Occupational Exoskeletons: Understanding the Impact on Workers and Suggesting Guidelines for Practitioners and Future Research Needs

Round 1

Reviewer 1 Report

Dear authors,

my main concern about this work, is the excessive length of the paper, which is interesting, but may discourage potential readers.

Therefore, I suggest cutting some parts that are not relevant or repeated many times.

- lines 153-160 (repetition)

- lines 181-184 (repetition)

- lines 196-205 (EMG technique definition: not relevant)

- lines 219-237 (try to keep it shorter and provide only the most relevant information)

- lines 242-247 (not relevant)

- lines 316-326 (try to keep it shorter and focus on the most relevant similarity/differences)

- lines 340-343 (repetition)

- lines 382-387 (repetition)

- lines 568-571 (repetition)

...

- lines 831-832 (repeat the previous sentences)

...and many others.

Moreover, a lot of sections are really heavy and too long.

The only novelty of the paper is in section 4.3 but also here the description of the 6 steps is excessively long and detailed, with concepts repeated several times.

For example, lines 811-819 can be replaced by only two sentences without missing important information.

"In Step 5, the focus is on the gradual implementation of the selected exoskeletons, limiting their initial use to a selected sample of workers and specific tasks. 

During this phase, thanks to the limited sample, the performance variations associated with the use of exoskeletons can be closely monitored and evaluated."

This is just an example, but there are really a lot of groups of sentences in the paper that can be summarized without losing any important data.

INTRODUCTION:

- There is a growing awareness of the risks of MusculoSkeletal Disorders (MSDs) in the workplace, which can result from repetitive or intensive manual tasks.

-> add references.

- In addition, the potential benefits of exoskeletons for workers in industries such as manufacturing, construction, and healthcare are becoming more widely documented.

-> add references.

- These devices, which may give more support and control than passive exoskeletons, are commonly utilized in sectors where workers do physically demanding activities, such as aerospace, defense, and healthcare.

-> that is not true. A lot of active exoskeletons are developed to be used also in manufacturing, construction, and agriculture.

MATERIALS AND METHODS:

- Figure 1: remove "-400" it has no meaning as it is the number of publications. 

RESULTS:

- you stated that you included 121 studies. Why there are a total of 263 different exoskeleton prototypes? 

Moreover, in Figure 3 there are 291 studies and 254 studies that investigated perceived usability and muscle activity. How is this possible?

- I suggest considering together Back (whole) + Back (lumbar) + Back (spine) + Back (trunk) and Upper limbs + shoulder to provide more valuable and useful results and considerations.

Moreover, in the following, many times you discussed the results or the considerations about the back-support exoskeletons together without distinguishing between the different back parts, so keeping them together will also be better for improving consistency e.g., lines 516, 715.

- Figure 2: Are you sure that when measuring the EMG, all these studies have analyzed muscle fatigue? I suggest replacing it with "muscle activity (EMG)".

- line 209 start a new paragraph.

- line 238 start a new paragraph.

- line 316 start a new paragraph.

- line 327 start a new paragraph.

- line 334 start a new paragraph.

- How do you define safety improvement and deterioration? 

There is no clear definition of safety regarding exoskeletons' assistance, so I have strong concerns about the results presented in this section.

From 426 to 439, you wrote many potential negative effects associated with exoskeleton use, but they are not directly related to safety (e.g., increased leg muscle activity: how this could decrease safety?).

The results of safety improvement and deterioration in Figure 5 are based on YOUR definition of safety or on the studies' authors definition?

Moreover, in Figure 5: the positive effects you have found on active and passive exoskeletons (5A) in which body areas were? 

There are shown no positive effects on 5C.

- line 543 type of locomotion -> type of actuation.

- from line 554 to 571 you mainly discussed the limitations of the subjective assessment.

As you are trying to summarize the total results of the exoskeleton assessment, the detailed description of the limitations is irrelevant, so keep it shorter.

DISCUSSION:

- in the first part of the discussion there are all the effects mixed between exoskeletons that support different body parts, so it is a bit confusing.

- line 621 start a new paragraph.

- line 679 start a new paragraph.

- line 689 do not start a new paragraph.

- line 706 start a new paragraph.

- I disagree with why step 2 should be before step 3. There is no "fixed" situation in which passive exoskeletons should be preferred instead of active exoskeletons (or the opposite).

