REvIEWS

Soft robotics

Biomedical applications of
soft robotics
Matteo Cianchetti   *, Cecilia Laschi   , Arianna Menciassi and Paolo Dario
Abstract | Soft robotics enables the design of soft machines and devices at different scales. The
compliance and mechanical properties of soft robots make them especially interesting for
medical applications. Depending on the level of interaction with humans, different levels of
biocompatibility and biomimicry are required for soft materials used in robots. In this Review , we
investigate soft robots for biomedical applications, including soft tools for surgery , diagnosis and
drug delivery , wearable and assistive devices, prostheses, artificial organs and tissue-​mimicking
active simulators for training and biomechanical studies. We highlight challenges regarding
durability and reliability, and examine traditional and novel soft and active materials as well as
different actuation strategies. Finally , we discuss future approaches and applications in the field.

The application of robots in the biomedical field dates identification and integration of available and emerg-
back a few decades, but recently, the use of soft matter in ing soft and smart materials, such as biocompatibility,
robotics1 has enabled new robot abilities2 that open up biomimicry, actuation4 and tuneable stiffness5, are dis-
possibilities for biomedical applications3 in which a soft cussed, and robotic design is examined in the context of
interaction with a patient is preferred. For example, in orchestrated actuation, control and sensing6.
surgery and endoscopy, robots operate inside a human
body, and for rehabilitation and assistance, robots are in Medical devices
physical contact with a patient. Moreover, robotic tech- Soft robotic devices for surgery . Surgery has undergone
nologies can be used as prosthetics to replace human a profound revolution in the past 30 years, from open
limbs or as artificial organs and body-​part simulators surgery to minimally invasive procedures, which provide
to mimic human body parts, and finally, robotic devices advantages such as greater safety and reduction of access
can be integrated inside or on the skin for drug delivery. trauma, resulting in faster recovery and scar limitation.
Biocompatibility and biomimicry are key considera- Especially in abdominal operations, minimally invasive
tions for soft robotics in biomedical engineering (Fig. 1). surgery (MIS) has become the gold standard. Normally,
The materials used in soft robotics need to be compatible MIS is performed by introducing two to three long and
to a certain extent with the human body and tissues to rigid tools into the insufflated abdomen through small
guarantee system functionality and body acceptability; incisions (about 10–15 mm in diameter) to perform
however, to what extent depends on the specific biomed- surgical tasks assisted by a rigid laparoendoscope for
ical application. For occasional external use, allergies endoscopic vision. In some procedures (for example, in
and contact reactions need to be taken into account; for single-​port laparoscopic surgery), surgeons create one
temporary internal use, immediate immune responses larger incision (about 20–40 mm) at the patient’s navel,
need to be considered, and long-​term implantation and several semi-​flexible instruments are introduced
of soft robotic devices affects the long-​term immune through this incision. This approach reduces the num-
response and can possibly cause rejection. The materials ber of necessary abdomen access ports but can lead to
also need to match the mechanical properties of human the problems of tool encumbrance and triangulation7.
tissues to a certain degree. For example, the use of soft MIS can also be accompanied by specific procedures to
robots as prostheses, organs, simulators or implantable better reach the target organs through natural orifices.
replacements requires mimicking of the mechanical For example, a flexible endoscope, endowed with mul-
properties and function of human tissues. tiple miniature tools on the tip, is introduced through
The BioRobotics Institute, In this Review, current biomedical applications of soft a natural orifice, such as the mouth, vagina or anus, to
Scuola Superiore Sant’Anna,
Pisa, Italy.
robotic technologies are discussed from a materials sci- then perforate the internal wall of an organ. This pro-
ence perspective. We survey applications of soft robots cedure is called natural orifice transluminal endoscopic
*e-​mail: matteo.cianchetti@
santannapisa.it as medical devices for surgery, therapy, drug delivery, surgery (NOTES)8. In all traditional MIS procedures, the
https://doi.org/10.1038/ rehabilitation and assistance as well as robots that mimic passage towards the surgical target can be obstructed by
s41578-018-0022-y the human body. Scientific challenges related to the the presence of organs or anatomical structures. Thus,

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Reviews

promising strategies include new routing approaches to

Body simulators Artificial organs cable-​driven flexible mechanisms, smart materials and
flexible fluidic actuators (FFAs) (Table 1). Cable-​driven
approaches have the advantage of easy miniaturization
(in the case of external positioning of the motors) and
light weight, but they are generally expensive and suffer
Prostheses from sterilization problems and mechanical limitations
such as fatigue, nonlinear friction, backlash hysteresis
and inadequately transmitted forces11. Smart materi-
Biomimicry

als address some of these issues and thus have been

explored not only for traditional endoscopic or surgical
Wearable robots procedures but also for catheter-​like procedures that
require miniaturization. For example, shape memory
alloys (SMAs) have been extensively investigated owing
to their excellent properties, including high corrosion
resistance, biocompatibility and non-​magnetic behav-
Assistive devices Surgical devices Drug delivery iour. Moreover, they possess high energy density, can
exert localized forces and can be fabricated in several
shapes and dimensions. SMAs enable on-​board actuation
with direct transmission on a small scale. In addition,
owing to their working principle, they perform better and
Biocompatibility faster when in the configuration of small wires, maximiz-
ing heat exchange and minimizing the current required
Fig. 1 | Biomedical soft robots from a materials perspective. Levels of biomimicry and for the Joule effect. Several catheters12, active endoscopic
biocompatibility are compared. capsules13 and one-​shot miniature surgical tools (Ovesco)
have been developed, aiming to find the best compromise
up to five abdominal incisions are often required because between actuation speed and controllability.
of the use of rigid or semi-​rigid tools with limited dex- However, SMAs have several severe limitations,
terity, flexibility and manoeuvrability. Even in NOTES including limited strain, low speed (low bandwidth that
or single-​p ort surgery, reachability can be a crucial is heavily dependent on thermal characteristics), control
issue, as is instrument clash during the operation, which issues (mainly owing to very complex thermo­mechanical
increases the overall complexity of the procedure9. behaviour) and the requirement of high currents to
Robotic technologies can help surgeons to improve reach the activation temperature11. Thus, SMAs, often
their accuracy, predictability and repeatability by referred to as ‘muscle actuators’ because of their bio-​like
restoring the intuitiveness of the procedure and by pro- overall performance, have been increasingly used in
viding additional dexterity to the tip, which was demon- their superelastic configuration. In this form, the alloy
strated by the success of the da Vinci surgical robot is in the elastic phase at normal working temperature
(Intuitive Surgical); however, this procedure still requires and therefore able to recover its shape once the external
rigid and inflexible tools, except for wrist articulation. By load (producing a plastic-​induced phase) is removed.
contrast, flexible instruments have high intrinsic flexi- The visible behaviour seems superelastic because the
bility and can be used in synergy with MIS procedures, material appears to return to its shape after very large
but they are often long and flexible with a swivelling tip, bending, which normally produces plastic deformation.
which implies that they also have low dexterity once they Superelastic materials have been applied in cannula-​like
reach the surgical site. Moreover, they can apply only lim- and continuum robots. These medical devices allow for
ited force and they lack stability10. From a medical point an increase in working space and improve the reach of
of view, precision in surgery is mainly achieved by the small-​diameter catheters. They consist of superelastic
use of rigid tools, traditional mechanical coupling and concentric tubes, which are moved into each other by
cable-​actuated solutions. In endoscopy and catheter-​like external motors to produce bent configurations able to
procedures, flexible tools are required that are less precise reach remote locations. For example, continuum robots,
but more adequate to navigate through tortuous paths that is, robots without rigid links that continuously bend
and to avoid obstacles to reach remote organs. In the field along their length14, have better reach than conventional
of surgical endoscopy, both approaches are combined, rigid-​link robots15. However, such robots cannot be con-
making endoscopic procedures as accurate and effective sidered soft because they contain rigid metals or alloys,
as traditional MIS procedures. Endoscopic and surgical the size of which is not altered in response to external
devices are used for acute operations and not for chronic forces. Force–contact sensors can be further integrated
applications. Therefore, tuneable stiffness, organ compli- to control the interaction forces between the medical
ance and overall safety are essential requirements for the device and tissue.
device, but long-​term immune reaction in response to FFAs, which are based on soft and shrinkable mate-
the soft robotic device does not represent an issue. rials16, address many of the aforementioned limitations.
Many active soft actuation technologies have been First used in colonoscopy17, FFAs made of pneumatic
explored to implement flexibility, accuracy, safety and bellows enable self-​propelled locomotion, and FFAs
dexterity in soft surgical tools, among which the most made of expanding balloons increase the friction

