Spinal cord injury (SCI) profoundly affects motor–sensory functions, reducing mobility and quality of life. Robotic exoskeletons offer a promising solution to support gait training, improve mobility, and prevent secondary complications. Existing research predominantly focuses on complete SCI, with limited exploration of long-term effects and tailored training for incomplete SCI. This study investigates device-based outcomes of personalized exoskeleton gait training in 33 individuals with incomplete SCI, with different lesion levels: cervical, thoracic, and lumbar. Participants underwent up to 39 sessions of gait training with a commercially available lower limb exoskeleton. Session parameters, including duration, intensity, and modality, were tailored to each individual’s clinical needs as determined by a medical team. Analysis focused on endurance, performance on the device, and patient-reported outcomes related to walking fluidity, safety, and satisfaction. Results showed overall improvement in endurance and performance, with the most significant gains observed in participants with thoracic-level injuries. All participants reported increased perceived safety, walking fluidity, and high satisfaction with the training. These findings support the potential of personalized exoskeleton training to enhance outcomes and experiences for individuals with incomplete SCI. The difference in improvement between lesion levels highlights the need for customized approaches to address the diverse clinical conditions within this population.

Several exoskeletons have been developed and increasingly used in clinical settings for training and assisting locomotion. These devices allow people with severe motor deficits to regain mobility and sustain intense and repetitive gait training. However, three factors might affect normal muscle activations during walking: the assistive forces that are provided during walking, the crutches or walker that are always used in combination with the device, and the mechanical structure of the device itself. To investigate these effects, we evaluated eight healthy volunteers walking with the Ekso, which is a battery-powered, wearable exoskeleton. They walked supported by either crutches or a walker under five different assistance modalities: bilateral maximum assistance, no assistance, bilateral adaptive assistance, and unilateral adaptive assistance on each leg. Participants also walked overground without the exoskeleton. Surface electromyography was recorded bilaterally, and the statistical parametric mapping approach and muscle synergies analysis were used to investigate differences in muscular activity across different walking conditions. The lower limb muscle activations while walking with the Ekso were not influenced by the use of crutches or walker aids. Compared to normal walking without robotic assistance, the Ekso reduced the amplitude of activation for the distal lower limb muscles while changing the timing for the others. This depended mainly on the structure of the device, and not on the type or level of assistance. In fact, the presence of assistance did not change the timing of the muscle activations, but instead mainly had the effect of increasing the level of activation of the proximal lower limb muscles. Surprisingly, we found no significant changes in the adaptive control with respect to a maximal fixed assistance that did not account for subjects' performance. These are important effects to take into careful considerations in clinics where these devices are used for gait rehabilitation in people with neurological diseases.