH), and quickDASH were often under-utilized 

with 4% use out of all tests extracted (30/765).  

Factors such as introducing variations and modifications in 

a validation method caused 65% (148/226) of the outcome 

measurement tools to only be present in the dataset once. 

Another factor increasing the number of unique outcome 

measures extracted is the use of condition-specific outcome 

measures such as the Stroke Impact Scale.38,110,134,152 

These tailored methods are useful tools to benchmark a 

person’s functionality within a set population173-176 but make 

validation across different cohorts difficult as it may not be 

an appropriate outcome measure for all. 

Technology Readiness Levels 

TRL 1 (proof of concept studies) and TRL 2 (software 

prototype studies) were not present due to our inclusion 

criteria provided in Table 1. The distribution of all TRL 

extracted can be found in Table 4, which also includes the 

definitions used in the data extraction. 

Overall, TRL 6 (21%, 28/135), TRL 9 (20%, 27/135) and 

TRL 4 (19%, 26/135) were the most prominent 

advancement levels. FES (63%, 17/27), EMG (44%, 12/27) 

and devices made to support people with cardiovascular 

diseases (74%, 20/27) made up most of the technological 

advancements of TRL 9. Non-electrical stimulation devices 

at TRL 9 included the MyoPro,109-112 which uses an EMG 

threshold for control and has been commercialized since 

2006, the SEM Glove,138 ReoGo-J,38 and Armeo Power II.50 

Of these, SEM Glove, ReoGo-J, and Armeo Power II were 

the only TRL 9 devices that did not include FES or EMG. 

Trends in TRL and demographics were also noticed; as the 

number of participants increases, the TRL level improves: 

case studies (1 participant) were an exemption to this trend. 

High-income countries also conducted studies at higher 

TRL and there has been a steady development in TRL in 

device testing over the years. 

Devices in category TRL 3 were proof of concept (Table 4), 

therefore these studies use analytical or feasibility 

methodologies. These methods focus on the validation of 

the device and include only healthy participants. Of these 

TRL 3 devices, 47% (8/17) used cable conduit mechanisms, 

and 29% (5/17) used pneumatic actuation. These devices 

tended to be designed for supporting the hands (47%, 8/17) 

and had on average between 2-3 DoF. Various user 

detection methods were charted, but manual control of the 

device was quite frequent in both TRL 3 and 9. 

DISCUSSION 

This study provides an overview of 135 research papers 

focused on actuated assistive devices for the hand and 

wrist. A notable result was the scarcity of rigorous clinical 

methodologies, with 34% (46/135) of studies involving 

clinical trials, of which 12 studies conducted RCTs. From 

these studies, 121 unique devices were analyzed to scope 

their intended user populations, design features, validation 

strategies, and TRLs. Most of the devices were designed for 

individuals with upper limb impairment due to stroke 46% 

(597/1310), and a significant proportion of devices had low 

DoF, particularly for wrist devices at an average of 2.8 DoF. 

Regarding the design, the devices predominantly utilized 

EMG (30%, 36/121) which tended to be in combination with 

muscle contraction via electrical stimulation (FES). Along 

https://doi.org/10.33137/cpoj.v7i1.43827


 

12 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 
with EMG, user interfaces such as buttons, joysticks, and 

touch screens were used to detect user intentions. The 

study categorized a total of 226 unique clinical and technical 

outcome measures. The validation methods predominantly 

relied on statistical analyses for technical outcomes, while 

clinical assessments were often observational. There was a 

lack of consistency across studies, with many outcome 

measures used only once (65%, 148/226). Objective or 

patient-reported outcomes were less frequently employed.  