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Table 1 | Soft robotics actuation technologies

Technology Acronym Subgroups Working principle
Flexible fluidic actuators FFAs McKibben, air muscle, pneumatic A flexible inflatable structure operated by a fluid. Modelling
artificial muscles, fluidic elastomer or adding of materials to introduce asymmetries enables the
actuators, PneuNets and PneuFlex design of structures that deform into specific shapes
Shape memory materials SMMs Shape memory alloys, shape memory Materials with the capability to recover a predetermined
polymers and shape memory (memorized) geometrical shape through heating following
composites plastic deformation. This shape memory effect is based on
the specific mechanical properties associated with different
stable crystalline phases
Electroactive polymers EAPs Dry (electric) and wet (ionic) Polymers able to undergo deformations in response to
electric fields
Tendon-​driven actuators – – Although not soft actuators, tendons exhibit very low flexural
rigidity if pulled remotely and are often used in continuous
soft robots
Material jamming – Granular and layer jamming Systems composed of an external elastomeric membrane and
a filler material. Applying a vacuum leads to the collapse of
the membrane on the filling material, increasing the density
and thus impeding the relative motion of the particles, which
results in an increase in rigidity of the whole system
Electrorheological and ERMs and MRMs, Electrorheological (fluids and Materials that incorporate magnetic or electrical particles.
magnetorheological respectively elastomers) and magnetorheological In response to an external magnetic or electrical field, the
materials (fluids and elastomers) particles are oriented and interact, resulting in greater
resistance to deformation

between the device and the intestine walls. Such systems with omnidirectional bending and elongation capabili-
have been integrated in inchworm-​like active colono­ ties can be designed based on a similar concept. In this
scopic systems. Current FFAs have many advantages for system, three fluidic chambers, but no internal spines,
use in surgical devices. Their elastomeric nature and are embedded in a cylindrical silicone body. Thus, the
the fact that they do not need a direct electric source simultaneous inflation of all three chambers results
enable applications in the presence of radioactivity and in a length increase. The system can be contained by a
magnetic fields (making them compatible with mag- bellows-​shaped sleeve25 or inextensible threads placed
netic resonance imaging)18. Moreover, leakages from the around the individual chambers26. Alternative to dif-
chambers that interact with tissues can be minimized ferential pressurization, the device can be based on an
because there is no rigid motion18,19. FFAs are capable anisotropic material composition. For example, pneu-
of complex movement using only a small number of matic balloon actuators (PBAs)27 are made of two flex-
parts20. Their compliance allows for safe interaction with ible films; the upper film is made of silicone rubber and
surrounding organs and tissues and decreases the risk acts as membrane, and the lower rigid (but still flexible)
of damage18,19; finally, FFAs are made of biocompatible polyimide film acts as the substrate. The two films are
materials. Furthermore, FFAs that use pressurized gas glued together to create a cavity that can be inflated.
are lightweight and can be inflated by low pressures21, When pressurized, the polyimide film bends owing to
which makes them safe from an activation point of the bending moment generated by the tensile forces
view. FFAs can be combined with other semi-​active of the silicone membrane. This behaviour results in a large
actuation technologies that enable rigidity control5. out-​of-plane vertical displacement. Bending is the most
Such systems have a soft structure that allows them to investigated actuation mode for fluidic-​driven systems.
reach the surgical site with dexterity, but they can also However, fluidic pressure can also be exploited for surgi-
take advantage of the adjustable rigidity to stabilize the cal micromanipulators to induce rotatory motion, owing
configuration and increase the stability of the robot for to the presence of radially and vertically arranged fibres28,
force transmission11. and torsion, owing to the combination of two FFAs with
FFAs have been used as actuators for needle inser- a rotational joint29. FFAs can also be used for the devel-
tion and driving cannula robots22, and in surgical opment of soft and effective tools, such as grippers. For
instruments and manipulators21. Small catheters and example, FFA-​based grippers can be composed of a plate
manipulators can be realized by combining multiple that is placed along the trajectory of a bending FMA30, of
chambers that can be pressurized differently. For example, multiple bending actuators connected at their base31 or of
the flexible micro-​actuator (FMA), introduced in 1991, a linear fluidic soft actuator to actuate a traditional metal-
is based on a cylinder composed of silicone rubber rein- lic claw32. The bending motion of FFAs has also been used
forced with nylon fibres, which are circularly deposited, to support task devices, such as retractors33 and forceps34.
forming three internal chambers that can be individually Despite the ideal properties of FFAs, issues related
inflated23,24. Alternatively, the chambers can be designed to miniaturization and control have hampered their
to act antagonistically in respect to a central floating wider use in surgery thus far. Miniaturization involves
flexible spine, which creates a neutral axis for the bend- the scaling down of the flexible fluidic actuator, which is
ing moment of the chambers18. A surgical manipulator challenging not only in terms of fabrication but also in

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a b extraordinary ergonomic and intuitive control per-

formance of the da Vinci system with the flexibility
of the soft robot41 (Fig. 2a).

Soft materials for drug delivery . If the target area for a

therapy is very remote, as is the case for the inner parts
of the brain, liver or pancreas, or if the therapy is based
on the chronic release of a drug by implantable devices,
endoscopic and surgical tools cannot be used. Navigating
through the vasculature to reach small target areas and
delivering drugs with a precise administration profile can-
not be realized with wired surgical tools. Many soft mate-
rials used in soft robotics for drug delivery are based on
hydrogels and biocompatible and biodegradable materials,
which degrade over time to release their cargo. The release
profile is only partially tuneable, and the reach often relies
on systemic administration, with limited effectiveness.
Fig. 2 | Soft robots for surgery and drug delivery. a | Stiffness controllable flexible and Such soft robots can be guided to a specific location, and the
learnable manipulator for surgical operations (STIFF-​FLOP) is a robotic manipulator for drug can be passively or actively released, for example, by
minimally invasive surgery. b | Concept (top) and photographs (bottom) of a soft device using external stimuli, such as magnetic fields, ultrasound
for drug delivery (scale bar = 100 μm). Panel b is adapted with permission from ref.44, John
or temperature.
Wiley and Sons.
Micelles, nanoparticles, microcarriers and thin
films can be used as drug delivery systems42. Thin-​film
terms of redimensioning. The fluid source can be placed technology was first introduced in the 1970s, with the
outside the device, and thus its size does not have to be aim of overcoming difficulties in ingesting tablets and
changed, but the rest of the fluidic system has to be redi- capsules43. Thin films are made of conformable material
mensioned. Moreover, internally located valves are often layers, with thicknesses ranging from a few nanometres
customized because only a few suitable micropumps to hundreds of micrometres. Thin films have a unique
are commercially available (The Lee Company). Such combination of properties, including high flexibility,
valves often require a complex fluid distribution sys- non-​covalent adhesiveness, molecular permeability,
tem35. Examples of approaches to miniaturize custom- large surface area, high aspect ratio and large drug-​
ized valves include classic spool valve design36, which is loading capacity. The inclusion of nanofillers, such as
composed of a series of membranes that are controlled magnetically or optically responsive particles, within
electro–thermo–pneumatically as well as by a driving the thin films further improves the properties of the
fluid37, featuring actuated valves with freely suspended materials in terms of implementing material responses
resistive heaters38. Alternatively, the pipes and their rout- and endows the material with new functionalities, turn-
ing can be designed to achieve an off-​board solution. ing a rather inert polymeric material into a responsive
However, such thin pipes are difficult to fabricate, and matrix that can be remotely controlled. Traditional
higher pressures are required to compensate pressure (passive) release usually employs the monotonic deliv-
drops. Finally, manufacturing of miniaturized devices ery of a drug, which can lead to adverse tissue reactions
is problematic not only in terms of chamber fabrication because of excessive drug concentrations. By contrast,
but also if multiple materials and structures are com- active drug release through external stimuli allows for
bined to realize specific system behaviours, for example, the temporal and spatial control of drug release and dos-
containment fibres to obtain elongation or bending39 or age, which enables long-​term treatment, for example, for
inextensible materials to create anisotropic rigidities. A chronic diseases.
simple solution is the introduction of geometrical asym- In the past 4–5 years, the field of soft microrobotics
metries by using non-​concentric moulds40. Elastomers has explored microscale carriers made of hydrogels that
also have highly nonlinear behaviour, making their incorporate magnetic particles for drug delivery. Such
precise modelling difficult and thus reducing possible responsive nanomaterials can be applied for therapy or
control strategies. diagnosis, and the use of a soft shell reduces the immune
For soft robots to replace traditional tools in endo- response of the body. For example, an untethered, self-​
scopic or surgical operations, extraordinary flexibility folding, soft microrobotic platform integrating different
is required to enable the robots to perform simple functionalities can be used for the targeted, on-​demand
tasks and to reach remote areas of the human body, delivery of biological agents44. This device contains
and additionally, the robots have to be capable of magnetic alginate microbeads that are encapsulated in
exerting high forces for precise surgical operations10 a bilayer hydrogel structure that is responsive to near-​
(for example, 2–6 N are required to make a suture). infrared light. The hydrogel structure is designed to seal
These features can be realized by implementing stiff- and protect the beads and to open and release them once
ness tunability or by designing hybrid solutions. the surrounding temperature reaches 40 °C (Fig. 2b). A
For example, integrating soft-​b odied robots made similar approach has been used for the development
of silicones and braided sleeves into the da Vinci of soft microgrippers that can self-​fold and possess
surgical system allows for the combination of the thermomagnetic responsiveness45. To improve their

