Exoskeleton Rehabilitation for Complete Thoracic Spinal Cord Lesion: A Case Study

Abstract

Background: Spinal cord injury is a life-changing condition for individuals who have previously been independent in activities of daily living. Motor recovery prognosis for individuals with complete spinal cord lesion above thoracic level ten is poor after nine months of injury. Although the corticospinal tract is responsible for voluntary mobility functions such as walking, it is possible, through neuroplasticity, that involuntary lower limb movements can be trained. Methods: This case study discusses the use of multi-modal rehabilitation strategies, from weightbearing exercises using traditional manual-controlled exoskeleton to ambulation using advanced automotive exoskeleton. Results: The patient’s perspective showed themes that align with the World Health Organization’s International Classification of Functioning and Disability. In spinal cord injury, majority of concerns are in environmental and personal factors. This could be due to the perceived permanent disability in complete spinal cord lesion. The moderate-intensity two-hour intervention using traditional and advanced exoskeletons during physical rehabilitation showed that it was possible to stimulate deep sensations, and muscle pull and cramp for a patient diagnosed with complete spinal cord lesion. Conclusions: The use of traditional and advanced exoskeletons in weightbearing exercises may benefit patients with complete spinal cord lesions in regaining deep sensations in the lower limbs.

1. Introduction

Over the past two decades, spinal cord injury, both traumatic and non-traumatic, has seen a progressive increase in incidence [1]. The likelihood of mobility recovery from spinal cord injury with complete lesion above thoracic level ten is low [2]. Individuals with spinal cord injury with complete lesions have poor motor recovery prognosis after 9 months of injury [3]. Kirshblum et al. [3] suggested that recovery during the acute and post-acute period of spinal cord injury is likely due to edema reduction or diaschisis. Spinal cord injury poses a significant burden globally, which is even higher for those with complete lesion in the cervical spine levels [4]. Whilst wheelchair advancement has promoted the quality of life among individuals with spinal cord injuries, the use of exoskeleton may further enhance their quality of life in partly adapted environments. To complement technological advancement, biomedical research in cellular regrowth provides a promising treatment for spinal cord injury [5], but the approach is still in early stage of research and thus not readily available for clinical implementation. Recently, spinal cord stimulation using an implant followed by seven months of physical rehabilitation showed improvements in motor function for three individuals with complete lesions in their thoracic spinal cords, but not sensory function [6]. However, not all individuals with spinal cord injury are suitable for the surgical implant procedure.

In the absence of recent novel interventions in managing individuals with spinal cord injury, the recommended management remains conservative. The recent literature has identified three useful conservative interventions for functional improvements among individuals with spinal cord injury, which are transcranial magnetic stimulation, functional electrical stimulation, and robotic-assisted treadmill training [7]. That said, Duan et al. [7] found the use of transcranial magnetic stimulation promising only for incomplete spinal cord lesion. This is because the mechanism acts through the corticospinal tract [8,9]. Thus, in complete spinal cord lesion, the only stimulation mechanism possible is through the reflex arc [10]. Whilst the use of functional electrical stimulation is similarly useful in managing individuals with incomplete spinal cord lesions as compared to those with complete spinal cord lesions, knowledge, cost, and time were barriers perceived by healthcare professionals in its adoption for clinical practice [11]. In the last recommendation, which is robotic-assisted treadmill training, the use of exoskeleton is increasingly popular not just out of novelty, but because of the potential to activate the central pattern generator [7]. However, evidence in the recovery of walking ability using supportive technology is limited. Overall, there is a lack of consensus on which rehabilitation intervention will be more effective [12], especially for those with complete spinal cord lesions.

Considering the challenges in the management of individuals with spinal cord injury, particularly those with complete lesions, this study presents a rehabilitation approach using traditional and robotic exoskeletons for physical rehabilitation. This case study is aimed at demonstrating the possibility of evoking sensorimotor changes despite a loss in corticospinal tract connectivity in complete spinal cord lesion. The rehabilitation strategy presented could then be considered by other clinicians.

2. Materials and Methods

In view of the scarcity and difficulty in recruiting spinal cord injury participants, a case study approach is used. This case study is presented in accordance with the Case Report (CARE) guidelines. The case has been sufficiently masked to maintain anonymity and written informed consent is obtained from the patient.