Most of the studies were conducted in high to upper-middle-

income economies (90%, 28/31). Although the need for 

assistive technology in low-income countries is high, there 

may be a lack of awareness and access to actuated 

devices, contributing to fewer studies conducted in these 

economies.15,16 Low-income economies must often import 

medical equipment,177 therefore these actuated devices 

must achieve high TRL to be considered for ordering and 

prescription. Yet, these devices have not met TRL >6 

requirements (76%, 92/121). To fulfil TRL >6, the device 

must meet the ISO standards, and regulatory requirements 

(such as CE marking) before distribution in the market or 

testing in operational environments (Table 4). These 

conditions provide insurance for device quality, safety and 

efficiency.178 A few factors which may contribute to these 

devices not surpassing TRL 6 include overcoming the 

dynamic and rapidly developing policies to meet regulatory 

requirements for testing,179 a lack of streamlined clinical 

tests and validation processes for these devices,180,181 and 

the effects of COVID-19 on reduced face-to-face 

research.182-184 

To validate these devices, 226 outcome measurement tools 

were charted. Classification of validation methods showed 

that 44% (99/226) of the outcome measurement tools were 

considered clinical; ROM, MAS and FMA were the most 

used for clinical trials whereas EMG, joint angles and device 

grasp force were conducted in technical studies (Figure 2). 

Since many of the devices were designed for stroke 

rehabilitation (46%, 597/1310), the outcome measures 

recorded show a strong correlation with existing literature 

on upper limb outcome measures in stroke recovery.173 

Patient-reported outcome tests were implemented 4% of 

the time (30/765). This value is considerably low as these 

outcomes are invaluable to validate the use of the assistive 

device.8,173,185 Patient-reported outcomes also provide 

valuable psychometric properties to the evidence base185 

and are an important part of upper limb assessment. It 

should be noted that comorbidities were not often reported, 

and outcome measures were not standardized, therefore 

inter-comparability of devices and populations was limited.  

The lack of inter-comparability was also noticed in the 

inconsistency in reporting device specifications. DoF and 

weight of the device were not reported routinely (62% and 

52% respectively), with some studies quoting their device 

as “lightweight” without reference to their objective weight. 

A slight trend toward reducing the weight of upper limb 

devices over the years was observed, but there is 

insufficient statistical evidence to support this claim. Many 

devices were designed with low (1 or 2) DoF and varied 

greatly in weight from 33g to 205kg. The variation in weight 

was due to differences in reporting weight, some studies 

report weight on the upper limb, while others report weight 

of the full system. The implication of these differing reporting 

styles makes synthesizing findings difficult for decision-

making and provides barriers to further research as the 

evidence base lacks standardized measures and methods. 

To improve inter-comparability, frameworks for 

development can be implemented,186,187 alongside robust 

and systematic testing using a large cohort.187,188 

In line with the works of Zhu et al, the field of soft wearable 

robotics has experienced rapid growth189 as demonstrated 

by the increasing number of fluidic transmission actuators 

identified in the study. These fluidic actuators, which include 

pneumatic and hydraulic, are typically lighter (averaging 

234g on the arm) and provide multidirectional force due to 

their flexible design.190 Previous studies have predicted the 

rise of soft robotics,187 which may continue to improve for 

use as an actuated assistive device. In addition to fluidic 

transmission actuators, supernumerary devices (n = 5) have 

Table 4: TRL Definitions defined by the HORIZON 2020 - Work Programme 2014-2015 and the scoping review abstraction of the HORIZON 

2020 definitions. 

TRL Definition Scoping Review E planation Count 

1 Basic principle observed The idea has been formulated, proof of concept only 0 

2 Technology concept formulated A software prototype has been made and tested virtually 0 

  Experimental proof of concept Analytical studies and feasibility studies. The device must be built 17 

4 Technology validated in the lab 
The device has been tested on non-human or one healthy case study for 
validation. 

26 

  
Technology validated in the relevant 
environment 

The device has been tested on healthy participants 21 

  
Technology demonstrated in the relevant 
environment 

The device has been tested on a target population in a clinical setting (ISO 
Standard not complete) 

29 

  
System prototype demonstration in an 
operational environment 

The device has been tested for its intended purpose in an operational 
environment (outside of the clinic and lab) ISO Standards should be complete 

14 

  System complete and qualified The device is ready to be commercialized and has been validated 1 

9 
Actual system is proven in an operational 
environment 

The device is available in the market 27 

 

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13 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 
shown potential for human augmentation.191 However, due 

to their state-of-the-art nature, the availability of real-world 

applications and longitudinal evidence supporting their 

effectiveness is limited.191,192 As these novel actuators 

continue to advance, future assistive devices should 

integrate them to improve weight and multifunctionality. 

