All articles are permanently available online to the public without restrictions or subscription fees. They are free to be used, cited, and distributed, provided that appropriate acknowledgment is included. Authors retain the copyright of their original contributions and grant the Canadian Online Publication Group (COPG) a license to publish the article and identify itself as the original publisher. CPOJ articles are licensed under the Creative Commons Attribution 4.0 International License. CPOJ Website: https://jps.library.utoronto.ca/index.php/cpoj/index Editorial Office: cpoj@online-publication.com ISSN: 2561-987X CPOJ is a member of, and subscribes to the principles of, the Committee on Publication Ethics (COPE). 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 https://publicationethics.org/about/our-organisation 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 5 10 15 20 25 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). 0 10 20 30 40 50 60 R O M E M G J o in t A n g le M A S F M A G ra s p A R A T F o rc e R M S E J o in t M o ti o n T a s k s G ri p T o rq u e P G T A N O V A A R O M P R O M B B T F re q u e n c y o f S tu d ie s Publication Year Outcome Measure O c c u rr e n c e s o f O u tc o m e M e a s u re 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 https://doi.org/10.33137/cpoj.v7i1.43827 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/). REFERENCES 1.Chen K-L, Tseng M-H, Shieh J-Y, Lu L, Huang C-Y. Determinants of quality of life in children with cerebral palsy: A comprehensive biopsychosocial approach. Res Dev Disabil. 2014; 35(2):520-528. DOI: 10.1016/j.ridd.2013.12.002 2.Mercier L, Audet T, Hébert R, Rochette A, Dubois M-F. 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DOI: 10.1186/s12984-021-00906-3 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