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grasping capability, a stiff segmented polymer (poly­ drawbacks that the device components have substan-
propylene fumarate) is added to the photo-​crosslinked tial inertia, which interferes with the natural motion of
soft hydrogel, and iron oxide nanoparticles are embedded humans, and that the joints have to be carefully aligned
to enable remote magnetic guidance. Such approaches to the joints of the user to prevent unphysiological loads
have been explored for many years and have only recently that can damage cartilage. These issues can be addressed
been collected under the umbrella of soft microrobotics by using soft and lightweight actuators that are in close
because different scientific communities are exploring contact with the skin of the user and that directly
links with soft robotics, for example, regarding scalable exploit human joints, without the need for external rigid
biohybrid actuators46. Moreover, traditional lithography structures54. However, in contact with the human body,
has been partially replaced by fabrication technologies SMA actuators have the disadvantage of thermal activa-
that are based on soft materials, including silicones and tion and thus need to be insulated. Moreover, additional
a variety of other polymers as well as hydrogels, ena- interfaces and devices are often necessary to improve the
bling the fabrication of various shapes of soft devices at response speed and working frequency.
the microscale. Alternatively, pneumatic actuators can be employed
for the development of more conformable and weara-
Rehabilitation and assistance ble robotic devices for ankle and foot rehabilitation55.
Assistive robots represent a viable solution to the needs Based on this concept, using cable-​driven mechanisms,
of an ageing society. Rigid-​component robots can help a whole-​body soft exosuit has been designed for gait
in assisting a person in daily activities; however, a soft assistance56 (Fig. 3a), exploring innovative textile mate-
approach to robotics expands the possibilities for safe rials that transmit assistive torques without the need for
interaction and cooperation. In rehabilitation, robotic rigid external structures57,58. These garments passively
assistance is beneficial for delivering therapy and for generate assistive forces for particular tasks owing to
restoring motor functionality47. The importance of their natural movement and can extend in response
active adaptable systems for assisting or replacing lower to movement of the user, thus not restricting the
limbs rather than passive approaches was realized in wearer. Different sensors can be embedded in wearable
the 1970s48, and the beneficial use of adaptive systems devices for force and deformation sensing, for example,
for upper limbs was exploited in 1958 by Dr Joseph elastomer-​based sensors have been successfully mounted
McKibben, who developed an assistive device based and tested on a soft exosuit59. These sensors are made of
on fluidic actuators (which took his name) to restore a liquid metal that is embedded in an elastomeric cham-
the motion of the polio-​paralysed hand of his young ber. Elongation of the chamber produces a variation in
daughter. Assistive and rehabilitation systems share the the cross section that leads to changes in the longitudinal
same challenges: to guide limb mass displacements by electrical resistance of the sensor.
providing the necessary force. Additionally, systems Incorporating soft actuators into platforms based on
that operate in intimate contact with the user have rigid links has also been explored for upper limbs60. Such
to be effective and safe, and they have to apply force systems can be actuated by pneumatic artificial muscles
(often higher than the user force) without hurting and have the advantage of controllable compliance, pro-
the patient. viding a wide range of functionalities, as well as safety
and light weight. Soft systems have also been developed
Wearable soft robots. Active adaptability can be for specific body parts, for example, the wrist61, elbow62,
achieved either by using compliance and impedance shoulders63,64 and single fingers65,66; however, most efforts
control on robots that are based on rigid links or by have been devoted to restoring hand functionality. To
using soft robots made of materials that have intrinsic exploit the joints of the patient, hand devices are often
adaptive characteristics. Biomimetic approaches, such as shaped as gloves. This approach enables the patient to
muscle-​like active technologies, including electroactive bend their fingers with enough torque to execute reha-
polymers (EAPs), SMAs and FFAs, have been employed bilitation exercises or assistive tasks. However, such
with the aim of exploiting their intrinsic variable stiff- technologies, for example, the use of EAP67, require high
ness. With the emergence of reliable and effective soft voltages, which can be dangerous to the user. Therefore,
mechatronic devices, robotic systems for rehabilitation pneumatic actuators and tendon-​driven solutions are
and assistance gradually developed from rigid interfaces being explored as alternatives.
connected through bioinspired actuators to entirely Gloves can also serve as exomusculature by using an
soft wearable systems, with the active adaptable parts integrated cable system to open and close the hand of
designed to stay in close contact with the user. the patient68. A Bowden system is used to deliver tensile
Simple assistive devices for lower limbs are based forces generated by servomotors (placed in a backpack)
on rigid interfaces and rotary joints, which are attached to the fingers, thus aiding extension and flexion. Each
to the body of the patient and driven by soft actuators, cable is passed through specific types of guides to maxi-
such as McKibben-​like actuators, to support ankle49 and mize comfort. To maintain design flexibility, each finger
hip50 rehabilitation for ambulation. The same interfacing is individually actuated, with a total of five servomotors
approach can be used with different types of soft actu- driving ten tendons (extension and flexion are provided
ators, for example, FFAs, whose restraining method is by the same motor). A less complete yet more opti-
based on straight, inextensible fibres51. SMAs can also be mized system is the Exo-​Glove69, which is based on the
implemented in assistive devices (for example, SHADE same concept but with a reduced number of required
and Leia) to promote ankle dorsiflexion52,53, with the tendons, achieved by the coupling of the motion of two

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a b c d

Fig. 3 | Wearable soft robots. a | Cable-​driven soft exosuit. b | Exo-​Glove Poly. c | Soft robotic glove. d | I-​SUPPORT soft arm
to support bathing tasks. Panel a courtesy of Conor Walsh, Harvard University , US. Panel b courtesy of Kyu-​Jin Cho, Seoul
National University , South Korea. Panel c is adapted with permission from ref.73, Elsevier.