(Moreover, you repeated several times in the paper that passive exoskeletons should not be used when there are possible collisions, but I do not see how active exoskeletons can be a better decision in case of collisions.)

First, you decide the body areas to be supported, then select the best exoskeleton to assist that body area for the specific tasks.

CONCLUSION

- from line 883 To line 920 you repeated the same concept over and over.

You can summarize these lines in much FEWER sentences.

e.g., "However, caution is warranted, as the evidence regarding the effectiveness of exoskeletons in reducing the risk of MSDs is lacking." 

Then the next sentence gives exactly the same information:

"The current body of research on occupational exoskeletons lacks sufficient evidence regarding their long-term effects on reducing MSDs."

some sentences later:

"Overall, without robust long-term research, it is challenging to provide conclusive evidence that exoskeletons effectively reduce MSDs in the occupational setting".

Author Response

Dear Referees,

we would like to thank you for allowing us to improve our paper and to review our work.

We appreciated your valuable suggestions, and we thank you for this effort in revising our paper. You will find in this document the replies to your suggestions. Revisions in the manuscript are in blue.

We deeply hope that you will appreciate our work.

Yours sincerely,

The authors

Reviewer 1

Dear authors,

my main concern about this work, is the excessive length of the paper, which is interesting, but may discourage potential readers.

Q1) Therefore, I suggest cutting some parts that are not relevant or repeated many times.

- lines 153-160 (repetition)

- lines 181-184 (repetition)

- lines 196-205 (EMG technique definition: not relevant)

- lines 219-237 (try to keep it shorter and provide only the most relevant information)

- lines 242-247 (not relevant)

- lines 316-326 (try to keep it shorter and focus on the most relevant similarity/differences)

- lines 340-343 (repetition)

- lines 382-387 (repetition)

- lines 568-571 (repetition)

...

- lines 831-832 (repeat the previous sentences)

...and many others.

A1) Thank you for your effort in checking the repetitions. We deleted the repetitions that you noticed, checked the whole manuscript for further repetitions and reduced the length of some paragraphs.

Q2) Moreover, a lot of sections are really heavy and too long.

A2) We made an extra effort to further reduce the length of multiple sections in the manuscript.

Q3) The only novelty of the paper is in section 4.3 but also here the description of the 6 steps is excessively long and detailed, with concepts repeated several times.

For example, lines 811-819 can be replaced by only two sentences without missing important information.

"In Step 5, the focus is on the gradual implementation of the selected exoskeletons, limiting their initial use to a selected sample of workers and specific tasks. 

During this phase, thanks to the limited sample, the performance variations associated with the use of exoskeletons can be closely monitored and evaluated."

This is just an example, but there are really a lot of groups of sentences in the paper that can be summarized without losing any important data.

A3) Thank you for your valuable suggestion. We have considered your feedback and have decided to reduce other sections of the manuscript while keeping intact the guidance for practitioners in Section 4.3. This is because what is currently lacking is a straightforward and effective support system for those who have never used an exoskeleton before and are wondering how to implement it in their own company. We appreciate your input, and we believe that focusing on practical guidance will enhance the utility and relevance of our work.

INTRODUCTION:

Q4) - There is a growing awareness of the risks of MusculoSkeletal Disorders (MSDs) in the workplace, which can result from repetitive or intensive manual tasks.

-> add references.

A4) We added the references from both medical and industrial studies on MSDs and repetitive movements performed at work.

Q5) - In addition, the potential benefits of exoskeletons for workers in industries such as manufacturing, construction, and healthcare are becoming more widely documented.

-> add references.

A5) We added the references as requested.

Q6) - These devices, which may give more support and control than passive exoskeletons, are commonly utilized in sectors where workers do physically demanding activities, such as aerospace, defense, and healthcare.

-> that is not true. A lot of active exoskeletons are developed to be used also in manufacturing, construction, and agriculture.

A6) We believe that there was a misunderstanding in our statement, which does not deny the use of active exoskeletons in manufacturing, construction, and agriculture, as you suggest. However, current practice shows that the use of active exoskeletons, which are usually heavier and bulkier (and more expensive), is less popular in such sectors. For the sake of clarity, we added the following statement: “However, numerous active exoskeletons have been developed for deployment in manufacturing, construction, and agriculture contexts.”

MATERIALS AND METHODS:

Q7) - Figure 1: remove "-400" it has no meaning as it is the number of publications. 

A7) We deleted the label as suggested.

