Challenges in the Development of Exoskeletons for People with Disabilities

Round 1

Reviewer 1 Report

Comments and Suggestions for Authors

This article is is current and relevant. Presents a structured and comprehensive synthesis of the challenges in the development and implementation of exoskeletons for people with disabilities. It integrates interdisciplinary perspective, including biomedical engineering, robotics, rehabilitation, and disability studies. It highlights the transformative potential of wearable robotics in rehabilitation and daily life. It is interesting the inclusion Sustainable Development Goals. The manuscript is generally well-written, but some minor grammatical inconsistencies and occasional repetitions.

From a methodological perspective, it is sound but can be improved.  It is somewhat short and superficial. The authors indicate using PRISMA® guidelines, with defined inclusion and exclusion criteria and outline the research questions guiding the analysis. However, it could have more description and clarity in the methods. It must be gathered in this section (some are scattered). The explicit full search algorithms and time periods used should explicit here (which are in the results section). Additionally, the quality assessment of the included studies should be exposed in the body of the article and not only the scoring matrix and include critical comparison across findings.

Additionally figure 2 must be figure 1. And the following must be renumbered. 

Author Response

REVIEWER 1

We sincerely thank the reviewer for their time and valuable comments, which have significantly contributed to improving the quality of our manuscript.

Comment 1

This article is is current and relevant. Presents a structured and comprehensive synthesis of the challenges in the development and implementation of exoskeletons for people with disabilities. It integrates interdisciplinary perspective, including biomedical engineering, robotics, rehabilitation, and disability studies. It highlights the transformative potential of wearable robotics in rehabilitation and daily life. It is interesting the inclusion Sustainable Development Goals.

The manuscript is generally well-written, but some minor grammatical inconsistencies and occasional repetitions.

Response 1

The entire document has been revised, unnecessary repetitions have been eliminated and grammatical inconsistencies have been improved, in addition to this, new findings have been incorporated in the results section.

Comment 2

From a methodological perspective, it is sound but can be improved.  It is somewhat short and superficial. The authors indicate using PRISMA® guidelines, with defined inclusion and exclusion criteria and outline the research questions guiding the analysis. However, it could have more description and clarity in the methods. It must be gathered in this section (some are scattered). The explicit full search algorithms and time periods used should explicit here (which are in the results section).

Response 2

The inclusion and exclusion criteria have been drafted in greater detail, in addition to this the search strings used for the search of documents have been placed.

Comment 3

Additionally, the quality assessment of the included studies should be exposed in the body of the article and not only the scoring matrix and include critical comparison across findings.

Response 3

The evaluation criteria in Table 1 present the questions to evaluate the quality of the articles and their contribution. In the methodology, an appointment is added to access the Mendeleydata dataset in which the details of this review and the Quality Assessment are described in spreadsheet number 5.

https://data.mendeley.com/datasets/6rd4h8b44m/1

Comment 4

Additionally figure 2 must be figure 1. And the following must be renumbered.

Response 4

Fixed the numbers of all figures in the manuscript.

 

Reviewer 2 Report

Comments and Suggestions for Authors

The manuscript has been well-structed, please consider the following suggestions for revision.

1. No Fig. 1 in the manuscript.
2. The text in Fig. 2 is too small and difficult to read.
3. In Fig. 5, the x-axis labels are unclear. Although the manuscript mentions "ten segments of similar samples," it remains ambiguous what these segments specifically represent. Please consider replacing the numeric labels (e.g., 1, 2, 3, ..., 10) with more descriptive names that reflect the underlying sample characteristics or conditions.
Additionally, the legend includes terms with wildcard characters (e.g., “disabilit*”) and prefixes such as “1)” without explanation.
4. The manuscript exhibits inconsistent paragraph indentation throughout the text
5. Although the PRISMA® checklist is mentioned, details such as the full search strategy and database-specific search strings are not fully presented.
6. Is there any limitation of this study.
7. Please ensure consistency in the use of capitalization across all figure labels and annotations.

 

Author Response

REVIEWER 2

We sincerely thank the reviewer for their time and valuable comments, which have significantly contributed to improving the quality of our manuscript.

Comment 1

The manuscript has been well-structed, please consider the following suggestions for revision.

No Fig. 1 in the manuscript.

Response 1

The respective numbering has been corrected

Comment 2

The text in Fig. 2 is too small and difficult to read.