To detect a user’s intention, EMG (30%, 36/121) and joint 

movement (30%, 37/121) sensors were regularly 

implemented. EMG control methods, which include surface 

electrodes, implanted wires, and probes,193 have a long 

history of use. However, they are not suitable for all 

individuals with hand and wrist impairment194 and may 

encounter system failures outside of testing settings.187 

EMG and joint movement sensors are limited by muscle 

activation threshold requirements, making them inadequate 

for addressing the full spectrum of people with upper limb 

impairment. The prescription of these devices would not be 

appropriate. Consequently, alternative user intention 

systems were explored including tongue-based 

interfaces,71,152 hands-free voice control,44 and foot-based 

interfaces.81 These systems are not limited by upper limb 

muscle threshold, yet they did not attain TRL >6. Alongside 

the requirements for attaining TRL >6, design factors may 

contribute to why these devices are not suitable for 

operating in a real-world context. Wearable sensing and 

control technology includes various elements which were 

not abstracted such as cost, consumption and battery 

lifespan, these may all affect useability.187,195 A systematic 

analysis of control systems which do not require upper limb 

muscle activation may be appropriate to validate the use of 

these underrepresented systems.  

Limitations  

The results of a scoping review are often quite broad; a 

synthesis of the conclusions will require additional 

resources to be used in policymaking. In addition, scoping 

reviews rarely include critical appraisal of included studies; 

therefore, the reliability of findings may be skewed. Despite 

this, a scoping review addresses the exploratory nature of 

upper limb devices compared to other methodologies. 

In addition, as with many studies, the design of this study is 

subject to limitations. These concerned the selection of 

studies, definitions of terms during screening and the 

exclusion of data charting items. Due to time constraints, 

this study did not screen all forms of grey literature such as 

market reports, patents or working papers, and the keyword 

selection may have excluded appropriate studies. In 

addition, 118 studies were not retrieved (Figure 1) due to 

restricted access to certain relevant research papers. This 

limitation arose primarily due to paywalls and institutional 

access restrictions. This introduced selection bias and may 

have hindered the scope and number of devices 

investigated with higher technological readiness levels. 

During the screening process, the reviewers ultimately 

agreed on a consensus with 86.9% accuracy, but the 

definition of portable was defined as easily moveable by 

healthy users. This meant results on the weight of the 

device had large variability. This limitation was somewhat 

mitigated by recording the device's weight on the arm, 

although some studies only reported the total weight of the 

device. This study did not chart how the device interacts 

with the user’s joint-segment, such as enabling voluntary 

hand-opening or supporting wrist flexion. This data charting 

item would have provided more context for the device's 

functions. 

CONCLUSION 

Active, actuated assistive devices offer promising solutions 

to improve functionality and quality of life for individuals with 

hand impairments. This study reviews 135 studies covering 

121 devices, providing insights into actuated devices for 

hand and wrist support in ADLs. Innovation in actuation 

systems and control methods is evident, yet many devices 

have not advanced beyond TRL 7, highlighting the gap 

between research and market-ready products. EMG and 

FES systems dominate the field but may not be suitable for 

users with limited muscle activation, showing the need for 

alternative approaches such as tongue interfaces and voice 

control systems.  

Key barriers to prescription included insufficient real-world 

evidence, concentration of development in high- and 

middle-income countries, lack of standardized reporting, 

and the absence of accepted clinical validation processes. 