fingers through an infra-​interdigital under-​actuated The incorporation of soft sensors in the glove for
mechanism. A single tendon runs along the index and upper limb systems should not affect the overall system
middle fingers passing through U-​shaped tubes, acting performance. For example, an integrated solution for
as pulleys. Shortening and tension of the tendon are hand rehabilitation can be achieved by using embedded
distributed to both fingers because they share the same sensorized actuators composed of soft pneumatic actu-
path. The mechanism enables adaptation between the ators and stretchable strain sensors75 to detect bending
phalanxes on the same finger and between the two fin- through electric resistance variation. These actua-
gers when the glove is in contact with uneven surfaces. tors are based on a thin layer of screen-​printed silver
In combination with the thumb, the use of two fingers nanoparticles on an elastomeric substrate, enabling
provides more stable grasping. This concept has been stretchability and flexibility while maintaining excellent
extended to an improved version, called Exo-​Glove Poly, conductance (~8 Ω−1).
in which the textile parts are completely substituted by
elastomers70 for easy sanitization (Fig. 3b). Other soft assistive robots. Rehabilitation devices can
Similar to surgical tools, the main drawback of also exploit soft robotic technologies and their intrinsic
systems based on cables is the difficulty to effectively advantages in standalone systems. For example, a haptic
transmit the force generated by the servomotors to the device76 for hand neuromuscular rehabilitation has been
end of the kinematic chain (that is, the fingers in this designed to offer adjustable stiffness in both clinical and
case) because of friction and interference with the body home settings. This handle is based on a pneumatic soft
of the wearer. Pneumatic actuators offer an alternative structure made of highly compliant materials that act
to minimize routing. The main transducer (the air as actuators of the haptic interface. The stiffness can be
compressor) also operates remotely, but the arrangement tuned through pressure increase (in an open or closed
of tubes is flexible as long as they transport compressed loop) and by using interchangeable sleeves that can be
air to the fluidic chambers. For example, Pneuglove71 is customized to include materials of varying stiffness. Soft
based on five polyurethane chambers placed along the robotic technologies can also be used for tremor sup-
fingers on the palmar side of an elastomeric glove. The pression. For example, the dynamically responsive inter-
device is designed for patients with residual control of vention for tremor suppression (DRIFTS) project aims
finger flexion, and chamber expansion is used to support to develop a dynamically responsive wearable orthosis to
digit extension. Flexible fibre-​reinforced actuators have suppress upper limb tremor without affecting natural
also been proposed as ‘wearable actuators’ (Ref.72) to movement. Using materials that can change their visco­
restore flexion. Strings embedded in the silicone mate- elastic properties through the application of magnetic
rial are used to constrain the expansion of the fluidic fields (magnetorheological fluids)77, the tremor energy
actuators so that the deformation is directed along the can be selectively attenuated.
fingers, thus causing finger flexion, similar to what Assistive devices can also aid in personal hygiene.
is used in soft robotic gloves73. In the first PneuNets Soft robots can get in contact with the user and effec-
prototype74, flexion is obtained with elastomeric pneu- tively cooperate with him or her. For example, a robotic
matic actuators based on internal patterning, limiting shower can support users in bathing tasks78. A soft robot
radial expansion. Improved systems use fibre-​reinforced arm (I-​SUPPORT soft arm) is built with three cylindrical
fluidic actuators (Fig. 3c). modules in series, capable of omnidirectional bending.

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a b interesting for non-​biomedical fields, such as the food

industry (Soft Robotics) and underwater exploration81.
The development of soft robotic prosthetics requires
the portability and controllability of the system, similar
to assistive and rehabilitation devices. Thus, similar tech-
nological solutions have been investigated for prosthetic
devices. For example, cable-​driven approaches can be
used to provide finger flexion of prosthetic hands made
of soft or flexible materials. Elastomeric fingers can be 3D
printed, which is a low-​cost and reproducible fabrication
method, and finite element method (FEM) simulations
can be used for their design to optimize material prop-
erties. Using this approach, it has been determined that
a non-​symmetric elliptical flexure hinge is the most suit-
c d able geometrical shape of a flexural hinge for a soft and
monolithic robotic finger82. However, in this case, only
a single material with a predetermined elastic modulus
has been investigated owing to the restricted amount
of available printable materials. Moulding is slower
and less reproducible than 3D printing but enables the
fabrication of a variety of elastomers. A study comparing
different materials and fabrication methods was carried
out to optimize the design of pneumatically driven fin-
Muscle fibre gers, taking into account both material properties and
Heart orientation DCC on heart geometrical features83. First, a real human hand was
scanned to define the segments representing phalanges
Fig. 4 | Soft robots as prostheses. a | Artificial soft hand with high adaptability and
and material sections. The optimal material for each sec-
stability to grasp unfamiliar objects. b | Soft grasper based on granular jamming.
c | Elastomeric sleeve to restore the functionality of a failing heart. d | Physical simulator
tion was then determined by a genetic algorithm-​based
of human vocal folds. DCC, direct cardiac compression. Panel a courtesy of Raphael optimization, using finite element analysis. The accurate
Deimel, Berlin University of Technology , Germany. Panel b courtesy of Nadia Cheng, definition of the geometries and material properties ena-
Empire Robotics, US. Panel c is adapted with permission from ref.88, AAAS. bles a simple approach (there is only one free parameter,
either pressure or cable displacement) to design a finger
with human-​like motion.
Each module is based on three tube-​shaped pneumatic Designing a prosthetic hand with fingers and a palm
chambers in a polymeric material covered by a plastic is extremely important from an aesthetic viewpoint, but
braided structure that guides the deformation to maxi- other effective systems have also been proposed to restore
mize elongation. The overall structure is shaped by trans- grasping capabilities; for example, a prosthetic terminal
verse plastic discs, which also distribute the deformations device based on jamming transition84 (Fig. 4b). Granular
of the three chambers along the longitudinal axis (Fig. 3d). jamming is a physical phenomenon that relies on the
Three cables per module enable shortening, contribute interaction between granules embedded in an elasto-
to omnidirectional bending and allow for tuning of the meric membrane. Applying a vacuum leads to the col-
arm stiffness through antagonistic action on the pneu- lapse of the membrane on the granular material, arresting
matic chambers. The material that interfaces with the the relative motion of the granules, which leads to fixa-
user is removable, washable and changeable, and can be tion of the shape of the system associated with an increase
fabricated according to the preferences of the user. in stiffness. In-​hand manipulation is not possible, but
objects can be very well grasped and handled. However,
Soft robots mimicking the human body pumps are needed for vacuum generation, and the object
Prostheses. Soft robotic technologies can greatly needs to be pushed to be grasped, limiting this system
improve the functionality and acceptability of limb pros- in terms of portability and acceptability by the patient.
theses. For example, upper limb prostheses can provide Comfortable wearing of prostheses is related to the
remarkable dexterity by using grippers or hands that are design and fabrication of the prosthesis and the attitude
adaptable and effective, with a low number of control and use of the patient. Research efforts are devoted to
variables. In general, soft robotics has improved robotic developing more comfortable prostheses. Soft robotic
manipulation performance. For example, compliance technologies can improve the conformability of tradi-
can implement forms of mechanical intelligence79 to tional prostheses, such as artificial limbs based on rigid
refine grasping capabilities80 (Fig. 4a). The main challenge materials, by actively or passively supporting the adapt-
is to exploit soft mechatronic technologies to distribute ability to body changes. A major problem in wearing
the necessary amount of compliance. A variety of arti- lower limb prostheses is related to the poor adaptability
ficial hands have been developed based on soft robotic of the socket between the stump and the artificial limb.
technologies, but only a few of them have been intended A rigid socket surrounding the stump can lead to lesions
for prosthetics. The implementation of delicate yet effec- or humidity problems, and a soft socket can cause sta-
tive grasping of objects, provided by soft robots, is also bility problems, making gait unstable. Moreover, the

