Robotic-Assisted Rehabilitation and Spinal Neuromodulation After Spinal Cord Injury: From Mechanisms to Trial-Informed Practice.

Spinal cord injury (SCI) is an acute, devastating neurologic condition that results in permanent progressive motor deficits, sensory disturbances, and autonomic dysfunctions, which limit function, participation, and quality of life. Although substantial progress has been made during the last several decades for both early trauma care and rehabilitation protocols following SCI, long-term neurological recovery remains unpredictable and often incomplete. This manuscript summarizes mechanistic and clinical evidence regarding robotic-assisted rehabilitation (RAR) and spinal neuromodulation (SN), which have been published since 2010 until the present time in a structured narrative review of the literature on these two emerging areas for neurorehabilitation after SCI. RAR provides high-intensity, task-specific training that consistently results in improvements in functional outcomes such as balance, coordination, and independence; however, its impact is limited when it comes to walking speed or voluntary motor control. SN (particularly epidural stimulation) can activate the residual neural pathways to standing up and stepping even after a complete injury but effects are typically stimulus dependent, with heterogeneous clinical results that often lack strong long-term evidence due in part to variability in patient selection, stimulation parameters and rehabilitation protocols. However, there is emerging mechanistic data supporting combining modulation of excitability through SN approaches along with structured sensorimotor training as an approach for enhancing recovery. Collectively, these findings support a shift toward more physiology-driven neurorehabilitation strategies and the need for future research to improve clinical translation and outcome predictability by patient stratification using standardized intervention protocols that include longitudinal evaluation.