2.1. Case Demographics and Clinical History

The patient is 48 years old, female, and Asian, who was involved in a road traffic accident 10 years ago, resulting in spinal cord injury—complete lesion. She has no medical conditions prior to the spinal cord injury and has been a homemaker. She was an active triathlete who participated in races annually. Her radiological report from the accident and emergency department showed multiple fractures at the posterior aspects of thoracic spine levels six and seven, and stable hyaline fractures at spinous processes of lower cervical spine level seven. In addition to the spinal fractures, she was diagnosed with right pneumothorax and bilateral hemothorax. Subsequently, she underwent spinal decompression surgery and interbody fusion to stabilize thoracic spine levels six and seven. There was no post-surgical complication reported. Prior to leaving the hospital for home, she was categorized as low rehabilitation potential, so she was counseled to adapt with her available physical ability after six months of outpatient rehabilitation. Her function above thoracic spine level six is preserved, which means her bladder and bowel control are impaired. She was also reviewed by the psychiatrist for emotional wellbeing back then and considered to be well, likely associated with her acceptance of her present physical condition and social support from family.

2.2. Therapeutic Interventions

Hospital B rehabilitation did not include her in robotics therapy as she was deemed to be of poor rehabilitation outcome in the past year. Hence, the patient decided to give private rehabilitation robotics therapy a trial in March 2025, 10 years after her spinal cord injury. On initial assessment, based on the American Spinal Injury Association (ASIA) impairment classification, the patient is classified as ‘A’, complete spinal cord lesion below thoracic level six. Although she understands that the prognosis is poor, she hopes that robotics training and physical rehabilitation will provide stimulation to her lower limb muscles. She attends a two-hour rehabilitation session, once a week. The first hour involves physical therapy with core strengthening exercises and fitness exercises assisted using the traditional exoskeleton—standing Thoracic-Hip-Knee-Ankle-Foot Orthosis (THKAFO).

In her initial sessions, the patient was guided in quadruped position to transit into kneeling as a form of core training. Apart from donning the THKAFO to walk with a forearm rollator frame, her rehabilitation exercises incorporated the element of fun with the aims of muscle strengthening and flexibility, aerobics training, and movement coordination. These exercises included overhead ball lift and throw, battle rope, stepping, trampoline jump, boxing, and lunges (

Table 1. Exercises in Upright Standing with the Traditional and Advanced Exoskeleton.

	Overhead Ball Lift and Throw with THKAFO
	Therapy staff positions behind the patient. The patient is instructed to maintain her balance throughout the exercise. The patient is then instructed to lift the gym ball off the ground and overhead. After a 5 s hold, the patient is instructed to throw the ball down as hard as possible. The exercise is performed for three sets of ten repetitions.
	Battle Rope with THKAFO
	Therapy staff positions behind the patient. The patient is instructed to maintain her balance throughout the exercise. While holding a rope firmly in each hand, the patient is instructed to alternate and whip the 6 m rope in each hand. The exercise is performed for three sets of ten repetitions.
	Stepping with THKAFO
	Therapy staff positions behind the patient. The patient holds firmly to overhead grip handles to maintain postural stability. With one foot standing on an elevated step-board, the patient is instructed to swing her non-elevated leg forward and step firmly. The patient is then instructed to step backwards on the non-elevated leg. The exercise is performed for three sets of ten repetitions.
	Trampoline Jump with THKAFO
	Two therapy staff position behind the patient on each side. The patient holds firmly to overhead grip handles for safety. The patient is instructed to lower her body lightly to initiate gentle bouncing. As the bounce height and pace increase, the patient is advised to control her pace and force exertion with the upper limbs. The exercise is performed for five sets of ten repetitions.
	Boxing with THKAFO
	The patient is positioned within the gait rehabilitation parallel bar, between an extra-large gym ball in front and a lumbar support belt behind. The therapy staff is positioned nearby in case patient needs to rest. The patient is instructed to punch the gym ball with alternating fist. The exercise is performed for five sets of ten repetitions.
	Lunges with THKAFO
	The patient is positioned within the gait rehabilitation parallel bar. A therapy staff is positioned in front and another behind the patient. The patient is instructed to lunge forward, stretching the calf muscle of the leg at the back. The patient holds the lunge position for 10 s. The exercise is performed for ten repetitions on each side.
	Walking with Robotic Exoskeleton
	The patient is positioned on the exoskeleton in seated position. The therapy staff either uses a stationary treadmill for walking or accompanies the patient for outdoor walking. The patient performs this activity for 45 min.

Note: THKAFO = Thoracic-Hip-Knee-Ankle-Foot Orthosis.

). The patient maintains perceived exertion within four to six points on the Borg’s ten-point rate of perceived exertion scale [13]. Each session ends with ambulation on the advanced exoskeleton for about 45 min. To ensure her safety during the exercises, all exercise movements were performed within her available joint range of motion.

2.3. Thematic Synthesis

The patient was interviewed with four open-ended questions, (1) “How is life after the incident?” (2) “What are your goals back in 2015 versus now [2025], ie. past versus present?” (3) How did you find out about exoskeleton rehabilitation in Singapore?” (4) “What are your future plans?” We employed a few common strategies to mitigate potential bias in data extraction and interpretation. The interview was recorded by author R.X.L.C. Two authors (J.L.O and B.C.K.) independently extracted and coded qualitative data, with discrepancies resolved through discussion to achieve consensus. Reflexive discussions were used to minimize subjective bias in theme development. The authors (J.L.O and B.C.K.) maintained reflexive notes to acknowledge their preconceptions and minimize interpretive bias. We triangulated interpretations with author interpretations (J.L.O. and B.C.K.), participant quotes (patient), and provider observations (R.X.L.C.) to ensure consistency.