Response 2

The font size has been checked according to the respective format.

Comment 3

In Fig. 5, the x-axis labels are unclear. Although the manuscript mentions "ten segments of similar samples," it remains ambiguous what these segments specifically represent. Please consider replacing the numeric labels (e.g., 1, 2, 3, ..., 10) with more descriptive names that reflect the underlying sample characteristics or conditions. Additionally, the legend includes terms with wildcard characters (e.g., “disabilit*”) and prefixes such as “1)” without explanation. Additionally figure 2 must be figure 1. And the following must be renumbered.

Response 3

The segments of the numbers of the X-axis have been included in the graph, additionally the use of * as a bounded search for words with different endings has been explained

Comment 4

The manuscript exhibits inconsistent paragraph indentation throughout the text

 

Response 4

Indentation has been revised and corrected throughout the document according to the reference format.

Comment 5

Although the PRISMA® checklist is mentioned, details such as the full search strategy and database-specific search strings are not fully presented.

 

Response 5

The criteria for inclusion and exclusion of the reference documents have been described in greater detail, and the table with the search strings used for each of the repositories has been included.

Comment 6

Is there any limitation of this study.

Response 6

It is mentioned in the text that there are no long-term studies on the use of exoskeletons for people with disabilities, which is a great limitation. In the same way, the discussion addresses the lack of clinical evidence and factors that hinder the implementation of these devices.

Comment 7

Please ensure consistency in the use of capitalization across all figure labels and annotations

Response 7

Improved this aspect in shape labels.

 

Reviewer 3 Report

Comments and Suggestions for Authors

The manuscript is well organized and follows the PRISMA framework for systematic reviews, which lends it strong methodological rigor. It surveys all major facets of the field—ranging from exoskeleton typologies and state-of-the-art technologies (AI, BCI, soft robotics, SMAs) to comparisons between general-purpose devices and systems tailored for people with disabilities. The sources reviewed are current, and the authors propose plausible solutions while outlining future research avenues.

To raise the scientific quality of the paper, however, I recommend several revisions. The narrative should be tightened by eliminating lengthy paragraphs and repetitive phrasing, establishing smoother logical transitions between sections, and improving the clarity of selected figures. Although the literature analysis is thorough, it does not culminate in an explicit authorial stance or even in a taxonomy of the field’s critical challenges. A more detailed comparative analysis would greatly enhance the contribution.

Author Response

REVIEWER 3

We sincerely thank the reviewer for their time and valuable comments, which have significantly contributed to improving the quality of our manuscript.

Comment 1

The manuscript is well organized and follows the PRISMA framework for systematic reviews, which lends it strong methodological rigor. It surveys all major facets of the field—ranging from exoskeleton typologies and state-of-the-art technologies (AI, BCI, soft robotics, SMAs) to comparisons between general-purpose devices and systems tailored for people with disabilities. The sources reviewed are current, and the authors propose plausible solutions while outlining future research avenues. To raise the scientific quality of the paper, however, I recommend several revisions.

The narrative should be tightened by eliminating lengthy paragraphs and repetitive phrasing, establishing smoother logical transitions between sections, and improving the clarity of selected figures.

Response 1

The wording has been improved, contributions from other reviewers have been incorporated and the organization of the document has been verified, in addition, the figures of the document have been better described.

Comment 2

Although the literature analysis is thorough, it does not culminate in an explicit authorial stance or even in a taxonomy of the field’s critical challenges. A more detailed comparative analysis would greatly enhance the contribution.

Response 2

The technical challenges have been enriched with sources that evidence developments to address the mostly technical challenges (new Table 4). Additional aspects have been discussed, such as the lack of clinical evidence and the lack of regulations and problems of adoption and coverage of health insurance that do not yet consider the use of exoskeletons.

 

Reviewer 4 Report

Comments and Suggestions for Authors

1. The manuscript claims to be a systematic review, but the formulation of the research questions (RQs) and their operationalization in the review process lacks sufficient depth. Please clarify how each RQ was addressed throughout the sections, especially in the results and discussion, to ensure traceability of findings back to the objectives.

 

2. The methodology section mentions adherence to PRISMA® guidelines, yet the description of the search strategy and inclusion/exclusion criteria lacks transparency and reproducibility. Provide the exact search strings used across all databases and justify the exclusion of engineering-focused papers on algorithms and modeling, which could contain relevant user-centered insights.

