Shoulder rehabilitation is prolonged, feedback-dependent, and frequently limited by adherence, particularly after surgery. Virtual reality (VR) and related immersive or semi-immersive technologies may support rehabilitation by combining motion tracking, visual feedback, graded repetition, and gamified engagement. This narrative review summarizes current evidence on VR and digitally assisted shoulder and upper-limb rehabilitation and critically evaluates the extent to which these data can inform post-arthroplasty pathways. A narrative review was performed using PubMed/MEDLINE, PubMed Central, and targeted cross-checking in Scopus, Web of Science, and the Directory of Open Access Journals up to May 2026. Search domains combined shoulder and upper-limb terms, virtual reality, augmented reality, mixed reality, extended reality, and exergaming terms, rehabilitation and telerehabilitation terms, and postoperative shoulder surgery or arthroplasty terms. Priority was given to systematic reviews, randomized or controlled studies, validation studies, feasibility studies, and clinician-perspective studies relevant to shoulder biomechanics and rehabilitation implementation. The available literature supports three main conclusions. First, consumer-grade immersive systems can provide reliable within-system shoulder motion monitoring, although absolute agreement across devices remains imperfect. Second, VR, exergaming, and digitally assisted rehabilitation have shown feasibility, high acceptability, and potential benefits for adherence, pain, range of motion, and patient-reported function in rotator cuff repair, adhesive capsulitis, subacromial impingement, and other shoulder disorders. Third, evidence directly specific to anatomic or reverse shoulder arthroplasty rehabilitation remains limited; therefore, extrapolation from rotator cuff repair, conservative shoulder disorders, and digital home-based arthroplasty rehabilitation should be made cautiously. Rehabilitation clinicians support supervised or hybrid use rather than autonomous unsupervised replacement of conventional care. VR should be interpreted as an adjunct to clinician-led rehabilitation, not as a stand-alone substitute. Its most plausible current roles are improving engagement, enabling structured repetition, supporting within-system range-of-motion monitoring, and extending supervised practice into home settings. Future studies should test procedure-specific, phase-based VR protocols for anatomic and reverse shoulder arthroplasty, with explicit attention to compensation control, safety limits, long-term outcomes, cost-effectiveness, and multidisciplinary oversight.
IntroductionHip osteoarthritis is a degenerative joint disease that significantly impacts quality of life. When conservative treatments fail, total hip arthroplasty becomes necessary to alleviate pain and improve mobility. Rehabilitation plays a crucial role in functional improvement after hip surgery, as it contributes to full motor recovery. However, traditional face-to-face rehabilitation can present several challenges. Telerehabilitation is an emerging approach, using e-Health tools to allow patients to perform exercises remotely. This technique could enhance accessibility, reduce costs, and increase adherence to rehabilitation programs, but it has yet to be fully investigated in terms of beneficial effects.Materials and methodsThis review was conducted following the preferred reporting items for systematic reviews and meta-analysis (PRISMA) statement guidelines. The scientific articles were identified through the PubMed, Google Scholar, Scopus and Cochrane Library databases. A qualitative assessment of the selected studies was performed using the modified Oxford quality scoring system. Five studies were included in this review. The risk of bias was evaluated using the Cochrane Collaboration tool. The protocol was registered at PROSPERO (n◦ CRD42025643872).ResultsThe review found that telerehabilitation is not inferior to traditional methods in improving functional outcomes and quality of life. Challenges include methodological differences, demographic variations, and the lack of long-term data.ConclusionsThe review suggests future research should focus on long-term outcomes, including older patients, to better understand telerehabilitation effectiveness in hip replacement rehabilitation.