3. Results

The patient expressed satisfaction with her rehabilitation program because she reported muscle pulls in the calf muscle during lunges exercise and cramps in the quadriceps and hamstrings during and after trampoline, lunges, and walking exercises. She has not had such feelings or sensations prior to the current rehabilitation program. Commonly, these new symptoms could be due to a stretch fracture evoked by the intensive training. In this case, her new symptoms were not adverse and improved with rest. She has been reviewed in Hospital B in September 2025 for consideration as a clinical trial participant for stem cell transplant, and in her medical review, there were neither osteoporotic fractures nor other injuries detected. In terms of functioning, her functional independence measure score on admission was high, so rehabilitation outcome is expected to be limited by ceiling effect (

Table 2. Functional Independence Measure (FIM) on Admissions and Follow-up in 2025.

Items	March	September
Self-care
a. Eating	7	7
b. Grooming	7	7
c. Bathing	6	6
d. Dressing—upper body	7	7
e. Dressing—lower body	7	7
f. Toileting	6	6
Sphincter control
g. Bladder management	6	6
h. Bowel management	6	6
Transfers
i. Bed, chair, wheelchair	7	7
j. Toilet	7	7
k. Tub, shower	7	7
Locomotion
l. Walk / wheelchair	7 (wheelchair)	7 (wheelchair)
m. Stairs	1	1
Motor Sub-total Score	81	81
Communication
n. Comprehension	7 (auditory and visual)	7 (auditory and visual)
o. Expression	7 (auditory and visual)	7 (auditory and visual)
Social cognition
p. Social interaction	7	7
q. Problem solving	7	7
r. Memory	7	7
Cognitive Sub-total Score	35	35
Total FIM Score	116	116

). As compared to baseline ASIA score and classification (Figure A1), the 6th month follow-up assessment showed improvements in sensory from thoracic spinal cord levels six to eight, and she reported feeling deep anal pressure that was previously absent (Figure A2).

3.1. Patient Perspectives

The themes synthesized from the patient’s perspective were mapped onto the International Classification of Functioning and Disability framework of the World Health Organization for ease of interpretation (Figure 1).

3.1.1. Life After the Incident

Patient started the interview with, “[There are] a lot of inconveniences especially when the environment is [designed] for people without disability. So even [when] my home was renovated for my convenience, it can never fully cater to my personal needs because there are other able people living in the same environment. Examples of physical inconveniences are like toilet flushing system, how things are kept in the storeroom/cupboards, and the method to cook in the kitchen. Therefore, much effort and time is required for even a small gesture.” In this segment, the themes ‘physical inconvenience’ and ‘adapting to disability’ were thematically synthesized.

Followed by, “Another aspect of inconveniences is the loss of skin sensation, which accidents can happen [frequently]. Examples are shower water too hot for the skin, thighs got scalded by hot objects leading to pressure sores and broken skin due to impaired sensation after the incident.” The emerging theme in this segment of interview is ‘environmental hazard’.

In continuation, “Apart from the physical inconveniences, I find both mental and emotional health are a big change in me. I put these two domains together because I find that both aspects are closely related. My perspective of mental is about spinal cord injury knowledge, previously challenging, but easy these days to attain certain knowledge about spinal cord injury. However, how to translate that knowledge to help people like us still live a life meaningfully and purposefully can be quite challenging. Because we have many things to juggle and limited by our physical abilities, we often must spend more time nurturing our emotions and make mental adjustments to our expectations. This can be seen as non-productive because it lacks quantifiable element. For example, our standard measure of productivity is based on the house we live in and the amount of money we earn. Having said this, I find myself fortunate because I don’t have to worry too much about livelihood because to start off with, I have been a homemaker before the accident. But I believe many out there have much to juggle. I mean for an able person to climb the ladder of success in a corporate world is already a huge challenge, what’s more for spinal cord injury persons. I am just contented to have food on the table and be with my loved ones. These have been quite overlooked before the accident.” The key themes synthesized in this segment of the interview are ‘knowledge’, ‘mental health’, ‘emotion regulation’, ‘fitting into society’ and ‘social support’.

And ending the first question with, “I tend to worry less these days compared to before the accident. Perhaps in my unconscious mind is that this is the worst I can get in life. What could be even worse than this? Then just live a day as it is, living in the present. Don’t look too far to the future and what’s the past is already past. There’s nothing I can do to change the past.” A single theme was synthesized from this segment—‘acceptance’.