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© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
Reviews

volume of the stump usually changes from the time of flow. In terms of implantation, the main limitations are
amputation and during the day, constituting a major the durability (3,000 beats) and the simultaneous com-
challenge for the design of an adaptive socket. Active pression of the two ventricle-​like chambers. The two
interfaces with variable stiffness can be used to address chambers cannot simultaneously pump blood in a closed
this issue. For example, magnetorheological fluids allow loop circuit unless atriums are provided. This issue can
for the control of both interface stiffness and volume85. be addressed by decoupling the chambers. Alternatively,
However, this approach is limited by the bulkiness of a polydimethylsiloxane (PDMS)-based heart can be
the control and power supplies. Granular jamming may designed that exploits gas combustion for actuation92.
offer an alternative technology that is able to solve both Monoblock structures can be used to guarantee long-​
the issue of high interfacial stresses and volume fluctu- term stability, as has been assessed by testing the power
ations, providing higher stiffness with increasing limb density and number of cycles. However, this system
volume, which usually occurs at softer tissue regions. might face challenges for clinical application in terms of
Alternatively, for lower limbs, inflatable actuators can be heat generation and exhaust gas expulsion. Open-​celled
inserted at specific sensitive locations within the socket foams, such as poroelastic foams, can be combined with
wall. The actuators can be filled with gas (light) or liquid inextensible materials to direct deformation inwards
(heavier but easier to control) and can be operated in and thus enable volume reduction, mimicking ventricle
an open loop (externally or manually adjusted) or in a contraction. Although not developed for implantation,
closed loop (through wearable sensors)86. such an approach allows for the simple fabrication of
complex soft robots with similar functionalities as an
Artificial organs. Active materials are mandatory to artificial heart93.
replicate physiological functions in artificial organs. Most studies aimed at developing artificial hearts and
Artificial organs or supporting devices for natural organs based on soft robotic technologies have focused on the
have the same demands as endoscopic or surgical soft mechanical requirements (achievable pressure, frequency
devices, but they are implanted, which requires the mate- and sometimes working cycles). However, to engineer a
rials and manufacturing technologies to be designed in a durable implantable device, biocompatibility and a sus-
way that limits the fibrotic response of the human body. tainable continuous energy source also have to be con-
The heart has been at the centre of soft robotics sidered, which is reflected in a recent European project
research efforts owing to its ‘simple’ function (a pump), aimed at integrating soft mechatronic components, tissue
its softness and the severe impact of organ dysfunction engineering and wireless energy transfer (HybridHeart).
on human health. Artificial supporting devices can be Soft robotic solutions have also been explored for
used to restore the mechanical function of the heart. other body parts with mainly mechanical functions.
For example, an elastomeric sleeve containing a series Sphincters are muscles that control the openings and
of McKibben actuators can be implanted around a fail- closings of body passages and orifices, and the malfunc-
ing heart to restore its ejection capability87. Physiological tioning of, for example, urethral sphincters affects more
apical twist and overall contraction (that is, volume than 300 million people worldwide94. Continence can
reduction) can be restored, but neither the number nor be restored by implanting an annular balloon system
orientation of actuators was analysed in this study. In a around the duct. The opening of the urethra can be
more biomimetic approach, the individual contracting manually controlled, or a shape change of the system
elements are oriented in a layered helical and circum- can be triggered by four SMA plates connected with
ferential fashion88, mimicking the outer two muscle bias springs to open the urethra95. However, the system
layers of the mammalian heart (Fig. 4c). A more simpli- generates heat and operates slowly. Alternatively, EAP96
fied extracardiac device89 contains a series of McKibben (with limitations related to the high operating voltage)
actuators that are connected by coupling bands. This or hydraulic systems, such as inflatable balloons97, can be
device was used to investigate its temporal synchroni- used with a certain degree of self-​controlled occlusion
zation with the native heart, the adhesion of actuators force, minimizing the risk of atrophy or erosion98.
to the ventricles and the contraction–relaxation ratio
of the actuators required to generate optimal cardiac Soft robots as body-​part simulators. The combination
output. As a more invasive approach, an implantable of soft materials, contractile actuators and flexible sen-
linear pneumatic artificial muscle was proposed as an sors in soft robotics also opens opportunities for the
intracardiac device to restore ventricle ejection in right generation of body-​part simulators. With the objective
heart failure cases90. of reducing animal or patient tests and motivated by
Entire soft artificial hearts have also been explored the need for standardized medical procedures, realistic
to completely replace the natural organ. The shape and body-​part simulators have been developed for the train-
function of the heart can be replicated with 3D-​printed ing of specialists in high-​fidelity health-​care simulation
devices91. The soft design allows for the recreation of scenarios and for the investigation of the physiology of
the physiological movement of the human heart during the body. For example, surgical training requires simu-
pumping and to reproduce physiological blood flow. The lators with a realistic response to external stimuli, which
design is based on three separate elastomeric chambers: can be realized using software simulators. Thereby, oper-
two ventricles (left and right) and an expansion chamber. ators drive virtual tools by operating a master console
Inflation of the expansion chamber by an external pump that is acting on virtual environments, which have been
leads to squeezing of the two ventricles and the conse- designed to specifically react to forces, torques and dis-
quent displacement of blood, resulting in a pulsatile placements. However, haptic feedback is often missing

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© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
 Reviews

or limited, and thus running simulations on actual body limbs and body parts. Finally, artificial organs and body-​
mimics is more effective for training. For example, the part simulators need to mimic human tissues in terms of
endovascular evaluator (EVE) simulator (BR Biomedical mechanical properties, motion and function.
Pvt Ltd) mimics body parts by embedding active mate- The controllability and tunability of the mechanical
rials with different mechanical properties, which can be properties, a controllable response to external stim-
used for practising endovascular procedures. In an EVE uli and morphological adaptability to physiological
simulator, vessels have realistic properties, and actuators environments are key features of materials for biomed-
simulate a pumping heart. Another example is a preterm ical soft robots to be able to meet biomedical needs
baby lung simulator, in which the stiffness can be finely that cannot be fully addressed by traditional rigid-​
tuned to simulate different stages of development or link robots. Thus, progress in the design of smart soft
pathologies99. Other various stiffness systems employ a materials plays a key role in the future development of
wide range of soft materials, such as magnetorheological biomedical soft robots.
fluids that can be produced in sponges to replicate the Fluidic actuation has been well investigated and is
realistic sensation of natural organs100. the most commonly used actuation technology in soft
Soft sensors can be embedded in the simulator to robotics. In the past 10 years, fluidic actuation has been
detect the contact and measure the force produced by combined with elastomeric chambers for the develop-
the operator during endoscopy or intubation. The Bionic ment of soft actuators. These FFAs are versatile and easy
Humanoid is an ambitious Japanese project aimed at to fabricate and thus became the gold standard for soft
developing a human model equipped with sensors and robotic actuation for most applications. The combination
actuators to serve as a substitute for animal tests. In the of elastomers and fluids with different configurations and
course of this project, a realistic eye surgery simulator elastomeric chamber modifications simulates natural
(Bionic-​EyE) has been developed based on a chemically muscle properties very well, thus representing an impor-
crosslinked poly(vinyl alcohol) (PVA) hydrogel to tant milestone towards biomimicry, which is important
practice the peeling of the superficial layer of the retina101. for surgical devices, assistive and rehabilitation robots and
For the creation of physical models to investigate realistic simulators; however, prosthetics, artificial organs
human physiology, the materials need to have similar and drug delivery systems need to be portable or implant-
mechanical properties as biological tissues. For exam- able. The portability of such systems is still limited owing
ple, a simulator of human vocal cords can be designed to the need for a source of compressed air. Some portable
based on three layers of tissues with different compli- solutions have already been developed105 but they do not
ance102 (Fig. 4d). By properly tuning the chemistry of yet represent a universal solution.
commercial silicones, three-​layer vocal cords can vibrate Most other emerging actuation technologies (Table 1)
in the same frequency range as human vocal cords. This are incompatible with biomedical applications. High tem-
simulator is able to replicate physiological conditions, perature, strong electric fields and high currents are com-
but it is envisioned to also recreate pathological con- mon issues hampering clinical translation. A futuristic
ditions, such as polyps and hypertonic vocal cords, in approach could be the use of the human energy source
the future. Dysphagia is a swallowing disorder that can ATP to sustain the functionality of wearable devices or
be studied using a bioinspired swallowing robot. The prostheses. Electrical signals are already being exploited
soft-​bodied robot is made of silicone rubber with lay- in artificial and natural systems for the sensing and con-
ers of inflatable chambers and contains an embedded trol of prostheses; alternatively, a chemical power source
stretchable deformation sensor matrix to replicate the could be provided by the user106. A joint effort of biology,
human swallowing process. A central pattern generator materials science, chemistry and engineering will be
model is used to generate peristaltic wave signals103. The necessary to realize such alternative power sources.
movement of the tongue and its interaction with the Biocompatibility aspects are currently addressed
surroundings can also be investigated using a soft robot mainly by the use of inert materials that do not induce
that mimics the motion of the human tongue104. This an immune response, such as silicones or hydrogels.
robotic tongue is simpler than a human tongue but can However, to implement biocompatibility, biomimicry,
recreate a realistic and flexible tongue model. It is made portability and functionality, improved active materials
of a soft material, such as silicone rubber, which forms and novel actuation and sensing principles are required.
an extensible layer, and PDMS as a less extensible layer, A real step forward would be the combination of mate-
with a series of embedded chambers. The robotic tongue rials science for implants and surgical tools with tissue
deforms under pressure owing to the difference in the engineering approaches. Moreover, the global trend
strain of the two layers. towards personalized medicine and patient-​specific
medical solutions requires a substantial revolution in
Conclusions and perspective instrumentation design. For example, controllable and
Biomedical soft robots face different challenges regard- intrinsically biocompatible tools could be realized by
ing the choice or development of materials depending designing actuators hosting biological cells of the patient
on the applications and the associated requirements for or DNA-​based molecular machines107. This approach
biocompatibility and biomimicry. Medical devices for would allow the design of tools that are not transparent
surgery, endoscopy and drug delivery require an acute to but accepted by the immune system, thus paving the
or semi-​chronic safe interaction with the human body. way for biohybrid soft robots for surgery.
Assistive robots and wearable soft robots need to provide
smooth and effective contact and coupling with human Published online 23 May 2018