An increasing amount of digital health data are being collected across rehabilitation settings, but their integration into routine clinical practice remains limited, despite its potential to motivate patients or inform clinical decision-making. Specifically, effective visualization and communication of assessment outcomes to both patients and health care practitioners (HCPs) represent a key gap in the neurorehabilitation practice. This study describes the development and evaluation of RehaLink (author ND, ETH Zürich), a proof-of-concept mobile app that delivers structured, interpretable feedback from conventional and technology-based assessments to neurorehabilitation patients and HCPs. The app was developed through a 3-step iterative co-design process involving 17 inpatients with multiple sclerosis and 15 HCPs from a single rehabilitation center. The app integrates a full battery of conventional assessments routinely conducted at the clinic, as well as digital health metrics from the Virtual Peg Insertion Test, a validated technology-based assessment of upper limb function, as a proof of concept for integrating technology-based assessment data into clinical workflows. Three structured feedback sessions were conducted, in which participants evaluated feedback types, visualization formats, and app usability using Likert-scale ratings, preference rankings, open-ended questions, and the System Usability Scale. Data were analyzed using descriptive statistics and directed content analysis. Across all 3 sessions, progress bars and color-coded indicators were consistently preferred over text-heavy or abstract formats by both patients and HCPs. A persistent set of competing demands was observed, with participants requesting both visual simplicity and access to absolute values and normative comparisons. HCPs tended to underestimate patients' preference for informative visualizations. The perceived value of structured feedback increased over the course of the study; patients' median ratings rose from 4.0 to 5.0 and HCPs' from 4.0 to 4.5 on a 5-point Likert scale. The resulting mobile app prototype demonstrated high usability, with patients achieving a mean System Usability Scale score of 93.6 (mean 6.4; best imaginable) and HCPs 80.9 (SD 8.1; good), according to established benchmarks. These findings demonstrate the feasibility and value of a co-designed digital feedback tool for neurorehabilitation. By combining conventional and technology-based assessment outcomes in an accessible, user-centered format, the app has the potential to enhance patient engagement, support clinical decision-making, and advance the implementation of value-based, personalized care.
Evaluate the effectiveness of exercise-based cardiac rehabilitation in improving aerobic capacity for people with stroke or TIA. This is a rapid review with meta-analysis. Four databases were searched from February 2015 - March 2025. Nine studies (n=490 participants) of low-moderate quality were included (two randomised controlled trials, two quasi-experimental trials, five pre-post studies), three of which were pooled for meta-analysis. Findings suggest cardiac rehabilitation improves aerobic capacity (28 m, 95% CI 16 m to 39 m, P=<0.00001) for people with TIA or stroke, with promising improvements also found for systolic blood pressure (95% CI -18 mm Hg to -5.3 mm Hg, P=0.0003), self-reported diet (95% CI 2.4 to 4.7, P=<0.00001) and self-reported physical activity (95% CI 1533 METmin/week to 5156 METmin/week, P=0.0003). No significant relationships were identified between program FITT (exercise frequency, intensity, type, time) principles and aerobic capacity outcomes. Cardiac rehabilitation may be effective in improving aerobic capacity post-TIA or stroke, however current evidence is limited and of low certainty. Further high-quality research on program effectiveness, and the influence of FITT principles, is needed to support evidence-based decisions making by clinicians, researchers and policy-makers.
IntroductionCognitive rehabilitation (CR) enhances the autonomy of patients with Alzheimer's disease. Their daily activities are likely dependent on attention networks.MethodThis pilot resting-state fMRI study investigated the cerebral correlates of CR in participants with mild Alzheimer disease (n = 22), compared to a control intervention in patients (n = 21) and in healthy participants (n = 27). Connectivity changes between dorsal and ventral attention networks were expected after 3 months of rehabilitation.ResultsA mixed ANOVA comparing pre- and post-intervention data across groups revealed increased connectivity between the dorsal and the ventral attention network following CR (FDR-corrected P = .0072). A post hoc correlation analysis of post-intervention data in the CR group showed that greater autonomy in daily activities was associated with stronger functional relationship between the two attention networks (FDR-corrected P = .0001).ConclusionEnhanced connectivity between attention networks may be a characteristic of CR benefits in individuals with mild Alzheimer disease.
In December 2024, the U.S. Department of Veterans Affairs (VA) and the U.S. Department of Defense (DoD) released a joint update of their 2017 clinical practice guideline (CPG) for the rehabilitation of individuals with lower limb amputation (LLA). This synopsis highlights the key aspects of the guideline development process and describes the CPG recommendations. The VA/DoD Evidence-Based Practice Work Group convened a joint VA/DoD guideline development work group (WG) that included clinical stakeholders and conformed to the Institute of Medicine's tenets for trustworthy clinical practice guidelines. The guideline WG conducted a patient focus group, developed key questions, and systematically searched and evaluated the literature from a eight year time frame (English-language publications from 6 July 2016 to 15 March 2024). The Grading of Recommendations, Assessment, Development and Evaluation (GRADE) system was utilized to evaluate the evidence and formulate recommendations. The WG developed 26 recommendations along with algorithms and supplemental materials to guide providers in providing evidence-based, interdisciplinary, patient-centered care through all phases of LLA rehabilitation. The CPG was reviewed by stakeholders outside the WG prior to approval by the VA/DoD Evidence Based Practice WG. This article summarizes key features of the guideline to help clinicians utilize the CPG to support patient-centered care.
