Characterizing adaptation to using exoskeletons: A narrative review and assessment framework for occupational contexts

Occupational exoskeletons are increasingly deployed to reduce physical demands and mitigate musculoskeletal disorder risk, yet successful implementation depends on how users adapt to these systems over time. This narrative review synthesizes evidence from 28 studies that examined user adaptation or familiarization to active and passive occupational exoskeletons across repeated or comparative exposure designs during occupationally relevant tasks. We characterize user adaptation as a multidimensional process, while using motor adaptation and related performance measures as the primary organizing focus for the review. Most existing evidence focuses on short-term motor adaptation for active lower-limb prototypes, whereas passive back- and arm-support devices are more often evaluated in multi-session or field contexts capturing longer-term changes. Integrating these findings, we propose an adaptation assessment framework outlining key measurable domains, temporal considerations, and methodological needs. This review provides guidance for designing future studies and supports effective development and implementation of exoskeletons in occupational settings.