 

3. The review heavily emphasizes challenges and future directions but only provides limited comparative synthesis of existing solutions across different device types. Consider integrating a comparative matrix or thematic synthesis to consolidate current innovations that have addressed each class of challenge (technical, economic, usability, and acceptance).

 

4. Despite highlighting various exoskeleton models, there is no critical appraisal or quality assessment of the studies referenced. Without evaluating the robustness of the cited works, the claims of effectiveness and limitations risk being perceived as anecdotal. Please include a qualitative assessment summary of the key studies reviewed.

 

5. The bibliometric visualization on page 2 (Figure 2) is descriptive but underutilized analytically. Expand on how the clustering analysis informs the current research gaps or overlaps among rehabilitation robotics, user experience, and demographic inclusivity.

 

6. There is extensive repetition in the description of technical and usability challenges across sections 3.3.1 to 3.3.4 and later in the discussion (Section 4). Please consolidate and streamline these sections to avoid redundancy while maintaining depth.

 

7. To enhance the technical depth and interdisciplinary relevance of the discussion on control system challenges in exoskeleton development, the authors are encouraged to read “Distributed Real-Time Control Architecture for Electro-Hydraulic Humanoid Robots”. This work provides a robust reference for decentralized control frameworks that could inspire more adaptable and energy-efficient solutions in exoskeletons for people with disabilities.

 

8. Given the increasing emphasis on intelligent control and personalized user interaction in wearable assistive devices, the authors should read “A Review of AIoT-based Human Activity Recognition: From Application to Technique”. This article offers a comprehensive perspective on how AI and IoT integration can improve human intent recognition and activity adaptation, which is particularly relevant to addressing usability and control system limitations highlighted in this manuscript.

 

9. The narrative often relies on generic claims such as "AI will transform the field" without specific illustrations or examples from the included literature. Strengthen such statements with evidence from existing exoskeleton systems that have integrated AI-based control or personalization features.

 

10. The PRISMA flow diagram (page 5) lacks numerical detail for each stage of filtering (e.g., number of full-text exclusions by reason). Include a clear breakdown and explanation to enhance transparency and adherence to review standards.

 

11. Figure 6 and Figure 7 offer conceptual overviews of current challenges and future prospects, but they are not adequately integrated into the textual argument. Reference them explicitly and interpret their structural hierarchy to deepen the discussion.

 

12. While the paper emphasizes inclusivity and social relevance, the review omits perspectives from users or clinical practitioners. If such data were not available in the reviewed literature, this limitation should be acknowledged explicitly and discussed.

 

13. There is a missed opportunity to frame the discussion within the context of regulatory, reimbursement, and clinical validation pathways, which are critical barriers to adoption. Consider adding a subsection to address these structural and policy-related dimensions.

 

14. Although Table 2 (page 8) compares general vs. disability-specific exoskeletons, it remains superficial. Expand the table or add supplementary material to include examples, control modalities, and application settings to substantiate the comparative claims.

Author Response

REVIEWER 4

We sincerely thank the reviewer for their time and valuable comments, which have significantly contributed to improving the quality of our manuscript.

Comment 1

The manuscript claims to be a systematic review, but the formulation of the research questions (RQs) and their operationalization in the review process lacks sufficient depth. Please clarify how each RQ was addressed throughout the sections, especially in the results and discussion, to ensure traceability of findings back to the objectives.

Response 1

It has been described in the methodology how each RQ was addressed in the results and discussion sections.

The proposed research questions allowed us to recover conclusions and criteria on the de-velopment of exoskeletons designed and evaluated for people with disabilities. RQ1 has made it possible to compile studies and updates from the last ten years. RQ2 made it pos-sible to identify the main functions performed by exoskeletons for people with disabilities and to contrast them with the functions of other types of exoskeletons. RQ3 has provided relevant information on the challenges and limitations, which have been classified into technological challenges, usability, costs, user acceptability and other aspects such as complexity in interaction, security and limitations of daily use. RQ4 presented useful and baseline information for future exoskeleton developments in this area.     

Comment 2

The methodology section mentions adherence to PRISMA® guidelines, yet the description of the search strategy and inclusion/exclusion criteria lacks transparency and reproducibility. Provide the exact search strings used across all databases and justify the exclusion of engineering-focused papers on algorithms and modeling, which could contain relevant user-centered insights.