Nature Reviews | MATeRIALS volume 3 | JUNE 2018 | 151

© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
Reviews

1. Wang, L. & Iida, F. Deformation in soft-​matter 30. Suzumori, K., Iikura, S. & Tanaka, H. in [1991] 54. Stirling, L. et al. Applicability of shape memory alloy
robotics: a categorization and quantitative Proceedings. IEEE Micro Electro Mechanical Systems wire for an active, soft orthotic. J. Mater. Eng.
characterization. IEEE Robot. Autom. Mag. 22, 204–209 (Nara, Japan, 1991). Perform. 20, 658–662 (2011).
125–139 (2015). 31. Low, J.-H., Delgado-​Martinez, I. & Yeow, C.-H. 55. Park, Y.-L. et al. Design and control of a bio-​inspired soft
2. Laschi, C., Mazzolai, B. & Cianchetti, M. Soft robotics: Customizable soft pneumatic chamber–gripper wearable robotic device for ankle–foot rehabilitation.
Technologies and systems pushing the boundaries of devices for delicate surgical manipulation. J. Med. Bioinspir. Biomim. 9, 016007 (2014).
robot abilities. Sci. Robot. 1, eaah3690 (2016). Device. 8, 044504 (2014). 56. Wehner, M. et al. in 2013 IEEE International
3. Cianchetti, M. & Laschi, C. Pleasant to the Touch: By 32. Gerboni, G. et al. A novel linear elastic actuator for Conference on Robotics and Automation 3362–3369
emulating nature, scientists hope to find innovative minimally invasive surgery: development of a surgical (Karlsruhe, Germany, 2013).
new uses for soft robotics in health-​care technology. gripper. Smart Mater. Struct. 25, 105025 (2016). 57. Asbeck, A. T., De Rossi, S. M. M., Holt, K. G. &
IEEE Pulse 7, 34–37 (2016). 33. Ranzani, T., Cianchetti, M., Gerboni, G., De Falco, I. & Walsh, C. J. A biologically inspired soft exosuit for
4. McEvoy, M. A. & Correll, N. Materials that couple Menciassi, A. A. Soft modular manipulator for walking assistance. Int. J. Rob. Res. 34, 744–762
sensing, actuation, computation, and communication. minimally invasive surgery: design and (2015).
Science 347, 1261689 (2015). characterization of a single module. IEEE Trans. Rob. 58. Awad, L. N. et al. A soft robotic exosuit improves
5. Manti, M., Cacucciolo, V. & Cianchetti, M. Stiffening in 32, 187–200 (2016). walking in patients after stroke. Sci. Transl Med. 9,
soft robotics: a review of the state of the art. IEEE 34. Lazeroms, M. et al. A hydraulic forceps with eaai9084 (2017).
Robot. Autom. Mag. 23, 93–106 (2016). force-feedback for use in minimally invasive surgery. 59. Mengüç, Y. et al. Wearable soft sensing suit for human
6. Pfeifer, R., Lungarella, M. & Iida, F. The challenges Mechatronics 6, 437–446 (1996). gait measurement. Int. J. Rob. Res. 33, 1748–1764
ahead for bio-​inspired ‘soft’ robotics. Commun. ACM 35. Gerboni, G. et al. Modular soft mechatronic (2014).
55, 76 (2012). manipulator for minimally invasive surgery (MIS): 60. Tsagarakis, N. G. & Caldwell, D. G. Development and
7. Rané, A., Tan, G. Y. & Tewari, A. K. Laparo-​endoscopic overall architecture and development of a fully control of a ‘soft-​actuated’ exoskeleton for use in
single-​site surgery in urology: is robotics the missing integrated soft module. Meccanica 50, physiotherapy and training. Autonom. Robots 15,
link? BJU Int. 104, 1041–1043 (2009). 2865–2878 (2015). 21–33 (2003).
8. Vitiello, V., Lee, S.-L., Cundy, T. P. & Yang, G.-Z. 36. Moers, A. J. M., De Volder, M. F. L. & Reynaerts, D. 61. Villoslada, A., Flores, A., Copaci, D., Blanco, D. &
Emerging robotic platforms for minimally invasive Integrated high pressure microhydraulic actuation and Moreno, L. High-​displacement flexible shape memory
surgery. IEEE Rev. Biomed. Eng. 6, 111–126 (2013). control for surgical instruments. Biomed. alloy actuator for soft wearable robots. Rob. Auton.
9. Vyas, L., Aquino, D., Kuo, C.-H., Dai, J. S. & Microdevices 14, 699–708 (2012). Syst. 73, 91–101 (2015).
Dasgupta, P. Flexible robotics. BJU Int. 107, 37. Ikuta, K., Ichikawa, H., Suzuki, K. & Yamamoto, T. in 62. Copaci, D., Cano, E., Moreno, L. & Blanco, D. New
187–189 (2011). 2003 IEEE International Conference on Robotics and design of a soft robotics wearable elbow exoskeleton
10. Loeve, A., Breedveld, P. & Dankelman, J. Scopes Automation https://doi.org/10.1109/ based on shape memory alloy wire actuators. Appl.
too flexible…and too stiff. IEEE Pulse 1, 26–41 robot.2003.1241991 (Taipei, Taiwan, 2004) Bion. Biomech. 2017, 1605101 (2017).
(2010). 38. Ruzzu, A., Bade, K., Fahrenberg, J. & Maas, D. 63. Galiana, I., Hammond, F. L., Howe, R. D. &
11. Le, H. M., Do, T. N. & Phee, S. J. A survey on Positioning system for catheter tips based on an active Popovic, M. B. in 2012 IEEE/RSJ International
actuators-​driven surgical robots. Sens. Actuators A microvalve system. J. Micromech. Microeng. 8, Conference on Intelligent Robots and Systems
Phys. 247, 323–354 (2016). 161–164 (1998). 317–322 (Vilamoura, Portugal, 2012).
12. Ikuta, K., Tsukamoto, M. & Hirose, S. in Proceedings. 39. Sun, Y., Song, S., Liang, X. & Ren, H. A. Miniature soft 64. Natividad, R. F. & Yeow, C. H. in 2016 6th IEEE
1988 IEEE International Conference on Robotics and robotic manipulator based on novel fabrication International Conference on Biomedical Robotics and
Automation 427–430 (Philadelphia, PA, USA, 1988). methods. IEEE Robot. Autom. Lett. 1, 617–623 Biomechatronics (BioRob) 989–993 (Singapore, 2016).
13. Menciassi, A. et al. Shape memory alloy clamping (2016). 65. Kim, D. H., Heo, S.-H. & Park, H.-S. in 2017
devices of a capsule for monitoring tasks in the 40. Gorissen, B., Vincentie, W., Al-​Bender, F., Reynaerts, D. International Conference on Rehabilitation Robotics
gastrointestinal tract. J. Micromech. Microeng. 15, & De Volder, M. Modeling and bonding-​free (ICORR) 1326–1330 (London, UK, 2017).
2045–2055 (2005). fabrication of flexible fluidic microactuators with a 66. Maeder-​York, P. et al. Biologically inspired soft robot
14. Robinson, G. & Davies, J. B. C. in Proceedings 1999 bending motion. J. Micromech. Microeng. 23, for thumb rehabilitation. J. Med. Device. 8, 020934
IEEE International Conference on Robotics and 045012 (2013). (2014).
Automation 2849–2854 (Detroit, MI, USA, 1999). 41. Diodato, A. et al. Soft robotic manipulator for 67. Carpi, F., Mannini, A. & De Rossi, D. Proc. SPIE 6927,
15. Burgner-​Kahrs, J., Caleb Rucker, D. & Choset, H. improving dexterity in minimally invasive surgery. Electroactive Polymer Actuators and Devices (EAPAD)