Health advocacy is increasingly recognized as a core professional responsibility of physicians; however, formal training in advocacy remains limited within graduate medical education. Physiatrists are uniquely positioned to participate in advocacy given their care of individuals with disabilities and intrinsic interdisciplinary care coordination to navigate the social, economic, and systemic barriers affecting health outcomes for our patients. This manuscript reviews the current perceptions of physician advocacy, the existing advocacy training models across medical specialties, and the current state of advocacy opportunities and requirements within Physical Medicine and Rehabilitation (PM&R) residency education. Drawing on existing frameworks and educational models, we outline suggestions to integrate advocacy training into PM&R residency educational offerings. Incorporating advocacy education in PM&R training may better prepare residents to address health disparities, promote patient-centered systems change, and mitigate burnout by promoting engagement in professional activities that align with physiatrists' ethical and professional priorities.
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Frozen shoulder (FS) is characterized by a multifactorial progression, often worsened by metabolic factors such as diabetes. Effective management may require a multidisciplinary approach that includes therapeutic exercise, physiotherapy, metabolic control, psychological support, and healthy lifestyle interventions. However, current evidence remains fragmented and predominantly focused on isolated domains, with limited integration of these factors within a biopsychosocial framework. The aim of this study was to comprehensively evaluate the influence of exercise-based interventions, as well as metabolic, psychological, and lifestyle-related factors, on clinical outcomes, including pain, function, range of motion, and quality of life, in patients with FS. This systematic review with meta-analysis, reported following the PRISMA guidelines, included 31 studies published between 2010 and 2024, comprising randomized controlled trials, observational studies, Mendelian randomization studies, and qualitative studies. MEDLINE, Web of Science, CINAHL, SPORTDiscus, and Scopus were searched until April 2025. The risk of bias was assessed according to study design. The Cochrane Risk of Bias tool (RoB 1) was used for randomized controlled trials. Observational studies (including cross-sectional, case-control, and cohort studies) were assessed using the Newcastle-Ottawa scale (NOS). Mendelian randomization studies were evaluated using established methodological quality criteria for MR studies, including the assessment of instrument validity, pleiotropy, and heterogeneity. Qualitative studies were appraised using appropriate qualitative assessment criteria. The certainty of evidence was rated using the Grading of Recommendations, Assessment, Development and Evaluation (GRADE) approach. Twelve studies evaluated physical interventions. Global effect summary of exercise versus control showed a small but statistically significant benefit favoring exercise (standardized mean difference [SMD], Hedges' g = 0.10; 95% CI 0.05-0.15) across clinical outcomes, particularly pain, function, and range of motion. Associations between FS and metabolic parameters (e.g., triglycerides, glucose, and HbA1c) were identified in 12 studies, although these results were synthesized narratively and no pooled effect estimates (e.g., odds ratios) were calculated due to heterogeneity. Seven studies showed that anxiety was consistently associated with FS severity, with potential impact on pain, functional outcomes, and quality of life, although this relationship may depend on sample characteristics. The risk of bias was low in exercise-related studies, unclear in those on quality of life, and high in metabolic studies. Overall, the certainty of evidence was rated as very low due to the risk of bias, heterogeneity, and imprecision. Evidence supports a multifactorial, biopsychosocial model for FS. Exercise-based interventions were associated with small improvements in pain, function, and range of motion, while metabolic dysfunction and anxiety were identified as factors associated with FS severity. However, the certainty of evidence was very low and findings should be interpreted with caution due to high heterogeneity and methodological variability across studies. Future research should prioritize integrated, multidisciplinary strategies to improve FS treatment.