RESULTS:

Q8) - you stated that you included 121 studies. Why there are a total of 263 different exoskeleton prototypes? 

Moreover, in Figure 3 there are 291 studies and 254 studies that investigated perceived usability and muscle activity. How is this possible?

A8) 121 is the number of documents included in this research, i.e. the papers that met the inclusion criteria described in Section 2. Some of the papers included in this research were reviews which collected data from studies on multiple devices. This is the reason of a greater number of exoskeletons (263 included both prototypes and commercial devices) compared with the number of papers included. Furthermore, data on the same exoskeleton that appeared in multiple papers, e.g. in a research paper and in a review study, were included in the present research once. Finally, more than one study may have investigated the same type of exoskeleton, i.e. the caption of Figure 3 refers to the studies (not the documents nor the exoskeletons).

Q9) - I suggest considering together Back (whole) + Back (lumbar) + Back (spine) + Back (trunk) and Upper limbs + shoulder to provide more valuable and useful results and considerations.

Moreover, in the following, many times you discussed the results or the considerations about the back-support exoskeletons together without distinguishing between the different back parts, so keeping them together will also be better for improving consistency e.g., lines 516, 715.

A9) We appreciate the reviewer's suggestion to consider consolidating the categorization of variables, such as "Back (whole) + Back (lumbar) + Back (spine) + Back (trunk)" and "Upper limbs + shoulder," for potentially more valuable insights. However, we have chosen to maintain consistency with the terminology utilized in the original paper, respecting the authors' specific categorizations in each study.

Moreover, we believe that grouping "Back (lumbar)" with "Back (spine)" or "Upper limbs" with "shoulder" may lead to an overly broad generalization, as these anatomical regions can have distinct biomechanical implications and considerations. This approach allows us to preserve the specificity and nuance within each study's context and findings.

Q10) - Figure 2: Are you sure that when measuring the EMG, all these studies have analyzed muscle fatigue? I suggest replacing it with "muscle activity (EMG)".

A10) We agree with you and we have adjusted the label in the graph, as you suggested.

Q11) - line 209 start a new paragraph.

- line 238 start a new paragraph.

- line 316 start a new paragraph.

- line 327 start a new paragraph.

- line 334 start a new paragraph.

A11) We started new paragraphs where you suggested.

Q12) - How do you define safety improvement and deterioration? 

There is no clear definition of safety regarding exoskeletons' assistance, so I have strong concerns about the results presented in this section. From 426 to 439, you wrote many potential negative effects associated with exoskeleton use, but they are not directly related to safety (e.g., increased leg muscle activity: how this could decrease safety?).

The results of safety improvement and deterioration in Figure 5 are based on YOUR definition of safety or on the studies' authors definition?

Q 13) Moreover, in Figure 5: the positive effects you have found on active and passive exoskeletons (5A) in which body areas were? 

There are shown no positive effects on 5C.

A12) We acknowledge the reviewer's valid concern regarding the definition of safety improvement and deterioration in the context of exoskeleton assistance. We considered “safety” as the state or condition of being protected from harm, injury, danger, or risk. We share the same reservations that arose when reviewing the literature, as the exact delineation of safety in relation to exoskeleton use remains somewhat ambiguous. Therefore, we opted to consider the data as reported by the authors of the individual analyzed papers, while being fully aware that such results cannot be regarded as absolute, particularly in the absence of long-term studies conducted over sufficiently extended observation periods. The issue of defining safety criteria for exoskeletons is indeed a complex one, and we appreciate the reviewer's observation. It underscores the need for standardized safety metrics and long-term investigations to establish a more comprehensive understanding of the safety implications associated with exoskeleton utilization, as we remarkerd in our discussion and conclusions.

A13) One possible explanation for the lack of explicit studies indicating safety improvements might be the focus on the exoskeleton's support of an individual's activity, potentially leading to health benefits rather than direct safety enhancement. As exemplified in the mentioned paper, the negative aspects often considered for lower limb exoskeletons encompass potential adverse effects related to increased leg muscle activity, elevated discomfort levels, and muscle deconditioning. These factors can subsequently give rise to safety concerns, such as balance loss or motor difficulties that may lead to collisions with obstacles. Finally, while we stated, "there have been limited instances where the use of passive exoskeletons has resulted in improved safety conditions, such as with arm support exoskeletons," please note that references to other studies reporting safety improvements following exoskeleton use are present.

