Robotic exoskeleton rehabilitation in incomplete L2 paraplegia: functional gains contrast with metabolic challenges - a multidimensional case report.

Introduction: Incomplete paraplegia presents complex rehabilitation challenges due to its multisystemic impact on motor function, bone health, and metabolic regulation. This case report evaluates the effects of robotic exoskeleton rehabilitation addressing a critical gap in understanding the multidimensional outcomes of this emerging technology. Case presentation: An 18-year-old male with traumatic L2 AIS C paraplegia underwent 20 sessions of robotic exoskeleton training (Atalante exoskeleton) during 60 min of therapy (20-min setup, 20-min walking, 10-min squats and recovery) combined with conventional physiotherapy over six months. Conventional therapy complemented exoskeleton training by addressing residual strength deficits through resisted knee extension (3 × 10 reps at 60% 1-RM) and functional mobility via overground gait training with knee-ankle-foot orthoses (KAFOs) (2×/week, 10 m walks. Comprehensive assessments included isokinetic dynamometry (CYBEX), bone densitometry (DXA), AIS impairment scale, and functional mobility tests (Timed Up and Go, 10-meter walk test). Results demonstrated neurological improvement (AIS L2-L3 motor score improved from 4/5 to 5/5, with light touch improving from 78 to 84) and gait capacity recovery (300 m with crutches). Musculoskeletal outcomes revealed a 21.7% improvement in right hip extensor torque (69→84 Nm), though still 19.2% below the patient's own 6-month post-injury baseline value (104 Nm), while bone mineral density showed site-specific effects (lumbar spine: +50%, T-score -2.6→0.8; femur: T-score -3.3→-1.3). Notably, functional gains correlated with hip torque recovery (TUG: r = -0.71), but bilateral deficit worsened (12%→42%), and visceral fat increased dramatically (359%) despite functional improvements. Discussion: This case demonstrates that exoskeleton training effectively enhances mobility and bone health through weight-bearing stimulation, particularly at lumbar spine. However, the paradoxical metabolic changes and persistent neuromuscular asymmetries reveal critical limitations of current robotic rehabilitation approaches. These findings support the concept of spinal cord injury as a multisystem disorder requiring integrated interventions that combine exoskeleton training with nutritional strategies and asymmetric muscle training. The case provides novel insights for developing comprehensive rehabilitation protocols that address both functional recovery and secondary health complications in incomplete paraplegia.