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After a stroke, individuals often experience mobility impairments because of weakness and loss of independent joint control in the lower limbs. As a result, gait recovery becomes a primary goal of physical rehabilitation, traditionally achieved through high-intensity therapist-led training. However, conventional therapist-led approaches involving manual assistance or resistance can be physically demanding and limit interaction at multiple joints simultaneously. Robotic exoskeletons have emerged as a promising solution, enabling multijoint support, reducing therapist strain, and offering objective performance feedback. However, typical exoskeleton control strategies limit the physical therapist's involvement and adaptability to the patient's needs, which may hinder clinical adoption and outcomes. In this study, we introduce a gait rehabilitation paradigm based on physical human-robot-human interaction that we call therapist-exoskeleton-patient interaction (TEPI), in which a therapist and a patient with stroke are each equipped with a lower-limb exoskeleton virtually connected at the hips and knees via spring-damper elements. This connection enables bidirectional physical interaction, allowing the therapist to guide the patient's movement while receiving real-time haptic feedback. We evaluated this approach with eight patients with chronic stroke using a within-subject design, comparing TEPI training with conventional therapist-guided mobilization during treadmill walking. Results showed that, compared with conventional therapy, TEPI led to greater joint range of motion, increased step length and height, similar muscle activation, and high self-reported motivation and enjoyment. These findings suggest that TEPI can integrate robotic precision with therapist intuition, offering a framework for enhancing gait rehabilitation outcomes in populations recovering from stroke.
Pediatric traumatic brain injury (TBI) is a leading cause of morbidity and mortality in the United States. Hispanic children face disproportionate socioeconomic disadvantage, underinsurance, and language barriers, yet disparities in their TBI outcomes remain under-investigated. This systematic review aims to (1) synthesize existing evidence on the epidemiology, mechanisms of injury, and outcomes of TBI among Hispanic children in the United States; (2) evaluate disparities in healthcare access, diagnostic evaluation, and access to rehabilitation services; and (3) identify gaps in the literature to inform culturally responsive prevention and intervention strategies. A systematic search of PubMed, Scopus, Web of Science, Embase, and Google Scholar was conducted in accordance with PRISMA 2020 guidelines. Eligible studies included those reporting primary data on TBI among Hispanic children (< 18 years) in the United States. Data were synthesized qualitatively given heterogeneity in study design, outcome measures, and population characteristics. Fifteen studies met the inclusion criteria and were evaluated using the NIH Quality Assessment Tool for Observational Cohort and Cross-Sectional Studies. Hispanic children sustained TBIs at younger ages and were disproportionately affected by severe mechanisms of injury, including falls from buildings, motor vehicle accidents, and violence. Helmet use was markedly lower among Hispanic children compared to their White peers. Across studies, Hispanic children exhibited higher rates of mortality (13.3% vs. 8.9% in White children). The payer-related barriers correlated with reduced access to inpatient rehabilitation and higher unmet post-discharge needs. Longitudinal studies demonstrated persistently poorer functional outcomes for Hispanic children, particularly in Spanish-speaking families, underscoring the amplifying role of language discordance. Hispanic children experience cumulative disparities in TBI that span exposure, acute care, and long-term recovery. These inequities are driven by structural determinants, including socioeconomic disadvantage, underinsurance, and language barriers, which transform an acute injury into a chronic disability. Interventions to mitigate these disparities must include culturally tailored prevention strategies, expansion of telemedicine, and integration of bilingual services. Further research is needed to disaggregate Hispanic subgroups and evaluate targeted interventions to achieve equity in pediatric TBI outcomes.
Clinical interest in psilocybin-assisted rehabilitation for motor disorders is growing. However, psilocybin's motor effects are under-researched, and quantifying them is essential for assessing treatment risks and outcomes. This study aims to clarify whether acute effects of psilocybin disrupt established patterns of manual dexterity and coordination. Specifically, we evaluate the impact of psilocybin on velocity, smoothness and kinematic manifold stability. In a randomised, blinded trial, healthy participants received three doses of psilocybin (5-20 mg) administered one week apart. Manual dexterity was assessed using the Box and Block Test (BBT) at baseline and 1.5, 3, and 4.5 hours post-drug administration. Task performance was analysed using a Bayesian mixed-effects model. For kinematic analysis, 21 hand landmarks were tracked from video recordings obtained at baseline and 1.5 hours post-administration. Principal component analysis (PCA) was the basis for evaluating the stability and dimensionality of latent structure. BBT performance showed a modest biphasic dose-response pattern at higher doses (10-20 mg), with slight impairment during peak effects and slight improvement 4.5 hours post-administration relative to baseline. Effect sizes were small compared to inter-individual baseline variability. Kinematic analyses revealed no substantial changes in movement smoothness or velocity. Dimensionality metrics indicated a stable coordination structure, although finger movements showed a subtle increase in complexity. Low to moderate doses of psilocybin did not meaningfully disrupt manual dexterity or the latent structure of hand coordination. These findings support the feasibility of combining psilocybin administration with active motor rehabilitation.