Response 2

The explanation of the inclusion and exclusion criteria has been improved, in addition the Table containing the text string for the search of reference articles has been added.

 

2.1 Inclusion criteria

Journal articles and conference papers that address the use of exoskeletons for people with disabilities have been chosen for information extraction. Review articles that describe the challenges from multiple approaches and recommend solutions to improve the performance and usability of exoskeletons have been preferred. The search terms included the following words: “challenges, exoskeleton, disabilities” (Table 2). Publications from the last ten years that preferably have first or second quartile in their journals according to the SJR Scimago ranking have been considered.

In addition, other sources have been used, such as reports from official websites related to the development of exoskeletons for disabilities. The study has been expanded to include articles specifically designed for particular disabilities.

 

Table 2. Cadenas de busqueda de articulos de referencia en literature científica

Database	String search	Studies number
ProQuest	exoeskeletons (Topic) and disabilities (Topic)	100
Taylor & Francis	[Abstract: exoeskeletons challenges] AND [Abstract: disabilities]	91
Scopus	ALL ( "exoeskeletons "disabilities""challenges" )	25
Science Direct	"exoeskeletons" "technologies"" disabilities"	167
PubMed	Search: (exoeskeletons) AND (disabilities)AND (Technologies)	14
	Total number of studies	397

 

2.2 Exclusion Criteria

Publications that did not explicitly focus on improving performance or functional strengthening of exoskeletons aimed at people with disabilities were excluded. This review prioritised user-centred contributions, particularly those that addressed aspects such as usability, comfort, adaptability, security or functional outcomes achieved with the use of the device. Therefore, we did not consider studies whose primary focus was theoretical or technical—for example, kinematic or dynamic modeling, control strategies, signal processing algorithms, or hardware design—unless they explicitly demonstrated their impact on the experience of the user with disabilities.

Papers that dealt with purely mechanical, electromechanical, or electrical systems without a direct relationship to user-centered performance metrics were also excluded. This included studies focused on sensor calibration, motor controller design, or simulations without experimental or clinical validation with people with disabilities. The aim of these exclusion criteria was to ensure that the review maintained a practical and user-oriented approach, avoiding technical developments that do not directly translate into functional improvements or greater accessibility of exoskeleton systems.

 

Comment 3

The review heavily emphasizes challenges and future directions but only provides limited comparative synthesis of existing solutions across different device types. Consider integrating a comparative matrix or thematic synthesis to consolidate current innovations that have addressed each class of challenge (technical, economic, usability, and acceptance).

Response 3

Table 3 has been added describing challenges linked to the technical field and studies with proposals to address the challenges described.

Table 3 summarizes the main challenges and proposed solutions in the design of exoskeletons for individuals with disabilities, organized into five key categories. In the mechanical and ergonomic field, problems such as joint misalignment [68], excessive weight [69] and the possibility of mechanical failures [70] stand out, which are addressed through highly customizable designs [71] and the use of lightweight materials such as those obtained by 3D printing [72]. In terms of control and sensing, complexity in algorithms [73] and sensor failures [74] are addressed using evolutionary computation methods, such as genetic algorithms [75], and technologies like force myography (FMG) [76]. In the field of energy management, high consumption is recognized as a limitation [70], for which the development of more efficient energy systems and regenerative solutions is proposed [74]. The interaction and safety category encompasses fall hazards and the need for adequate training [77], which is addressed through real-time monitoring, emergency training, and response programs. Finally, in customization and accessibility, the challenges of adapting devices to individual needs [71] and maintaining their affordability [9] are noted; these challenges are mitigated through economical manufacturing and the design of portable devices that do not require clinical supervision [72]. This classification enables us to visualize both the complexity of exoskeleton design and the emerging lines of research in recent literature.

 

    Tabla 3 Sintesis de algunos desafíos técnicos y contribuciones para solucionarlos                            

Category		Identified Challenges		Proposed Category
Mechanical and Ergonomic		"Joint misalignment and poor fit [70], [68]		"Highly customizable designs [69]; [78]
Control and Sensing		Excess weight and mobility restriction [69]; [72]		Use of lightweight materials and 3D printing [72]; [71]
Energy and Power		Mechanical failures [70]		"Evolutionary computation methods like genetic algorithms [75]
Interaction and Safety		"Complex control algorithms [70],[73]		Force myography (FMG) for reliable control [76]
Customization and Accessibility		Sensor failures and unreliable feedback [70];[74]		Efficient power systems and regenerative energy solutions [70]; [74]

 

Comment 4

Despite highlighting various exoskeleton models, there is no critical appraisal or quality assessment of the studies referenced. Without evaluating the robustness of the cited works, the claims of effectiveness and limitations risk being perceived as anecdotal. Please include a qualitative assessment summary of the key studies reviewed.