Q14) - line 543 type of locomotion -> type of actuation.

A14) Edited.

Q15) - from line 554 to 571 you mainly discussed the limitations of the subjective assessment.

As you are trying to summarize the total results of the exoskeleton assessment, the detailed description of the limitations is irrelevant, so keep it shorter.

A15) We reduced this paragraph as suggested.

DISCUSSION:

Q16) - in the first part of the discussion there are all the effects mixed between exoskeletons that support different body parts, so it is a bit confusing.

A16) We have adjusted this paragraph making it leaner and more concise.

Q17)

- line 621 start a new paragraph.

- line 679 start a new paragraph.

- line 689 do not start a new paragraph.

- line 706 start a new paragraph.

A17) We started the new paragraphs where you suggested and joined the contents in lines 689 and 690..

Q18) - I disagree with why step 2 should be before step 3. There is no "fixed" situation in which passive exoskeletons should be preferred instead of active exoskeletons (or the opposite).

(Moreover, you repeated several times in the paper that passive exoskeletons should not be used when there are possible collisions, but I do not see how active exoskeletons can be a better decision in case of collisions.)

First, you decide the body areas to be supported, then select the best exoskeleton to assist that body area for the specific tasks.

A18) We definitely agree with you and we are sorry about this mistake because it is not actually want we have accidentally inverted the two steps, which now appear in the correct order.

Regarding your statement “Moreover, you repeated several times in the paper that passive exoskeletons should not be used when there are possible collisions, but I do not see how active exoskeletons can be a better decision in case of collisions” we believe that there was a further misunderstanding of our statement, i.e. when we state that passive exoskeletons should not be used when there are possible collisions we do not mean that active exoskeletons are better options.

CONCLUSION

Q19) - from line 883 To line 920 you repeated the same concept over and over.

You can summarize these lines in much FEWER sentences.

e.g., "However, caution is warranted, as the evidence regarding the effectiveness of exoskeletons in reducing the risk of MSDs is lacking." 

Then the next sentence gives exactly the same information:

"The current body of research on occupational exoskeletons lacks sufficient evidence regarding their long-term effects on reducing MSDs."

some sentences later:

"Overall, without robust long-term research, it is challenging to provide conclusive evidence that exoskeletons effectively reduce MSDs in the occupational setting".

A19) We stressed such concept because we believe it is of extremely importance. However, we agree with you and we deleted repetitions to make this section more concise

Author Response File: Author Response.pdf

Reviewer 2 Report

Thank you for the opportunity to review this very interesting and valuable paper summarising the current status of occupational exoskeletons. My comments are as follows:

1.      While the paper is generally well-written, I struggled with reading it due to the lack of paragraph structuring and signposting, meaning there were very long passages, even pages of dense text to navigate, detracting from the story the researchers are trying to tell.

Please restructure your paper into paragraphs within the structured headings where each new idea or topic has a new paragraph, and this will assist the reader to navigate the distinct points being raised and be better able to evaluate their merit. Page 8 provides an example of what I mean – it is one full page of text with no structure and very difficult to process. Use of sub-headings will also help minimise the perception of repetition of information for each type of exoskeleton, e.g. reporting of the various outcome criteria – productivity, safety, health, comfort etc.

2.      The materials and methods section, while well-written is complex and has various steps involved. The section would benefit from a graphic describing the steps involved, the numbers of documents considered at each step, and a brief description of the criteria for inclusion, exclusion. I envisage something similar to the PRISMA structure used in systematic reviews.

3.      The graph in Figure 1 is a useful inclusion for summarising the rise of interest in research into exoskeletons across the time period of the study, adding weight to the value of the topic as a research focus.

4.      The Results section is generally well-written and provides useful summaries both in the text and supported with the figures. You have done a good job of working from the broad to the specific detail in your summary of the extracted studies.

 The Results section is mapped well against the respective research questions, summarising the data to present a balanced interpretation, with good critique of key studies.

5.      The Discussion section is also well-written and as required should take an overview of the findings and synthesise them into an interpretation and their relevance to research, practice, policy and education/training. The respective sections address such a broader view i.e. active versus passive versus hybrid and value of each, insights on exoskeletons value based on analysis of supported body areas, and the systematic approach to adopting exoskeletons in the workplace (one of the most important aspects of technology adoption).