Continuum robots for medical applications: a survey. Surg. Innov. 25, 69–76 (2018). 2008 https://doi.org/10.1117/12.774644 (San
IEEE Trans. Rob. 31, 1261–1280 (2015). 42. Karki, S. et al. Thin films as an emerging platform for Diego, CA, USA, 2008).
16. Polygerinos, P. et al. Soft Robotics: Review of fluid-​ drug delivery. Asian J. Pharm. Sci. 11, 559–574 68. Delph, M. A. et al. in 2013 IEEE 13th International
driven intrinsically soft devices; manufacturing, (2016). Conference on Rehabilitation Robotics (ICORR) https://
sensing, control, and applications in human-​robot 43. Borodkin, S. & Tucker, F. E. Drug release from doi.org/10.1109/ICORR.2013.6650426 (Seattle, WA,
interaction. Adv. Eng. Mater. 19, 1700016 (2017). hydroxypropyl cellulose-​polyvinyl acetate films. USA, 2013).
17. Phee, L. et al. Analysis and development of locomotion J. Pharm. Sci. 63, 1359–1364 (1974). 69. In, H., Kang, B. B., Sin, M. & Cho, K.-J. Exo-​Glove: a
devices for the gastrointestinal tract. IEEE Trans. 44. Fusco, S. et al. An integrated microrobotic platform wearable robot for the hand with a soft tendon routing
Biomed. Eng. 49, 613–616 (2002). for on-​demand, targeted therapeutic interventions. system. IEEE Robot. Autom. Mag. 22, 97–105 (2015).
18. Bertetto, A. M. et al. A novel fluidic bellows Adv. Mater. 26, 952–957 (2014). 70. Kang, B. B. et al. in 2016 IEEE International
manipulator. J. Robot. Mechatron. 16, 604–612 45. Breger, J. C. et al. Self-​folding thermo-​magnetically Conference on Robotics and Automation (ICRA)
(2004). responsive soft microgrippers. ACS Appl. Mater. 3750–3755 (Stockholm, Sweden, 2016).
19. Volder, M. D. et al. Production and characterization of Interfaces 7, 3398–3405 (2015). 71. Connelly, L. et al. A pneumatic glove and immersive
a hydraulic microactuator. J. Micromech. Microeng. 46. Ricotti, L. et al. Biohybrid actuators for robotics: A virtual reality environment for hand rehabilitative
15, S15–S21 (2005). review of devices actuated by living cells. Sci. Robot. training after stroke. IEEE Trans. Neural Syst. Rehabil.
20. Howell, L. L., Magleby, S. P. & Olsen, B. M. Handbook 2, eaaq0495 (2017). Eng. 18, 551–559 (2010).
of Compliant Mechanisms. (John Wiley & Sons, 2013). 47. Tefertiller, C., Pharo, B., Evans, N. & Winchester, P. 72. Guo, S. et al. in 2015 IEEE International Conference
21. De Greef, A., Lambert, P. & Delchambre, A. Towards Efficacy of rehabilitation robotics for walking training on Mechatronics and Automation (ICMA) 2197–2202
flexible medical instruments: review of flexible fluidic in neurological disorders: a review. J. Rehabil. Res. (Beijing, China, 2015).
actuators. Precis. Eng. 33, 311–321 (2009). Dev. 48, 387–416 (2011). 73. Polygerinos, P., Wang, Z., Galloway, K. C., Wood, R. J.
22. Comber, D. B., Slightam, J. E., Gervasi, V. R., 48. Herr, H. M. & Kornbluh, R. D. in Proc. SPIE 5385, & Walsh, C. J. Soft robotic glove for combined
Neimat, J. S. & Barth, E. J. Design, additive Smart Structures and Materials 2004: Electroactive assistance and at-​home rehabilitation. Robot. Auton.
manufacture, and control of a pneumatic MR-compatible Polymer Actuators and Devices (EAPAD) https:// Syst. 73, 135–143 (2015).
needle driver. IEEE Trans. Rob. 32, 138–149 (2016). doi.org/10.1117/12.544510 (San Diego, CA, 74. Ilievski, F., Mazzeo, A. D., Shepherd, R. F., Chen, X. &
23. Suzumori, K. Elastic materials producing compliant USA, 2004). Whitesides, G. M. Soft robotics for chemists. Angew.
robots. Rob. Auton. Syst. 18, 135–140 (1996). 49. Gordon, K. E., Sawicki, G. S. & Ferris, D. P. Mechanical Chem. Int. Ed. 50, 1890–1895 (2011).
24. Suzumori, K., Koga, A., Kondo, F. & Haneda, R. performance of artificial pneumatic muscles to power 75. Yeo, J. C. et al. Flexible and stretchable strain sensing
Integrated flexible microactuator systems. Robotica an ankle–foot orthosis. J. Biomech. 39, 1832–1841 actuator for wearable soft robotic applications. Adv.
14, 493 (1996). (2006). Mater. Technol. 1, 1600018 (2016).
25. Ranzani, T., Gerboni, G., Cianchetti, M. & Menciassi, A. 50. do Nascimento, B. G., Vimieiro, C. B. S., 76. Yap, H. K., Lim, J. H., Nasrallah, F. & Yeow, C.-H.
A bioinspired soft manipulator for minimally Nagem, D. A. P. & Pinotti, M. Hip orthosis powered by Design and preliminary feasibility study of a soft
invasive surgery. Bioinspir. Biomim. 10, 035008 pneumatic artificial muscle: voluntary activation in robotic glove for hand function assistance in stroke
(2015). absence of myoelectrical signal. Artif. Organs 32, survivors. Front. Neurosci. 11, 547 (2017).
26. Arezzo, A. et al. Total mesorectal excision using a soft 317–322 (2008). 77. Manto, M. et al. Dynamically responsive intervention
and flexible robotic arm: a feasibility study in cadaver 51. Kawamura, T., Takanaka, K., Nakamura, T. & Osumi, H. for tremor suppression. IEEE Eng. Med. Biol. Mag. 22,
models. Surg. Endosc. 31, 264–273 (2016). in 2013 IEEE 13th International Conference on 120–132 (2003).
27. Konishi, S., Kawai, F. & Cusin, P. Thin flexible Rehabilitation Robotics (ICORR) https://doi.org/ 78. Ansari, Y. et al. Towards the development of a soft
end-effector using pneumatic balloon actuator. 10.1109/ICORR.2013.6650350 (Seattle, WA, manipulator as an assistive robot for personal care of
Sens. Actuators A Phys. 89, 28–35 (2001). USA, 2013). elderly people. Int. J. Adv. Rob. Syst. 14,
28. Noritsugu, T. et al. Development of pneumatic rotary 52. Pittaccio, S. et al. SHADE: a shape-​memory-activated 172988141668713 (2017).
soft actuator made of silicone rubber. J. Robot. device promoting ankle dorsiflexion. J. Mater. Eng. 79. Pfeifer, R. & Bongard, J. How the Body Shapes the
Mechatron. 13, 17–22 (2001). Perform. 18, 824–830 (2009). Way We Think: A New View of Intelligence. (MIT Press,
29. Yang, Q. et al. in IEEE Conference on Robotics, 53. Pittaccio, S. & Viscuso, S. An EMG-​controlled SMA 2006).
Automation and Mechatronics, 2004 https:// device for the rehabilitation of the ankle joint in post-​ 80. Deimel, R. & Brock, O. A novel type of compliant and
doi.org/10.1109/RAMECH.2004.1438950 acute stroke. J. Mater. Eng. Perform. 20, 666–670 underactuated robotic hand for dexterous grasping.
(Singapore, 2004). (2011). Int. J. Rob. Res. 35, 161–185 (2015).