Response 4

As part of the methodology applied, we have evaluated the quality of the articles with the criteria in Table 1. The quality questions proposed in Table 1 allow us to identify and qualify the contribution of the articles on a standardized scale, the same that can be consulted in the dataset that corresponds to citation 19. In this dataset that can be consulted in the Mendeleydata repository (https://data.mendeley.com/datasets/6rd4h8b44m/1), the evaluation has been carried out and can be visualized in spreadsheet number 5. The final question evaluates the quartile of the journal and finally the contribution of the articles is evaluated on a normalized scale from 0 to 1.

Comment 5

The bibliometric visualization on page 2 (Figure 2) is descriptive but underutilized analytically. Expand on how the clustering analysis informs the current research gaps or overlaps among rehabilitation robotics, user experience, and demographic inclusivity.

Response 5

The bibliometric visualization generated by VOSviewer (Figure 2) enables us to iden-tify three main thematic clusters that structure the current research landscape on exoskel-etons for people with disabilities. The red cluster brings together studies focused on tech-nological development, with terms such as "exoskeleton robotics", "robotic skeletons" and "people with disabilities", and represents the core of research aimed at the design of robot-ic systems, sensors and control interfaces. This line of work focuses on improving the functionality, efficiency and accuracy of devices, seeking increasingly robust solutions for motor assistance. The green cluster, on the other hand, reflects an orientation towards the application and social impact of these technologies, addressing concepts such as "brain-computer interfaces", "quality of life" and "activities of daily living". This group fo-cuses on integrating the exoskeleton into the daily lives of users, with an emphasis on ac-cessibility, ergonomics, and customization tailored to specific needs. The blue cluster in-cludes demographic, perceptual and methodological research, with terms such as "male", "female" and "priority journal", which suggest an interest in the diversity of participants, the analysis of subjective experience, and sensory and emotional interaction with the de-vice.

Although these three dimensions address fundamental aspects of technological de-velopment, practical integration and user experience, the analysis of their interconnec-tions reveals a worrying thematic fragmentation. The connections between the technology cluster (red) and the experiential cluster (blue) are weak, making it challenging to design solutions that effectively respond to the experiences and needs of end-users. Similarly, although the green cluster reflects a concern for demographic inclusion, its links to senso-ry and emotional dimensions remain limited. This thematic separation highlights the ur-gent need for more interdisciplinary approaches that integrate engineering with us-er-centered design and the social sciences. Only through greater convergence between these areas will it be possible to move towards exoskeletons that are truly effective, acces-sible, culturally accepted and ethically designed to improve the quality of life of people with disabilities.

Comment 6

There is extensive repetition in the description of technical and usability challenges across sections 3.3.1 to 3.3.4 and later in the discussion (Section 4). Please consolidate and streamline these sections to avoid redundancy while maintaining depth.

Response 6

The wording has been improved so as not to repeat the same ideas and to focus them better on the aspect they address according to their theme.

Comment 7

To enhance the technical depth and interdisciplinary relevance of the discussion on control system challenges in exoskeleton development, the authors are encouraged to read “Distributed Real-Time Control Architecture for Electro-Hydraulic Humanoid Robots”. This work provides a robust reference for decentralized control frameworks that could inspire more adaptable and energy-efficient solutions in exoskeletons for people with disabilities.

Response 7

A description has been added in the technical challenges section.

To address the challenge posed by the control system of exoskeletons and their use by people with disabilities, a distributed control architecture for electrohydraulic humanoid robots (HYDROïD) has been proposed, inspired by the functionality of the human nervous system [67], and could be applied to active exoskeletons. This architecture overcomes the limitations of classical systems by distributing intelligence among joint controllers, allowing them to make decisions, control actuators and communicate their status autonomously. One of the advantages of this development is that it allows for operation in a flexible, centralized, or decentralized manner, depending on the task, facilitating precise control of movement or dynamic compliance as required. According to evaluations by the National Institute of Science, the company has achieved a 50% improvement in update rate and a 30% reduction in latency, consolidating itself as an original and adaptable advance in the control of robotic systems that can be applied to active exosuits and exoskeletons.