To my mind there appeared to be a degree of repetition between the Results section and the Discussion. It may help reduce this perception if the Results section made use of sub-headings distinguishing types of exoskeleton then followed by the findings for each outcome criterion.

I would like to see the content of the Discussion section rationalised to remove repetition and focus on high level summary findings, paring away some of the information already well described in the Results section. You have done a good job of summarising the overall findings in percentages of studies and readers will find this very useful in drawing conclusions on the detail reported earlier in the paper.

6.      The Conclusion is very long and to my mind contains much of the information I would expect to see discussed in the Discussion, though correctly does not enter into critique. The Conclusion section should not introduce new information, rather it should draw together the key points of the paper into distinct findings that address the research questions.

7.      The Table 1 summarising the systematic approach to adoption is an important contribution in your paper. It recommends in step 1: Evaluation of workplace and identification of demand and barriers of organisation and activities.

Step 1 should also include analysis of existing injury occurrences over a prolonged period to identify patterns, also initiate the consultation phase with the workforce about reasons for implementation, how to be implemented and issues and concerns that may need to be addressed prior to implementation. Most occupational health and safety legislation requires such consultation when implementing changes in a workplace.

Step 5 – should also include screening individual users for health and safety risk factors such as underlying health conditions - cardiac risks, hypertension, existing MSDs at least using self-report data, such as a questionnaire.

On page 19- line 801 the text states Customization and modification options should be addressed to guarantee long-term safety and user comfort. Individual preferences and requirements should be accommodated by exoskeletons and workplaces. This may include including aspects that allow for personalization and adjustments to provide the best fit and comfort for each user. By providing flexibility in the design, it becomes possible to meet the unique requirements of different individuals and enhance overall user satisfaction

This is essential – exoskeletons are worn devices and must be tailored to each individual’s needs to prevent further injury, discomfort and increase safety risks.

Table 1 needs more emphasis on the organisational preparation for implementation with a focus on change management processes, which need to be mentioned and defined.

Overall a well-written and researched paper with valuable contributions to the literature and practice of using exoskeletons in industry. Appropriate suggestions are provided for future research.

However I am recommending a major revision related to the significant restructuring of the content required to make this paper easier to read and interpret.

I also make a few suggestions for minor edits to grammar or typographical changes as follows:

Abstract line 17 – suggest replace ‘get a better’ with ‘gain knowledge’

p. 1 Introduction – line 35 delete ‘of’ after comprise

p. 2 line 45 delete ‘into’ following ‘investigated’

p. 2 line 71 – delete ‘most tough’ and replace with ‘toughest’

p. 2 line 92 – delete ‘in this paper’ – it is redundant

Overall the quality of English is excellent - very few and minor issues identified as per end of written comments

Author Response

Dear Referees,

we would like to thank you for allowing us to improve our paper and to review our work.

We appreciated your valuable suggestions, and we thank you for this effort in revising our paper. You will find in this document the replies to your suggestions. Revisions in the manuscript are in blue.

We deeply hope that you will appreciate our work.

Yours sincerely,

The authors

Reviewer 2

Thank you for the opportunity to review this very interesting and valuable paper summarising the current status of occupational exoskeletons. My comments are as follows: 
1.    While the paper is generally well-written, I struggled with reading it due to the lack of paragraph structuring and signposting, meaning there were very long passages, even pages of dense text to navigate, detracting from the story the researchers are trying to tell. 
Please restructure your paper into paragraphs within the structured headings where each new idea or topic has a new paragraph, and this will assist the reader to navigate the distinct points being raised and be better able to evaluate their merit. Page 8 provides an example of what I mean – it is one full page of text with no structure and very difficult to process. Use of sub-headings will also help minimise the perception of repetition of information for each type of exoskeleton, e.g. reporting of the various outcome criteria – productivity, safety, health, comfort etc. 
A1) We agree with you and we added sub-section to our “heavy” sections, e.g. Section 1. We also reduced the overall length of the paper to make it more concise, as suggested by Reviewer 1. 

2.    The materials and methods section, while well-written is complex and has various steps involved. The section would benefit from a graphic describing the steps involved, the numbers of documents considered at each step, and a brief description of the criteria for inclusion, exclusion. I envisage something similar to the PRISMA structure used in systematic reviews. 
A2) Thank you for this useful suggestion. We have added Figure 2 which represents a graphical description of the adopted article selection protocol.

