The exoskeletons and exoskeletons for rehabilitation They are completely changing the way neurorehabilitation and motor impairment are approached. What sounded like science fiction a few years ago is now a reality in clinics, hospitals, and research centers around the world, helping people with spinal cord injury, stroke, neurodegenerative diseases, or brain damage to stand up, walk again, and recover functions that seemed lost.
Far from being just a “robot that helps you walk”, a clinical exoskeleton is a complex medical device, regulated, validated and tested From a biomechanical, clinical, and safety perspective, this article will explain, in clear and accessible language, what these exosuits are, how they work, what benefits they offer, what risks and limitations they have, what regulations require for their use with patients, and how they are already being used in leading centers in Spain and internationally.
What is an exoskeleton or exoskeleton for rehabilitation?
A rehabilitation exoskeleton is, in essence, a wearable robotic device that fits the body The device is designed for the patient and its therapeutic purpose is to assist, guide, or amplify movement, especially during walking and other functional tasks. It is normally placed on the lower limbs and pelvic area, although models exist for the upper limbs and trunk.
In the case of exosuits for walking on the ground (not just on treadmills or suspended walkways), the system consists of support structures in thighs, legs and pelvisRobotic joints at the hips, knees and, in some models, ankles, as well as a series of straps and pads that secure the equipment to the body safely but comfortably.
These systems incorporate electric motors and actuators that generate joint movement and accompany or propel gait. The control electronics receive continuous information from a set of sensors and, using advanced algorithms, determine how and when to move each joint to reproduce a physiological and repeatable gait pattern.
The exoskeleton is usually fed by rechargeable batteries integrated into the structure itself or in a small backpack. Typical autonomy in intensive clinical use is around 3 to 4 hours, so its management is part of the session planning.
To start walking or change phases (sitting-standing, standing-sitting, turning, etc.), different models use varied control strategies: detection of user weight change, activation by voluntary muscle contraction, pressing buttons on a remote control or crutch, or even commands sent by the therapist through an interface.
Key components of a rehabilitation exosuit
The heart of these devices is a very well-thought-out combination of mechanics, electronics, sensors and softwareAlthough each manufacturer has its own design, most share common elements.
On one side is the lightweight and resistant mechanical structureManufactured from aluminum alloys, titanium, special steels, or high-strength polymers, this structure must withstand thousands of loading and unloading cycles, distribute weight appropriately, and adapt to different heights and body proportions, all without being excessively heavy for the patient.
The joints are located motors, actuators and gearboxes These devices convert electrical energy into controlled movement. Their task is to sequentially reproduce the hip and knee movements necessary for walking, adjusting the speed, amplitude, and timing of each step so that the pattern is as natural as possible, but also constant and repetitive—essential for neuromuscular re-education.
The integrated sensors They record critical information: joint angles, speed, accelerations, load on each leg, displacement of the center of mass, control button activity, etc. In some research environments, additional inertial sensors or external motion capture systems are also integrated to further refine the analysis.
The control unit and software apply motor control algorithms and, increasingly, artificial intelligence These systems interpret the user's intentions and adjust the level of assistance in real time. This allows, for example, the exoskeleton to "provide more assistance" when the patient becomes fatigued, or reduce assistance when they begin to generate more force on their own.
Finally, we must not forget the fastening and comfort elements: padded straps, hip and thigh supports, insoles and shells that distribute pressure and minimize the risk of chafing or wounds, something critical in people with reduced sensitivity or at risk of pressure ulcers.
Differences between medical, industrial, and entertainment exoskeletons
When we talk about exosuits, not everything is suitable for everything. There are important differences between a exoskeleton for clinical use, one designed for industry or those geared towards leisure and gaming.
Medical or rehabilitation exoskeletons are designed and regulated as medical devices under Regulation (EU) 2017/745 (MDR) when their purpose is therapeutic. They must demonstrate safety, clinical performance and benefits for the patient's health; therefore, they undergo technical trials and rigorous clinical evaluation, as well as post-marketing monitoring.
In the industrial sector we find exoskeletons designed to assist with physical tasks and prevent work-related injuriesFor example, in factories, logistics, or construction. Its main objective is not rehabilitation, but rather to reduce the load on the back, shoulders, or legs, improve ergonomics, and decrease the risk of musculoskeletal disorders.
There are also exoskeletons and exosuits for entertainment, virtual reality and immersive experiencesThe focus here is on increasing the sense of presence and reproducing forces or resistances that make a video game or simulation more realistic, without necessarily having a clinical or preventative purpose.