 

Comment 8

Given the increasing emphasis on intelligent control and personalized user interaction in wearable assistive devices, the authors should read “A Review of AIoT-based Human Activity Recognition: From Application to Technique”. This article offers a comprehensive perspective on how AI and IoT integration can improve human intent recognition and activity adaptation, which is particularly relevant to addressing usability and control system limitations highlighted in this manuscript.

Response 8

It addresses how the integration of AioT based on human activity can improve the recognition of human intention and adaptation of activities with the use of active exoskeletons.

The integration of Artificial Intelligence with the Internet of Things (AIoT) has the potential to significantly enhance the recognition of human intent and the dynamic adaptation of activities, enabling systems to respond more accurately and contextually, as highlighted [67]. This synergy is key to overcoming usability and control limitations, as it allows us to anticipate behaviors, optimize interaction with the user, and adjust devices or environments in real-time according to the needs detected, which is essential in applications such as personalized assistance, rehabilitation, or intelligent automation

Comment 9

The narrative often relies on generic claims such as 'AI will transform the field' without specific illustrations or examples from the included literature. Strengthen such statements with evidence from existing exoskeleton systems that have integrated AI-based control or personalization features.

Response 9

Specific studies have been included that show the use of AI for the customization of exoskeletons .

AI-based adaptive control systems allow the impedance of joints to be dynamically adjusted based on human-orthosis interaction, providing more accurate and personalized assistance [99]. In addition, the use of deep learning algorithms and neural networks to generate specific gait trajectories has significantly improved the synchronization between the user and the exoskeleton, promoting a more natural user experience [100]. Another prominent line is bio-signal-based control, where myoelectric (EMG) and even brain (BCI) signals are employed to detect the user's intention to move, allowing the exoskeleton to act with a highly intuitive and personalized  response [101]. These capabilities have already been implemented in experimental devices and clinical rehabilitation platforms. AI has been used to develop personalized rehabilitation therapies, through continuous analysis of user data and adaptive feedback, allowing rehabilitation programs to be designed tailored to each patient's individual progress [102] [103].

Comment 10

The PRISMA flow diagram (page 5) lacks numerical detail for each stage of filtering (e.g., number of full-text exclusions by reason). Include a clear breakdown and explanation to enhance transparency and adherence to review standards.

Response 10

The numerical data of the document filtering stages have been described in greater detail

Figure 4 shows the selection process of reference articles related to the search keywords: "challenges, development, people with disabilities, exoskeletons." This workflow is based on a search carried out in the indicated scientific databases to apply the inclusion and exclusion criteria described. Of a total of 397 articles identified, 45 were excluded because they were duplicates, 271 were discarded due to the title of the work that did not address developments or evaluations related to exoskeletons for people with disabilities, of which 81 articles remained, finally, abstracts were evaluated and 36 documents were discarded, obtaining 45 reference documents,  of which, 43 were accessible

Comment 11

Figure 6 and Figure 7 offer conceptual overviews of current challenges and future prospects, but they are not adequately integrated into the textual argument. Reference them explicitly and interpret their structural hierarchy to deepen the discussion.

Response 11

The following descriptions have been included for Figures 6 and 7

Figure 6 categorizes the main challenges that limit the development and adoption of exoskeletons for people with disabilities into four hierarchical and interdependent cate-gories: technical, usability, economic, and user acceptance. At the heart of it are technical challenges, including aspects such as range, weight, mobility, kinematic compatibility and control techniques. These elements are critical, as they define the functional viability of the device. From this base, usability challenges emerge, related to ease of use, us-er-exoskeleton interaction and the ability to customize, aspects that determine the com-fort and effectiveness of daily use. Economic challenges, such as high development and maintenance costs, as well as a lack of insurance coverage, affect both the accessibility and sustainability of these technologies. Finally, challenges related to user ac-ceptance—such as stigmatization, the need for assistance in donning the device, or the lack of accessible infrastructure—represent social and cultural barriers that directly in-fluence the actual adoption of the exoskeleton..

Figure 7 illustrates the key areas for the development and implementation of exoskel-etons for persons with disabilities. Technological aspects are highlighted to address prob-lems such as spasticity and to improve the ability to perform standing tasks without assistance. Personalization emerges as a strategic axis that integrates interdisciplinary advances, particularly in artificial intelligence, nanoelectronics, and extended reality, to tai-lor devices to the individual needs of users.