3.    The graph in Figure 1 is a useful inclusion for summarising the rise of interest in research into exoskeletons across the time period of the study, adding weight to the value of the topic as a research focus. 
A3) Thank you for your feedback, this is exactly the message that we wanted to give to our readers 

4.    The Results section is generally well-written and provides useful summaries both in the text and supported with the figures. You have done a good job of working from the broad to the specific detail in your summary of the extracted studies. The Results section is mapped well against the respective research questions, summarising the data to present a balanced interpretation, with good critique of key studies. 
A4) Thank you very much indeed for this comment. We really appreciate your feedback.

5.    The Discussion section is also well-written and as required should take an overview of the findings and synthesise them into an interpretation and their relevance to research, practice, policy and education/training. The respective sections address such a broader view i.e. active versus passive versus hybrid and value of each, insights on exoskeletons value based on analysis of supported body areas, and the systematic approach to adopting exoskeletons in the workplace (one of the most important aspects of technology adoption). 
To my mind there appeared to be a degree of repetition between the Results section and the Discussion. It may help reduce this perception if the Results section made use of sub- headings distinguishing types of exoskeleton then followed by the findings for each outcome criterion. I would like to see the content of the Discussion section rationalised to remove repetition and focus on high level summary findings, paring away some of the information already well described in the Results section. You have done a good job of summarising the overall findings in percentages of studies and readers will find this very useful in drawing conclusions on the detail reported earlier in the paper. 
A5) Thank you for this suggestion. We agree with you and we have added sub-sections to the longest sections in our manuscript. 

6.    The Conclusion is very long and to my mind contains much of the information I would expect to see discussed in the Discussion, though correctly does not enter into critique. The Conclusion section should not introduce new information, rather it should draw together the key points of the paper into distinct findings that address the research questions. 

A6) We reduced the length of both our Conclusions and Discussion, to make them more concise.

7.    The Table 1 summarising the systematic approach to adoption is an important contribution in your paper. It recommends in step 1: Evaluation of workplace and identification of demand and barriers of organisation and activities. 
Step 1 should also include analysis of existing injury occurrences over a prolonged period to identify patterns, also initiate the consultation phase with the workforce about reasons for implementation, how to be implemented and issues and concerns that may need to be addressed prior to implementation. Most occupational health and safety legislation requires such consultation when implementing changes in a workplace. 
A7.1) We edited Step1.2 including the importance of analysing historical injury occurances and the commencement of the consultation phase with the workforce

Step 5 – should also include screening individual users for health and safety risk factors such as underlying health conditions - cardiac risks, hypertension, existing MSDs at least using self- report data, such as a questionnaire. 
A7.2) We added this information in the description of Step5, stating that the step should include the screening of individual users for health and safety risk factors, such as underlying health conditions. 

On page 19- line 801 the text states Customization and modification options should be addressed to guarantee long-term safety and user comfort. Individual preferences and requirements should be accommodated by exoskeletons and workplaces. This may include including aspects that allow for personalization and adjustments to provide the best fit and comfort for each user. By providing flexibility in the design, it becomes possible to meet the unique requirements of different individuals and enhance overall user satisfaction 
This is essential – exoskeletons are worn devices and must be tailored to each individual’s needs to prevent further injury, discomfort and increase safety risks. 
A7.3) We remarked this concept adding the following statement in the last sub-section of our discussion: “[Exoskeletons] necessitate customization to cater to the specific requirements of each individual. This customization is crucial to mitigate the risk of exacerbating injuries, minimize discomfort, and enhance safety.”

Table 1 needs more emphasis on the organisational preparation for implementation with a focus on change management processes, which need to be mentioned and defined. 
A7.4) We added a focus on these important aspects in Step 5.1, where practitioners are invited to implement the selected exoskeletons gradually.

8.    Overall a well-written and researched paper with valuable contributions to the literature and practice of using exoskeletons in industry. Appropriate suggestions are provided for future research. 
However I am recommending a major revision related to the significant restructuring of the content required to make this paper easier to read and interpret. 

A8) We have restructured the paper by introducing subheadings to enhance structural clarity. Furthermore, we have conducted concise synthesis of sections that may have appeared dense or redundant. Please see the edits in blue in the manuscript.