The key difference is that medical exoskeletons must comply much stricter regulatory requirements (MDR, risk management, clinical evaluation, etc.), as well as undergoing biomechanical validations and user trials in a health context, while the other devices operate under different product safety regulatory frameworks.
Clinical applications of exosuits in neurorehabilitation
In neurorehabilitation, exoskeletons have opened a very powerful door to Retraining gait in people with severe limitations mobility. It's no longer just about walking while attached to a harness on a treadmill, but about moving around on the ground, in real spaces, which completely changes the patient's experience.
In centers such as the Teknon Clinic in Barcelona, with the Traumaunit neurorehabilitation unit directed by Dr. Pablo Peret, or in hospitals specializing in brain injury, exoskeletons are integrated within personalized therapeutic programs for spinal cord injury, stroke, multiple sclerosis, Parkinson's disease, or other neurological and neuromuscular diseases.
In these protocols, the exoskeleton does not act alone, but as advanced technical assistance further within a range that includes well-fitted wheelchairs, canes, crutches, walkers, splints, ankle, knee or hip orthoses, and other walking support systems.
The overall goal of neurorehabilitation is to achieve maximum possible autonomy with minimal dependence on technical aidsBut often it is precisely the intelligent use of these aids, including the exoskeleton, that allows for faster recovery, improved walking safety, and enhanced neuronal plasticity.
A key point is having a highly trained and coordinated multidisciplinary team (rehabilitation doctors, physiotherapists, occupational therapists, clinical engineers, specialized orthopedists), able to assess which patients benefit from an exoskeleton, when to introduce it and how to combine it with other interventions.
Spinal cord injury and gait assisted by exoskeletons
People with spinal cord injury (SCI) They have been one of the groups in which exoskeleton-assisted gait (EAG) has been most researched and applied. With these devices, many patients with paraplegia have been able to stand and take steps on the ground again, under supervision, something unthinkable with traditional therapies in some cases.
Walking with an exoskeleton means much more for LME than just “getting around”: it contributes to reduce the time and difficulties in bowel care, improve the efficiency of evacuations and promote transit, thanks to movement and repeated standing.
The CAE has also partnered with reduction of chronic pain and spasticity In certain patients, improvements in cardiovascular and respiratory function, increased caloric expenditure, reduction of body fat, and increased or maintained bone density by subjecting the leg bones to weight loading.
On a psychological level, being able to get up from a chair and walk, even with help, has a huge impact on the self-esteem, confidence, and motivation to continue with rehabilitation and participate in social activities. Many users express that they regain "the feeling of being able to stand up in the world."
However, most of the available evidence comes from studies with relatively small samplesTherefore, the scientific community insists on the need to continue investigating what training dose, what frequency, and what patient profiles benefit most in order to make more refined recommendations.
Rehabilitation after stroke, brain injury and neurodegenerative diseases
Beyond spinal cord injury, exoskeletons are being used in stroke, traumatic brain injury, and other forms of acquired brain injurywhere there are often deficits in strength, coordination, balance and postural control, frequently on only one side of the body.
In these cases, the exoskeleton helps to retrain symmetrical and functional gaitguiding the movement of the most affected limb and allowing the patient to practice a correct pattern over and over again, without relying entirely on the physiotherapist's manual strength.
In pathologies such as multiple sclerosis or Parkinson's diseaseFor patients with progressive loss of mobility, stiffness, fatigue, or gait disturbances, training programs with exoskeletons are being explored, aimed at both maintaining function for as long as possible and improving stability and reducing the risk of falls.
Thanks to external mechanical assistance, many patients achieve maintain autonomy in activities of daily living for a longer time, delaying the need for more invasive aids and experiencing a greater sense of control over their own body.
At a neurophysiological level, all this repetitive and guided training contributes to enhancing the Neuronal plasticity: the brain's ability to reorganize itself, create new connections, and readapt motor circuits after an injury or in the face of a degenerative process.
Biomechanical, physiological, and psychological benefits
One of the great strengths of exosuits is their ability to reproduce a biomechanically correct and consistent gait patternSomething that is very difficult to achieve manually, session after session. This quality repetition is pure gold for neuromuscular re-education.
When the exoskeleton guides the gait, the patient receives a very rich proprioceptive inputJoint sensations, load, and leg and foot position in each phase of support. This information travels to the central nervous system and helps reinforce the desired motor patterns.
Standing and assisted walking also provide multiple benefits systemic benefitsThey improve venous return and circulation, promote bone metabolism by subjecting the skeleton to load, stimulate intestinal transit, and help prevent complications associated with prolonged immobility.
