Bridging the reality gap: can we trust upper-limbexoskeletons in clinical practice?

Medical exoskeletons—wearable robotic devices that augment or replace lost limb functionalities—have captured significant interest in the field of Robotics for Medicine and Healthcare in recent years. Their potential for improving function and dexterity in individuals with neuromotor conditions (like stroke or spinal cord injury) is undeniable. Research efforts have been particularly flourishing lately, presenting a diverse array of exoskeleton designs documented in the scientific literature and attracting large investments and major funding allocations. Through the Tuscany Health Ecosystem (THE) and the Fit For Medical Robotics (FIT4MEDROB) project alone, the PNRR ("Piano Nazionale di Ripresa e Resilienza") and PNC ("Piano Nazionale Complementare") have budgeted a total of nearly €250 million on the topic for the three-year period 2023 - 2026. However, despite this surge in innovation, they have not yet achieved widespread adoption within clinical practice: the use of upper limb exoskeletons, in particular, appears to be quite lagging behind. Several key challenges—such as technological limitations, cost, and integration into therapy—are impeding this transition. Current exoskeletons often lack the dexterity and adaptability to completely mirror the intricate movements of the human body. Additionally, bulkiness and weight can hinder user comfort and long-term wearability. On the economical side, the cost of developing and manufacturing these devices is still significant, while reimbursement policies often lag behind technological advancements, making access to this technology difficult for patients. The sum of these factors causes the effective integration of upper-limb exoskeletons into established clinical practice to require further research and development. Addressing these challenges is crucial to unlocking the full potential of hand exoskeletons, and cannot be done without a multidisciplinary co-design that involves engineers, clinicians, stakeholders, and end-users. The purpose of this workshop is precisely to analyze from such different perspectives how close or far hand exoskeletons are to clinical practice presently, and to discuss what possible steps can be taken to bridge the reality gap in the near future.