Current State, Needs, and Opportunities for Wearable Robots in Military Medical Rehabilitation and Force Protection

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

comments：

1 The introduction provides a broad overview but lacks specific details on the current state of wearable robots in military and rehabilitation contexts. It is suggested that the author should provide a more detailed literature review within the current body of knowledge and better highlight its innovation and research gap.

2  Although it is reasonable to use the modified Delphi method, this section lacks specific implementation details. 

For example, it did not elaborate on the selection criteria of the panel, the design of the questionnaire, the data analysis process or how to resolve differences among experts.  These details are essential to ensure the transparency and repeatability of the research.

3 The results part summarizes three main application areas of wearable robots in military environment, but most of the discussions are still qualitative. It is suggested that there should be more data or quantitative methods and combined with specific case to enhance the persuasive power and practical relevance of the results.

4 The discussion section of this paper lacks an in-depth discussion of the long-term impact of the use of wearable robots.  For example, there is little discussion about long-term health effects, psychological effects and potential technology dependence. These aspects are essential for a comprehensive assessment of the feasibility and potential risks of applying the technology.

Author Response

Thank you for taking the time to review our manuscript. The responses to your comments are provided below:

1. The introduction provides a broad overview but lacks specific details on the current state of wearable robots in military and rehabilitation contexts. It is suggested that the author should provide a more detailed literature review within the current body of knowledge and better highlight its innovation and research gap.

We expanded the research gap with the following text in the Introduction section: Despite the rapid development of wearable robot technology in various fields, there is no consensus on the definition and framework of wearable robots for military rehabilitation and assistance in preventing MSK injuries. Proud et al [14] highlight that evaluation procedures for exoskeletons vary widely across different fields, complicating comparisons. They also emphasize that significant adaptation of existing technologies, such as industrial exoskeletons, would be necessary to meet the specific requirements of military applications. Meanwhile, other studies focus on the design considerations for lower [15] and/or upper exoskeletons [16] tailored for military use, but they often neglect alternative wearable robots designed, particularly for rehabilitation and reintegration purposes.

2. Although it is reasonable to use the modified Delphi method, this section lacks specific implementation details. For example, it did not elaborate on the selection criteria of the panel, the design of the questionnaire, the data analysis process or how to resolve differences among experts. These details are essential to ensure the transparency and repeatability of the research.

Thank you for the comment. We provided a more detailed description of the modified Delphi method applied to this study in the ‘Materials and Methods’ Section. The Modified Delphi Consensus Method used a structured communication to achieve a convergence of opinion among the group of experts. The Delphi process involved multiple rounds of controlled feedback. Conflicts were resolved through using a diverse panel of experts chosen to ensure a wide range of perspectives. The selection criteria included expertise, experience, and relevance to wearable robotics for MSK prevention, who had an existing or prior collaboration with the US Department of Defense or US Department of Veterans Affairs. Experts were asked to provide a presentation summarizing the relevant literature on wearable robot applications for MSK injury prevention and military medical rehabilitation, technology currently in use or under development and design requirements and challenges, with a set of questions and statements related to wearable robotics. During round 1, common themes, agreements, and disagreements were identified by the steering group team. Experts received a summary of the group's responses from their presentations and any comments. In Round 2, the panel reviewed this feedback and revised initial positions in light of the group's collective input. The process of feedback, review, and response was repeated to reduce the range of answers and move towards a consensus. Experts were encouraged to justify their opinions, especially if they deviate significantly from the group's response. Controlled feedback ensured that experts were aware of the collective viewpoints and the reasons behind differing opinions. This helped in understanding the rationale of other experts and led to convergence. Additional rounds allowed experts to refine their views and address any misunderstandings. Conflicts were resolved as experts adjusted their opinions based on new information and insights gained from the feedback. A neutral facilitator group guided the process, helped clarify misunderstandings, and ensured that all voices were heard. After over four rounds, a consensus was achieved. The final result was a well-rounded agreement that reflected the collective judgment of the expert panel.

3. The results part summarizes three main application areas of wearable robots in military environment, but most of the discussions are still qualitative. It is suggested that there should be more data or quantitative methods and combined with specific case to enhance the persuasive power and practical relevance of the results.

Thank you for the suggestion We focused our study on qualitative findings derived from discussions with panel experts. We acknowledge this as a limitation of our study and provide it as guidance for future research in this area. A Study limitation section was added in the manuscript: Due to the short time to perform the modified Delphi consensus method in presence with the panelists and the steering group, the results were limited to qualitative findings. While results showed design considerations in wearable robots from experts in the field, future studies with similar approach should consider supporting these findings with qualitative data.

