Robotic Rehabilitation in Spinal Cord Injury: Neurophysiological Basis and Severity-Based Clinical Framework

Background/Objectives: Spinal cord injury (SCI) causes heterogeneous motor, sensory, autonomic, and participation limitations; recovery priorities vary by injury level, completeness, time since injury and residual function. Robotic rehabilitation has expanded from assistive technology to restorative, compensatory and health-promoting interventions, but patient-tailored prescription frameworks remain underdeveloped. Methods: PubMed/MEDLINE was searched from database inception to May 2026 using predefined domain-specific strategies, and findings were synthesized narratively to integrate mechanistic, clinical, safety and implementation evidence. Results: Robotic systems can increase task-specific repetition, sensorimotor feedback, active engagement and quantitative monitoring. Upper-limb robotics are feasible in cervical SCI and may support reach, grasp and activities of daily living, although SCI-specific controlled evidence remains limited. Lower-limb exoskeletons and locomotor robots can support gait practice, upright mobility, exercise exposure and selected secondary health outcomes, but walking speed, energy expenditure, cost, supervision needs and community translation remain important barriers. Sensory and non-motor effects, including proprioceptive input, spasticity, pain, bowel routine, cardiometabolic conditioning, participation and psychological well-being, are clinically relevant but should be interpreted according to evidence strength. Robotics combined with functional electrical stimulation, virtual reality, brain-computer interfaces, non-invasive brain stimulation and artificial intelligence-driven adaptation is promising but not yet routine. Conclusions: Robotic rehabilitation in SCI should be prescribed through a severity-based process that considers lesion level, American Spinal Injury Association Impairment Scale grade, residual voluntary and sensory function, safety, patient priorities and measurable goals. The proposed framework supports transparent selection and prospective validation of individualized robotic rehabilitation and shifts decisions beyond device availability toward clinically meaningful and equitable implementation.