Toileting is a fundamental activity of daily living that presents significant challenges in bed-based care, particularly for individuals with mobility limitations and neurodevelopmental or intellectual disabilities. Despite its importance, assistive toileting has received limited attention at early design and feasibility stages. This study evaluates the technical feasibility of a bed-deployable, plumbing-independent automated toileting concept using simulation-based methods and structured expert appraisal. A mixed-methods approach was employed, including computer-aided design (CAD), quasistatic finite element analysis (FEA), controller timing simulations, and qualitative flow coverage assessments. An interdisciplinary expert panel (n = 15) provided structured feedback on system architecture and technical plausibility. Simulation results indicate that the proposed system architecture can execute the intended operational sequence and integrate key subsystems within a controlled virtual environment. Expert feedback identified design considerations and areas requiring further investigation but does not represent real-world performance or validated outcomes. This study is positioned as a preliminary feasibility investigation and provides a structured, standards-aware framework for early-stage evaluation of assistive toileting systems. Findings are based on simulation and expert perception and do not reflect clinical effectiveness or user outcomes. Future work should include physical prototyping, standardized bench testing, and empirical validation with end users to assess safety, usability, and real-world performance. The Auto Potty prototype provides individuals with autism and physical disabilities greater autonomy and emotional comfort, which can reduce caregiver dependency.Rehabilitation professionals can integrate this technology into home-based and clinical care plans to improve hygiene management and dignity preservation.Simulation-based evaluation offers a safe and cost-effective method for testing assistive devices before large-scale clinical trials.The device’s portable and smart features make it suitable for community-based rehabilitation, especially for individuals with limited mobility or access to specialised care.
To investigate the behavior of the auditory system in people's first year of hearing aid use. The study included 24 individuals of both sexes with moderate and severe sensorineural hearing loss. The first data collection stage occurred before fitting the hearing aids, through the P300 electrophysiological examination and the Portuguese Sentence List test. The second and third stages occurred 6 and 12 months after starting rehabilitation, applying these two tests and the Hearing Handicap Inventory for Adults or Hearing Handicap Inventory for the Elderly. The P300 latency and amplitude did not differ between the stages with either tone-burst or speech stimulus. The post-fitting hearing thresholds allowed accessibility to speech sounds, therefore differing between stage 1 and stages 2 and 3, with no difference between the last two. There was evidence of improved speech perception throughout the three phases, particularly in individuals with moderate hearing loss. The self-assessment questionnaire showed that the use of hearing aids reduced perceived participation restrictions in emotional and social contexts. Despite the lack of changes in electrophysiological measurements during the first year of use, speech perception (recognition) improved. Users also reported an improvement in quality of life, highlighting the benefits of using hearing aids. Investigar o comportamento do sistema auditivo em indivíduos que fazem uso de aparelhos de amplificação sonora individual, ao longo do primeiro ano de uso. Participaram do estudo 24 indivíduos, de ambos os sexos, com perda auditiva sensorioneural moderada ou severa. A primeira etapa de coleta ocorreu antes da adaptação dos aparelhos de amplificação sonora individual, mediante a aplicação do exame eletrofisiológico P300 e do teste Listas de Sentenças em Português. A segunda e terceira etapas ocorreram 6 e 12 meses após o início da reabilitação, sendo aplicados os dois testes mencionados e o questionárioHearing Handicap Inventory for AdultsouHearing Handicap Inventory for The Elderly. Não houve diferença na latência e amplitude do P300 entre as etapas, tanto quando realizado com tone burst, como para estímulo de fala. Os limiares auditivos pós adaptação permitiram acessibilidade aos sons da fala, diferindo, portanto, a etapa 1 das etapas 2 e 3, sem diferença entre as duas últimas. Houve evidência de melhora na percepção da fala ao longo das três fases, principalmente nos indivíduos com perda auditiva de grau moderado. O questionário de autoavaliação mostrou que o uso de aparelhos de amplificação sonora individual reduziu a restrição de participação percebida em contextos emocionais e sociais. Embora não haja alterações nas medidas eletrofisiológicas ao longo do primeiro ano de uso, observou-se melhora na percepção da fala (reconhecimento). Além disso, os usuários relatam uma melhora na qualidade de vida, evidenciando os benefícios do uso de aparelhos de amplificação sonora individual.