9.    I also make a few suggestions for minor edits to grammar or typographical changes as follows: 

Abstract line 17 – suggest replace ‘get a better’ with ‘gain knowledge’
p. 1 Introduction – line 35 delete ‘of’ after comprise
p. 2 line 45 delete ‘into’ following ‘investigated’ 
p. 2 line 71 – delete ‘most tough’ and replace with ‘toughest’ p. 2 line 92 – delete ‘in this paper’ – it is redundant 

A9) Thank you very much for your suggestions. We adjusted the manuscript accordingly.

Author Response File: Author Response.pdf

Round 2

Reviewer 2 Report

The resubmitted manuscript is much improved with restructuring that allows the story to be followed more easily, facilitating the weighing up of the evidence and the reader's ability to form an understanding of the state of the art.

This paper is well-written overall and comprehensive providing a valuable resource to academics, practitioners and industry decision makers on the advantages, disadvantages and potential applications and risks of implementing occupational exoskeletons. A particular strength is the framework for implementation, providing evidence-informed practical advice on how to proceed.

The authors have done an excellent job in writing in English however there remain some minor edits I recommend to ‘smooth out’ the flow as follows:

p. 3 line 119 – replace ‘next’ with ‘near’ before ‘future’

p. 7 line 226 – delete ‘a’ in front of ‘certain work’

p. 7 line 239 is labelled as Section 3.1 which is also a sub-heading on p. 4  - the authors need to check the sequencing of the numbered headings and sub-headings throughout the full paper to ensure they are correct.

p. 15 Table 1 – Step 2 ‘occurrences’ is misspelled and delete ‘the’ in front of ‘consultation’

p. 17 line 661 – this paragraph remains a large block of text and is not easy to navigate. Suggest making a new paragraph starting with ‘Work performance….’

p. 19 Conclusion section – as above – this is still a large block of dense text containing many distinct ideas that should be separated – suggest a new paragraph at line 445 starting with ‘Future studies….’

p. 19 Conclusion section – as above - suggest a new paragraph at line 750 starting with ‘The field……’

These are all minor editing changes that will enhance the readability of your paper.

The editorial team can ensure these relatively minor changes are made and I do not wish to see the paper again in review but look forward to seeing it published in the near future.

High quality of written English but minor issues with prepositions (i.e. words that join main ideas in sentences - as I have indicated in my suggested minor edits). These often arise due to minor differences in translation and native speakers tend to use short cuts. The authors overall have done a great job with their writing but need to be more aware of the power of well-placed paragraphs.

Author Response

Dear Referee,

we would like to thank you again for your precious suggestions. Revisions in the manuscript are in blue.

We deeply hope that you will appreciate our work.

Yours sincerely,

The authors

Reviewer 1

The resubmitted manuscript is much improved with restructuring that allows the story to be followed more easily, facilitating the weighing up of the evidence and the reader's ability to form an understanding of the state of the art.

This paper is well-written overall and comprehensive providing a valuable resource to academics, practitioners and industry decision makers on the advantages, disadvantages and potential applications and risks of implementing occupational exoskeletons. A particular strength is the framework for implementation, providing evidence-informed practical advice on how to proceed.

The authors have done an excellent job in writing in English however there remain some minor edits I recommend to ‘smooth out’ the flow as follows:

Q1) p. 3 line 119 – replace ‘next’ with ‘near’ before ‘future’

1. 7 line 226 – delete ‘a’ in front of ‘certain work’

A1) All corrections done.

Q2) p. 7 line 239 is labelled as Section 3.1 which is also a sub-heading on p. 4  - the authors need to check the sequencing of the numbered headings and sub-headings throughout the full paper to ensure they are correct. 

A2) All subsections checked and corrected.

Q3) p. 15 Table 1 – Step 2 ‘occurrences’ is misspelled and delete ‘the’ in front of ‘consultation’

A3) All corrections done.

Q4) p. 17 line 661 – this paragraph remains a large block of text and is not easy to navigate. Suggest making a new paragraph starting with ‘Work performance….’

A4) Done.

Q5) p. 19 Conclusion section – as above – this is still a large block of dense text containing many distinct ideas that should be separated – suggest a new paragraph at line 445 starting with ‘Future studies….’

A5) Done.

Q6) p. 19 Conclusion section – as above - suggest a new paragraph at line 750 starting with ‘The field……’

A6) Done.

These are all minor editing changes that will enhance the readability of your paper.

The editorial team can ensure these relatively minor changes are made and I do not wish to see the paper again in review but look forward to seeing it published in the near future.

Author Response File: Author Response.docx