3.1.2. Past Versus Present Goals

The patient shared, “I think not much difference because I have always wanted to stand and walk again. In fact, I feel even more hopeful now because of advanced technology.” The themes that emerged from this question are ‘hope’ and ‘technology-assisted rehabilitation’.

3.1.3. Awareness of Exoskeleton

In this question, she shared, “Initially from Hospital A and then from social media.” The single theme that emerged from this response is ‘publicity’.

3.1.4. Future

She concluded the interview with, “I am planning to go for the stem cell clinical trial in Hospital B. I will still be going for rehab as long as my financials allow me to do so.” The emerging themes are ‘scientific advancement’, ‘long-term burden’, and ‘healthcare cost’.

4. Discussion

This case study showed that even though corticospinal tract connectivity is lost in complete spinal cord lesion, it is still possible to evoke sensory changes through lower limb weightbearing exercises. However, motor changes were not found after six months of rehabilitation. Nonetheless, the interview with the patient showed that private rehabilitation settings that incorporate traditional and advanced exoskeletons have benefits beyond physical functioning for those with spinal cord injuries below thoracic spine level six.

Literature demonstrating some signs of recovery in spinal cord injury is scarce. It is evident that robot-assisted rehabilitation benefits individuals with incomplete spinal cord lesions [14]. In our case study of complete spinal cord lesion, we offer a few possible reasons for the lower limb sensation felt by the patient. First, the symptoms could be triggered via spinal stretch reflex, an involuntary and overly active muscle contraction as observed in the muscle spasms during exercise. This altered reflex pathway occurs because the inhibitory signals from the brain to the spinal cord are lost in complete spinal cord lesion. Thus, there is a possibility for the patient to perceive a pulling sensation at the calf muscle during lunges exercise. Second, while the spinal cord lesion is diagnosed as complete, there could be a chance that some sensory fibers are spared, thus allowing some signals through the spinothalamic tract. Third, similar to amputees, the sensation felt could be a phantom sensation. However, this is unlikely as the patient reports of the calf pulling sensation only during the lunges exercise for the rear foot, which she did not expect to have any feelings. Her muscle cramps during rehabilitation were also exercise-specific. With regard to her regaining of deep anal pressure, it is an unusual phenomenon that warrants future investigation. Overall, superficial sensation is not significantly regained, and this case shows the possibility of regaining some sensation through physical rehabilitation.

The thematic synthesis mapped to the International Classification of Functioning and Disability framework of the World Health Organization provided an overview of the multi-disciplinary care needs of an individual with spinal cord injury. It is not surprising that physical inconvenience emerged as a theme because of the loss of motor function in spinal cord injury. In view that the motor impairments are difficult to reverse, a patient with spinal cord injury will need to adapt to available physical function. It is possible that advancement in technology can support physical rehabilitation and daily functioning. Advanced technology could support the patient in social activity participation. Social support plays an important role in supporting patients with spinal cord injuries [15]. The environment of patients with spinal cord injuries matters a lot as their loss of thermal sensitivity could lead to burns. The environmental safety of spinal cord injuries might be an overlooked care issue based on our patient’s perspective.

Awareness of rehabilitation advancement, which relates to knowledge, is important in keeping updated with the possibility of recovery. Advancement in science keeps hope alive but can also be a barrier to physical rehabilitation or advanced care because of the rising healthcare cost. The acceptance of one’s health condition is vital in regulating emotion and maintaining mental health. Overall, these themes reflect the long-term burden of spinal cord injury on quality of life. The themes highlight the importance of an inclusive society by improving accessibility for patients with spinal cord injuries and considering long-term healthcare subsidies. The patient’s perspective thus provides information for clinicians and policymakers to consider in developing an inclusive society.

Whilst this case study provides the genuine experience of a patient, it is possible that other patients, younger or older adults, with complete spinal cord lesions may have different life experience and expectations. Hence, generalizing the intervention plan of this case study to other patients requires careful consideration. Patients with higher levels of spinal cord lesions such as at the cervical spine or higher thoracic spine levels would likely have more physical impairments, which include reduced upper limb functioning. The novelty of robotic-assisted therapy may provide hope to individuals with spinal cord injuries. This case study shows the importance of weightbearing exercises and making exercise sessions fun, especially when the exercises cannot be performed in the gymnasium by patients independently. Future research using case series or large cohort studies will be useful in confirming if such intensive training protocol yields similar results without adverse events.

5. Conclusions

In this case study, a patient with complete spinal cord lesion at thoracic spine level six showed deep sensory improvement with weightbearing exercises assisted with traditional and advanced exoskeletons. To achieve this progress, moderate exercise intensity and two hours of rehabilitation session are necessary. The use of robotic-assisted walking can reduce the physical strain on allied health professionals, as well as provide extended rehabilitation care in view of limited allied health professional manpower.