152 | JUNE 2018 | volume 3 www.nature.com/natrevmats

© 2018 Macmillan Publishers Limited, part of Springer Nature. All rights reserved.
 Reviews

81. Galloway, K. C. et al. Soft robotic grippers for 93. Mac Murray, B. C. et al. Poroelastic foams for simple 104. Lu, X., Xu, W. & Li, X. A. Soft robotic tongue —
biological sampling on deep reefs. Soft Robot. 3, fabrication of complex soft robots. Adv. Mater. 27, mechatronic design and surface reconstruction. IEEE/
23–33 (2016). 6334–6340 (2015). ASME Trans. Mechatron. 22, 2102–2110 (2017).
82. Mutlu, R., Alici, G., in het Panhuis, P. & Spinks, G. M. 94. Irwin, D. E., Kopp, Z. S., Agatep, B., Milsom, I. & 105. Wehner, M. et al. Pneumatic energy sources for
3D printed flexure hinges for soft monolithic Abrams, P. Worldwide prevalence estimates of lower autonomous and wearable soft robotics. Soft Robot.
prosthetic fingers. Soft Robot. 3, 120–133 (2016). urinary tract symptoms, overactive bladder, urinary 1, 263–274 (2014).
83. Thompson-​Bean, E., Das, R. & McDaid, A. incontinence and bladder outlet obstruction. BJU Int. 106. Roseman, J. M. et al. Hybrid integrated biological–
Methodology for designing and manufacturing 108, 1132–1138 (2011). solid-​state system powered with adenosine
complex biologically inspired soft robotic fluidic 95. Chonan, S. et al. Development of an artificial urethral triphosphate. Nat. Commun. 6, 10070 (2015).
actuators: prosthetic hand case study. Bioinspir. valve using SMA actuators. Smart Mater. Struct. 6, 107. Menciassi, A. Swell findings in hydrogels. N. Engl.
Biomim. 11, 066005 (2016). 410–414 (1997). J. Med. 378, 864–865 (2018).
84. Cheng, N. et al. Prosthetic jamming terminal device: 96. Weiss, F. M., Deyhle, H., Kovacs, G. & Müller, B. in
a case study of untethered soft robotics. Soft Robot. 3, Proc. SPIE 8340, Electroactive Polymer Actuators and Acknowledgements
205–212 (2016). Devices (EAPAD) 2012 https://doi.org/10.1117/ The authors acknowledge support from the European
85. Ogawa, A., Obinata, G., Hase, K., Dutta, A. & 12.914649 (San Diego, CA, USA, 2012). Commission through the Hybrid Heart (#767195) and
Nakagawa, M. in 2008 30th Annual International 97. Hached, S. et al. Novel, wirelessly controlled, and I-​SUPPORT (#643666) projects.
Conference of the IEEE Engineering in Medicine and adaptive artificial urinary sphincter. IEEE/ASME Trans. Author contributions
Biology Society 330–333 (Vancouver, BC, Canada, Mechatron. 20, 3040–3052 (2015). C.L. and M.C. conceived the topic of the Review. M.C. ana-
2008). 98. Lamraoui, H. et al. Development of a novel artificial lysed aspects related to prostheses, wearable devices and
86. Paterno, L., Ibrahimi, M., Gruppioni, E., Menciassi, A. urinary sphincter: a versatile automated device. artificial organs. C.L. and M.C. analysed aspects related to
& Ricotti, L. Sockets for limb prostheses: a review of IEEE/ASME Trans. Mechatron. 15, 916–924 assistive robots and body-​part simulators. A.M. and P.D. ana-
existing technologies and open challenges. IEEE Trans. (2010). lysed aspects related to surgery and drug delivery. All authors
Biomed. Engineer. https://doi.org/10.1109/ 99. Baldoli, I. et al. A novel simulator for mechanical equally contributed to the writing and revising of the paper.
TBME.2017.2775100 (2018). ventilation in newborns: MEchatronic REspiratory All authors contributed to the discussion to draw conclusions
87. Roche, E. T. et al. A bioinspired soft actuated material. System SImulator for Neonatal Applications. Proc. and perspectives.
Adv. Mater. 26, 1200–1206 (2014). Inst. Mech. Eng. H 229, 581–591 (2015).
88. Roche, E. T. et al. Soft robotic sleeve supports heart 100. Kim, S., Kim, P., Park, C.-Y. & Choi, S.-B. A new tactile Competing interests
function. Sci. Transl Med. 9, eaaf3925 (2017). device using magneto-​rheological sponge cells for The authors declare no competing interests.
89. Payne, C. J. et al. An implantable extracardiac soft medical applications: experimental investigation.
robotic device for the failing heart: mechanical coupling Sens. Actuators A Phys. 239, 61–69 (2016). Publisher’s note
and synchronization. Soft Robot. 4, 241–250 (2017). 101. Someya, Y. et al. in 2016 International Symposium on Springer Nature remains neutral with regard to jurisdictional
90. Horvath, M. A. et al. An intracardiac soft robotic Micro-​NanoMechatronics and Human Science (MHS) claims in published maps and institutional affiliations.
device for augmentation of blood ejection from the https://doi.org/10.1109/MHS.2016.7824208
failing right ventricle. Ann. Biomed. Eng. 45, (Nagoya, Japan, 2016). Related links
2222–2233 (2017). 102. Manti, M., Cianchetti, M., Nacci, A., Ursino, F. & Intiutive Surgical: http://www.intuitivesurgical.com/
91. Cohrs, N. H. et al. A soft total artificial heart-​first Laschi, C. in 2015 37th Annual International Ovesco: http://www.ovesco.com
concept evaluation on a hybrid mock circulation. Artif. Conference of the IEEE Engineering in Medicine The Lee Company: http://www.theleeco.com/
Organs 41, 948–958 (2017). and Biology Society (EMBC) 3623–3626 Soft Robotics: https://www.softroboticsinc.com/
92. Schumacher, C. M., Loepfe, M., Fuhrer, R., (2015). HybridHeart: http://www.hybridheart.eu/
Grass, R. N. & Stark, W. J. 3D printed lost-​wax casted 103. Zhu, M., Xu, W. & Cheng, L. K. Esophageal peristaltic BR Biomedical Pvt Ltd: http://www.brbiomedicals.com
soft silicone monoblocks enable heart-​inspired control of a soft-​bodied swallowing robot by the The Bionic Humanoid: http://www.jst.go.jp/impact/
pumping by internal combustion. RSC Adv. 4, central pattern generator. IEEE/ASME Trans. bionichumanoids/en/index.html
16039–16042 (2014). Mechatron. 22, 91–98 (2017).

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