Two facilitating factors of acceptance stand out: user-centered design, which priori-tizes ease of use, comfort, simplicity, and the sustainability of materials, and the consideration of recyclable and durable components. These elements, although not strictly techno-logical factors are essential to ensure social integration, a positive perception, and the via-bility of prolonged device use.

Comment 12

While the paper emphasizes inclusivity and social relevance, the review omits perspectives from users or clinical practitioners. If such data were not available in the reviewed literature, this limitation should be acknowledged explicitly and discussed.

Response 12

This aspect has been included:

4.4 Absence of clinical and end-user perspectives

The absence of studies that directly integrate the perspectives of end users or clini-cians represents a major limitation for the development of exoskeletons for people with disabilities. Most of the research analyzed focuses on technical, functional or design as-pects, leaving aside qualitative data from lived experience or clinical practice. This ab-sence of studies limits the comprehensive understanding of the factors that influence ac-ceptance, usability, and effectiveness in real-world contexts. It is recommended that future research incorporate participatory methodologies, interviews, case studies or us-er-centered approaches, in order to align technological development with the real needs, expectations, and challenges faced by both users and health professionals in the imple-mentation of these technologies.

Comment 13

There is a missed opportunity to frame the discussion within the context of regulatory, reimbursement, and clinical validation pathways, which are critical barriers to adoption. Consider adding a subsection to address these structural and policy-related dimensions.

Response 13

The following text has been included:

 

Barreras estructurales: regulación, reembolso y validación clínica

Más allá de los desafíos técnicos y de aceptación por parte de los usuarios, la adopción generalizada de exoesqueletos también enfrenta barreras estructurales relacionadas con la regulación, los mecanismos de reembolso y la validación clínica. Actualmente, muchos dispositivos carecen de rutas regulatorias claras que permitan su aprobación como tecnologías médicas dentro de los marcos normativos nacionales e internacionales. Esta ambigüedad normativa dificulta su integración en sistemas de salud públicos o privados, y limita la cobertura por seguros o programas de reembolso, lo que restringe el acceso a usuarios que podrían beneficiarse significativamente de su uso. Además, la escasez de ensayos clínicos controlados y estandarizados impide demostrar de forma concluyente la eficacia, seguridad y costo-beneficio de estos dispositivos, obstaculizando su reconocimiento institucional como herramientas terapéuticas. Por tanto, se vuelve prioritario impulsar investigaciones clínicas robustas, así como establecer políticas de innovación que faciliten la validación técnica y clínica, promuevan la financiación pública o privada, y aceleren el camino hacia una adopción segura, equitativa y sostenible de los exoesqueletos.

 

Comment 14

Although Table 2 (page 8) compares general vs. disability-specific exoskeletons, it remains superficial. Expand the table or add supplementary material to include examples, control modalities, and application settings to substantiate the comparative claims.

Response 14

The table has been enriched and the respective dimensions that evidence the information provided have been included.

Feature	General exoskeletons		Exoskeletons for specific disabilities
Primary Use	Military, industrial, general medical  [38]		Rehabilitation, daily assistance [39];[8];  [40];[41]
Design Focus	Strength, performance, ergonomics [42]  [43]	;	Customization, user comfort, adaptive control [8]
Control Mechanisms	Electrical motors, impedance control, force control [42]		EMG sensors, electro-stimulators, specialized control strategies [39]; [44]; [41]
Control Systems	Advanced synchronization with human movements [45]; [38]		Biosignal-based, adaptive to user needs [44]; [41]
Safety and Usability	General safety features  [46]; [43]		High priority on minimizing fall risk, ease of use, comfort [8]
User Benefits	Enhanced capabilities, reduced fatigue [42]		Mobility restoration, improved quality of life [47]; [40]

 

 

Round 2

Reviewer 2 Report

Comments and Suggestions for Authors

Please consider the following minor revisions:

1. The font size in Figure 1 appears too small, hard to interpret. Please increase the font size.
2. In Figure 4, the legend includes a "1)" prefix before each keyword. Could you explain the purpose of this prefix.
3. The caption of Figure 4 appears to contain a mixture of Spanish and English, please entirely in English.
4. I suggest placing each figure closer to its first mention in the text to improve readability. For example, Figure 5 is currently separated from its first reference by five pages.