To overcome these challenges, it is essential to establish 

standards for device design, testing, and reporting (e.g., 

weight, degrees of freedom), develop comprehensive 

outcome measures combining objective methods with 

patient-reported experiences, and improve the accessibility 

of devices in low-income countries. 

The field of hand and wrist exoskeletons shows increased 

popularity in the innovation of control systems and 

actuators. Addressing these challenges and implementing 

standardized frameworks will help improve the prescription 

of these devices. As technology advances, tailored 

solutions for individuals with varying levels of hand 

functionality are becoming increasingly feasible, offering 

significant benefits to those with upper limb impairments. 

Overall, there is promise and growth in the field of hand and 

wrist exoskeletons. 

ACKNOWLEDGEMENTS 

We would like to acknowledge the funding and support from the 

University of Strathclyde and the UK Engineering and Physical 

Sciences Research Council (EP /S02249X). 

DECLARATION OF CONFLICTING INTERESTS 

The authors declare no conflict of interest.   

https://doi.org/10.33137/cpoj.v7i1.43827


 

14 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 
AUTHORS’ CONTRIBUTION 

• Angel Galbert: Study conception and design, data collection, 

analysis and interpretation of results, draft manuscript 

preparation, and manuscript revision. 

• Arjan Buis: Supervision, study conception and design, and 

manuscript revision. 

Both authors have read and approved the final version of the 

manuscript. 

 

SOURCES OF SUPPORT 

ESPRC doctoral training grant (EP/S02249X/). 

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List of Abbreviations 

 

Acronym Definition  

ADL Activities of Daily Living 

AHA Assisting hand assessment 

AHP Allied Health Professional 

AMEA Absolute Mean Error Analysis 

ANCOVA Analysis of Covariance 

ANOVA Analysis of Variance 

AOU Amount of Use 

ARAT Action Research Arm Test 

ARI Active Resistance Index 

AROM Active Range of Motion 

ASIA 
American Spinal Injury Association (ASIA) Impairment 
Scale 

BBT Box and Block Test 

BI Barthel Index 

BMRC British Medical Research Council Scale 

CGI Clinical Global Impression 

Chedocke Chedocke McMaster Hand Portion 

CMC Coefficient of Multiple Correlation  

CMSA Chedocke-McMaster Stroke Assessment  

COPM Canadian Occupational Performance Measure  

CTS Carpal Tunnel Syndrome 

CUE-T Capabilities of upper extremity test 

CVA Cerebral Vascular Accident 

DMD Duchenne Muscular Dystrophy  

DOF Degree of Freedom 

Donn/Doff Putting on and Removing Task 

D-QUEST 
Dutch- Quebec User Evaluation of Satisfaction with 
Assistive Technology 

DTM Dart throwing motion  

DTSaM  Dynamic Traction Splint by Artificial Muscle  

EEG Electroencephalogram  

EMG Electromyography 

FAT The Frenchay Arm Test  

FEA Finite Element Analysis 

FES Functional Electrical Stimulation  

FIM Function Independence Measurement  

FMA Fugl-Meyer Assessment 

https://doi.org/10.33137/cpoj.v7i1.43827
https://hermanwallace.com/download/The_ABC_of_EMG_by_Peter_Konrad.pdf
https://hermanwallace.com/download/The_ABC_of_EMG_by_Peter_Konrad.pdf
https://www.ijser.org/researchpaper/Trends-and-Challenges-in-EMG-Based-Control-Scheme-of-Exoskeleton-Robots-A-Review.pdf
https://www.ijser.org/researchpaper/Trends-and-Challenges-in-EMG-Based-Control-Scheme-of-Exoskeleton-Robots-A-Review.pdf
https://www.ijser.org/researchpaper/Trends-and-Challenges-in-EMG-Based-Control-Scheme-of-Exoskeleton-Robots-A-Review.pdf


 

