"Comparison Between Robotic and Conventional Walking Recovery Training Methods in People With Spinal Cord Injury": Systematic Review with Pairwise and Network meta-analysis

Objective: 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). Design: 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. Results: 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. Conclusion: 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.