Helmet loads have been identified as a source of neck pain in fighter pilots. To minimize risk for neck pain, the effect of helmets on cervical spine biomechanics must be understood. In-vivo methods are difficult and invasive, so finite element modeling (FEM) techniques have been utilized recently to understand neck pathology development. Accurate muscle forces are crucial for physiologically relevant results. Therefore, this study evaluated the relationship between helmet loads and cervical muscle forces using two FEM muscle activation strategies. A validated cervical spine model was altered to include a fighter pilot's helmet load and muscle activations. The following simulations were analyzed: a no-helmet (NH) and helmet (H) conditions using both proportional-integral-derivative (PID) and shear wave elastography (SWE) techniques to estimate muscle forces to stabilize the head in a neutral position. Intervertebral disc (IVD) forces and pressures were reported to validate the muscle forces. PID and SWE methods produced different muscle activation patterns, with PID recruiting larger muscles first. SWE muscle forces were more closely aligned with EMG data, displaying larger activations in the deep stabilizer muscles. NH model loads suggest that both PID and SWE will produce physiological loads on structures in the spine. The use of SWE allows for more subject- and muscle-specificity in FEM, and the results are more consistent with in-vivo data. With the implementation of SWE-informed FEMs, pain mechanisms may be more accurately predicted which can lead to production of more optimal helmet designs, injury prevention protocols, and individualized rehabilitation strategies.
Promoting equal career opportunities for employees with disabilities is a key component of workplace inclusion and vocational rehabilitation. However, employees with disabilities continue to face unique challenges in their career development. Identifying both barriers and facilitators is essential to guide organizational practices and policy. This scoping review was conducted using the Population, Concept, and Context (PCC) framework and reported in accordance with the PRISMA extension for scoping review guidelines. Systematic searches were conducted across the Web of Science, Scopus, PsycINFO, EBSCO, PubMed, Google Scholar, Semantic Scholar, and IEEE Xplore databases. Studies were eligible if they examined factors influencing the career development of employees with disabilities in organizational settings. From 2781 references extracted, 10 studies were selected. The synthesis revealed barriers and facilitators across three domain: (1) individual factors (e.g., career self-management); (2) group-level factors (e.g., support system); (3) organizational factors (e.g., workplace accommodation); and (4) family (e.g., family advocacy and expectation). This review highlights the multidimensional nature of career development for employees with disabilities. By categorizing the influencing factors into individual, group, family, and organizational levels, the findings provide a foundation for future research and practical strategies to promote inclusive career advancement.
To compare Robotic Body Weight Supported Treadmill Training (RBWSTT), Overground Robotic Exoskeleton Training (ORET), and Conventional Physiotherapy (CP) on gait and cardiovascular outcomes in individuals with Spinal Cord Injury (SCI) eligible for walking recovery training and stratified by injury level, severity and onset (subacute: early post-spinal shock phase until 12 months; chronic: >12 months). Systematic review and network meta-analysis of randomized controlled trials (RCTs), registered in PROSPERO (CRD42023462361) and conducted following PRISMA-NMA guidelines. Eligible studies compared gait or cardiovascular recovery after RBWSTT or ORET. Searches were performed in MedLine, CENTRAL, Scopus, and Web of Science until May 2025. Cochrane RoB2 tool assessed the risk of bias. Meta-analysis synthesized the data. Twenty-five RCTs (n=905) were included. In subacute SCI, RBWSTT significantly improved the 6-Minute Walking Test (+43 m), Lower Extremity Motor Score (+4.94), and Walking Index for Spinal Cord Injury II (+1.55) compared with CP. In chronic SCI, ORET improved the Lower Extremity Motor Score (+2.77) and aerobic efficiency. RBWSTT showed better tolerability. Evidence quality ranged from very low to moderate. RBWSTT seems more effective in subacute SCI; ORET may benefit chronic cases. These results support individualized robotic rehabilitation. Stronger evidence is needed for long-term effects.