4. The discussion section of this paper lacks an in-depth discussion of the long-term impact of the use of wearable robots.  For example, there is little discussion about long-term health effects, psychological effects and potential technology dependence. These aspects are essential for a comprehensive assessment of the feasibility and potential risks of applying the technology.

These items were previously addressed in the Subsection titled “Challenges and Areas of Opportunities”. To enhance clarity, we have restructured the Results section into separate Results and Discussion sections.

Reviewer 2 Report

Comments and Suggestions for Authors

The article deals with a very interesting study focused on the use of wearable robots in various situations where it is necessary to increase a person's strength or overcome their health handicap. The solved problem is important for the development in this area because of the clear definition of the area, the use of individual types of wearable robots.

The title of the article (Current State, Needs, and Opportunities for Wearable Robots in Military Medical Rehabilitation and Force Protection) is in accordance with the content of the article, and adequately describes the problem being addressed.

The literature used (69 sources) is well above average, while I would recommend putting the references in square brackets.

The first chapter describes the issue of injury to a person who physically puts a lot of strain on his body. This leads to the creation of an assumption that the use of a wearable robot can help a person bear a greater load, or eliminate already damaged parts of the body.

The second chapter describes the use of a modified Delphi process, which was used to create a "consensus" allowing researchers from different fields to create a common definition of a wearable robot.

The third chapter describes what types of devices we can classify under wearable robots and in which applications they are most common. Prevention of injuries when using wearable robots in the mentioned sectors can reduce the burden on health care and prolong the active life of its wearer. In the article, the authors also mention possible health benefits, but they also do not avoid naming possible risks that may arise on the human body during excessive use of wearable robots. At the end of the chapter, the authors also state the challenges facing the developers of these robots in the future.

 

I consider a strong point of the article to be the realization of a discussion (panel) with 14 participants, who have many years of experience in the addressed issue, which led to the creation of a definition of wearable robots and their division according to the required application.

As a weak point of the article, I consider the inappropriate solution of links to the used literature and the failure to specify the starting points for the selection of participants in the discussion (panel), or the inclusion of direct links to wearable robots used in the study.

Comments:

I ask the authors to consider providing references to the used literature in square brackets, in order to improve clarity.

At the end of the sentence, where the reference to the used literature will be given, there should be a period after the square bracket containing the reference number (not the other way around, such as line 166 or 212).

I would recommend to consider including links (e.g. a link to a robot, or a laboratory where this issue was solved, etc.) to the evaluated wearable robots that were used in this study (panel), so that readers have the opportunity to view them.

Author Response

Thank you for taking the time to review the manuscript and your positive feedback. To address the comments efficiently, we only include those that required responses.

1. I ask the authors to consider providing references to the used literature in square brackets, in order to improve clarity.

References were cited in square brackets.

2. At the end of the sentence, where the reference to the used literature will be given, there should be a period after the square bracket containing the reference number (not the other way around, such as line 166 or 212).

The comment was addressed throughout the manuscript.

3. As a weak point of the article, I consider the inappropriate solution of links to the used literature and the failure to specify the starting points for the selection of participants in the discussion (panel), or the inclusion of direct links to wearable robots used in the study. I would recommend to consider including links (e.g. a link to a robot, or a laboratory where this issue was solved, etc.) to the evaluated wearable robots that were used in this study (panel), so that readers have the opportunity to view them.

Thank you for this feedback. The selection criteria included expertise, experience, and relevance to wearable robotics for MSK prevention, who had an existing or prior collaboration with the US Department of Defense or US Department of Veterans Affairs. Most wearable robots used by panelists for testing and/or development were included in each application field section. In addition, Figure 1 and 2 show wearable robots presented by the panel. Panelist’s research relevant to this topic were added in the ‘Challenges and areas of opportunities’ section. Also, authors’ institutions are provided in the first page for more information.

Round 2

Reviewer 1 Report

Comments and Suggestions for Authors

accept 

Author Response

Thank you for reviewing our manuscript. No comments provided

Reviewer 2 Report

Comments and Suggestions for Authors

In chapter 1, the authors added a text that better defines the problem being solved.

In chapter 2, the authors have added a significant part of the text in which they describe the implemented Delphi process in more detail. The mentioned part improves the informative value of the study.

The authors moved subsections 3.2 to 3.4 to chapter 4 (Discussion), which I evaluate as a positive change in the presented study. At the end of chapter 4, there are also limitations that were limiting during the conducted study. I also rate this positively.

Additional links to relevant sources have been added to the article, use them when processing the study.

The authors in the article removed most of my comments. I have no significant comments on the article.

Author Response

Thank you again for reviewing our manuscript. No responses needed