22 

Galbert A, Buis A. Active, actuated, and assistive: A scoping review of exoskeletons for the hands and wrists. Canadian Prosthetics & Orthotics Journal. 2024; 
Volume 7, Issue 1, No.9. https://doi.org/10.33137/cpoj.v7i1.43827 

CANADIAN PROSTHETICS & ORTHOTICS JOURNAL 

ISSN: 2561-987X A SCOPING REVIEW OF EXOSKELETONS FOR THE HANDS AND WRISTS 

Galbert A, and Buis A, 2024 

 

fMRI Functional magnetic resonance imaging 

GAIN Global Appraisal of Individual Needs 

GRASSP 
Graded Redefined Assessment of Strength, Sensibility 
and Prehension 

GRT Grasp and Release test 

IBEP Integral Value of a Bioelectric Potential 

IMU Inertial measurement units 

IOTA Isolated orthosis for thumb actuation  

IRQ  Interquartile range 

JTHFT Jebson Taylor Hand Function Test 

KINARM 
Kinesiological Instrument for Normal and Altered 
Reaching Movement 

LGMD Limb Girdle Muscular Dystrophies 

MAL Motor Activity Log 

MANOVA multivariate analysis of variance  

MAPR Multi-Attribute Preference Response 

mARAT Modified Action Research Arm Test 

MARP Mean arrest period ratio 

MAS Modified Ashworth Score 

MAV Mean Absolute Value 

MDC Minimal detectable change  

MES Mean Error Squared 

MMSE Mini-Mental State Examination  

MMT Manual Muscle Testing 

Movement 
ABC 

Movement Assessment Battery for Children 

MPF Mean Power Frequency  

mPPT modified Purdue Pegboard Test 

MVC Maximum Voluntary Contraction  

NASA-TLX The NASA Task Load Index 

NHPT Nine Hole Peg Test 

NIHSS National Institute of Health Stroke Scale 

NSA Nottingham Sensory Assessment  

PCGI-I Patient Clinical Impressions-Improvements 

PIADS Psychosocial Impact of Assistive Devices Scale  

PRISMA-
ScR 

The Preferred Reporting Items for Systematic Reviews 
and Meta-Analysis Extension for Scoping Reviews 

PROM Passion range of motion 

PRS Pain Assessment Rating Scale 

PUL Performance of the Upper Limb scale 

QIF-SF Quadriplegia Index of Function-Short Form 

QoL Quality of Life  

QOM Quality of movement scale 

QUEST 
Quebec User Evaluation of Satisfaction with Assistive 
Technology 

QuickDAS
H 

Quick Disabilities of the Arm, Shoulder, and Hand 
Questionnaire 

RCT Randomized Control Trial 

RMA Rivemead Motor Assessment  

RMSD Root means square difference 

RMSE Root means square error 

RMSED Root Mean Standard Error of Deviation 

ROM Range of motion 

RTLX Raw NASA-Task Load Index 

SAL Spectral arc length  

SCIM-SR Spinal Cord Independence Measure–Self-Report 

sEMG Surface Electromyography 

SEPs Somatosensory evoked potentials 

SIAS Stroke Impairment Assessment Set 

SIS Stroke Impact Scale 

SUS System Usability Scale  

SWMT Semmes-Weinstein monofilament test 

TAM Total Active Motion 

TBI Traumatic Brain Injury 

TLT Thumb localizing test 

TRI-HFT Toronto Rehabilitation Institute Hand Function Test 

TRL Technology Readiness Level 

UDQ Use of Device Questionnaire 

USE 
the Usefulness-Satisfaction-and-Ease-of-use-
Questionnaire 

VAS Visual Analog Pain Assessment Scale 

WHO-ICF 
World Health Organisation - The International 
Classification of Functioning, Disability and Health 

Wilco on 
Test 

The Wilcoxon signed-rank test 

WMFT Wolf Motor Function Test 

 

 

 

 

 

 

 

https://doi.org/10.33137/cpoj.v7i1.43827