Author Response

REVIEWER 2

We sincerely thank you for your valuable feedback and the time dedicated to reviewing our work, which has significantly contributed to improving the quality of the manuscript.

Comment 1

The font size in Figure 1 appears too small, hard to interpret. Please increase the font size.

Response 1

The font size has been increased accordingly for improved readability.

Comment 2

In Figure 4, the legend includes a "1)" prefix before each keyword. Could you explain the purpose of this prefix.

Response 2

The prefixes were removed, as they had no meaningful purpose.

Comment 3

The caption of Figure 4 appears to contain a mixture of Spanish and English, please entirely in English.

Response 3

It has been written entirely in English.

Comment 4

I suggest placing each figure closer to its first mention in the text to improve readability. For example, Figure 5 is currently separated from its first reference by five pages.

Response 4

The figure numbers have been corrected, and the figures are now placed close to their first mention in the text.

Reviewer 3 Report

Comments and Suggestions for Authors

The content of the manuscript has improved; however, I still recommend the correction of the following aspects:
- A clear separation of ideas within the “Usability Challenges” and “User Acceptance” sections is necessary, distinguishing: Usability — focused on technical and ergonomic aspects; User acceptance — oriented towards psychological and social dimensions.
- In their current form, Sections 4.1, 4.2, and 4.3 overlap thematically, and require structural clarification to avoid redundancy.
- Although the absence of clinical and user feedback is acknowledged, the manuscript should also suggest concrete methods for integrating this perspective in future research, such as: qualitative studies, user interviews, and experimental validation in real-life settings.
- All bibliographic references should include complete information, specifically: article title, journal name, volume and page numbers, DOI, and indexing status (WoS/SJR Q1–Q2).
- Some sentences can be improved for conciseness and clarity. For example: This review prioritized user-centered contributions... The review prioritized user-centered studies addressing usability, comfort, and functional outcomes; It is crucial to implement ergonomic designs that minimize pressure on the body... Ergonomic designs minimizing pressure points are essential to prevent injuries and enhance comfort.

Author Response

REVIEWER 3

We sincerely thank you for your valuable feedback and the time dedicated to reviewing our work, which has significantly contributed to improving the quality of the manuscript.

Comment 1

A clear separation of ideas within the “Usability Challenges” and “User Acceptance” sections is necessary, distinguishing: Usability — focused on technical and ergonomic aspects; User acceptance — oriented towards psychological and social dimensions.

Response 1

We have improved the wording to clearly distinguish the aspects of usability and acceptance within their respective sections.

Comment 2

In their current form, Sections 4.1, 4.2, and 4.3 overlap thematically, and require structural clarification to avoid redundancy.

Response 2

We have revised Sections 4.1, 4.2, and 4.3 to enhance clarity and reduce redundancy.

Comment 3

Although the absence of clinical and user feedback is acknowledged, the manuscript should also suggest concrete methods for integrating this perspective in future research, such as: qualitative studies, user interviews, and experimental validation in real-life settings.

Response 3

We have emphasized the importance of conducting qualitative studies, user interviews, and experimental validation in real-life settings.

Comment 4

All bibliographic references should include complete information, specifically: article title, journal name, volume and page numbers, DOI, and indexing status (WoS/SJR Q1–Q2).

Response 4

We have verified the references according to the formatting requirements of this journal. Information regarding indexing status (WoS/SJR Q1–Q2) can be found in the dataset (Sheet 5) referenced in citation 19: https://data.mendeley.com/datasets/6rd4h8b44m/1

Comment 5




Some sentences can be improved for conciseness and clarity. For example: This review prioritized user-centered contributions... The review prioritized user-centered studies addressing usability, comfort, and functional outcomes; It is crucial to implement ergonomic designs that minimize pressure on the body... Ergonomic designs minimizing pressure points are essential to prevent injuries and enhance comfort.

Response 5

We have refined the wording to enhance clarity and consistency.

Reviewer 4 Report

Comments and Suggestions for Authors

The current version is ok to be accepted. 

Author Response

REVIEWER 4

We sincerely thank you for your valuable feedback and the time dedicated to reviewing our work, which has significantly contributed to improving the quality of the manuscript.

Comment 1

The current version is ok to be accepted. 

Response 1

We appreciate your comments, which enabled us to produce an improved version of our manuscript.