From a metabolic point of view, regular use of the exoskeleton implies a moderate to high intensity exercise For many people with LME or other pathologies, contributing to weight control, body composition and cardiorespiratory capacity.
On an emotional level, getting up, looking others in the eye, and being able to take steps represents a powerful psychological reinforcementMany patients describe a clear improvement in their mood, a reduction in the feeling of dependence, and a notable gain in motivation to continue working on their rehabilitation.
How exosuits work during movement
During a typical session, the user puts on the exoskeleton with the help of a therapist or trained companion, and it is adjusted the dimensions and contact points to ensure a secure and comfortable fit, and a pre-check of all systems is performed.
To begin the step, the device may require that patient shifts weight toward one leg, press a button on the crutch or walker, or have the therapist activate a command. From there, the hip and knee motors execute the programmed sequence of movements for the swing and stance phase.
Balance control often relies on the use of walker or crutchesexcept in some research models that allow walking without these supports. Training includes learning to change direction, stop, sit back down in a controlled manner, and manage fatigue.
In many systems, if the user It does not follow the expected marching patternIf it offers too much resistance or an unexpected disturbance occurs, the exoskeleton blocks the motors or enters a safe mode to prevent uncontrolled movements.
Mastering the use of an exoskeleton doesn't happen overnight: clinical experience indicates that it usually takes between [number of] sessions. 12 and 24 training sessions, from 30 to 120 minutes, to handle it fluently enough to consider its home use in certain models.
Who can use a rehabilitation exoskeleton
Not everyone with gait problems is a candidate for using an exoskeleton; a specific assessment is essential. individualized assessment by the medical and physiotherapy teamThere are physical and medical requirements that must be met for safety.
On the physical side, it is required that the level of injury or impairment be within the approved ranges for the specific model (e.g., T3 and below for personal use in LME, C7 and below for clinical training), as well as a compatible height and weight: most exoskeletons are designed for people between 160 and 190 cm and less than 100 kg.
Also required is a adequate range of motion in shoulders, hips, knees and anklesso that the device can be adjusted without creating dangerous levers or excessive pressure points. It is also important that the length of both legs be very similar to avoid imbalances that increase the risk of injury.
In many cases, the user needs to have good control of arms and hands to manage crutches or a walker, maintain balance, and assist with sitting-to-standing transitions. Some experimental models allow walking without support, but currently, it is common to use a cane or walker.
In addition, the person must be able to Understand and follow the coach's instructions. with precision. Working with the exoskeleton requires coordination, attention, and the ability to adapt to the rhythm imposed by the system; if this is not achieved, the risk of constant stops or even falls increases.
Medical requirements and contraindications
From a medical point of view, exoskeleton training involves significant effort, so it is essential to have a sufficient cardiac and pulmonary capacity to tolerate moderate to intense exercise. The doctor may order specific stress tests if there are any doubts.
They should not exist open wounds, pressure ulcers, chafing, or skin lesions in the areas where the exoskeleton makes contact (coccyx, hips, knees, feet), as repeated friction could seriously aggravate them.
The presence of untreated blood clots (thrombosis) In the lower extremities, it is a clear contraindication, because moving the leg could dislodge the clot and cause a pulmonary embolism, stroke, or a serious cardiac event. Even if you are on anticoagulant therapy, the risk of bleeding after a fall is higher, so extreme caution is necessary.
Pregnancy is another situation in which the use of exoskeletons is not recommended, both because of the risk of falling as well as the physical limitations in fitting the device as the pregnancy progresses.
The risk of orthostatic hypotension For people who feel dizzy or faint upon standing up, compression stockings, abdominal binders, specific medication, or tilt tables can be used to gradually acclimate the body before transitioning to the exoskeleton.
La severe spasticity (intense and uncontrolled muscle spasms) makes it extremely difficult to fit the device and can prevent the motors from working properly, since many exoskeletons have safety systems that block movement when they detect excessive resistance.
Finally, it is crucial to rule out severe osteoporosis or non-healed fractures in the lower extremities. Weight-bearing walking can cause fractures in very fragile bones, so bone densitometry or additional imaging tests are sometimes required before starting the program.
Risks and limitations of exoskeleton-assisted gait
Like any intervention with a certain level of complexity, CAE is not exempt from potential risksThe main one is the fall, with the consequent consequences: sprains, blows, bruises, head trauma or bone fractures.
If the device It doesn't fit properly.It can cause irritation, abrasions, or even pressure ulcers in pressure areas, especially in people with reduced sensitivity. Therefore, monitoring the skin's condition during and after each session is mandatory.
In patients with spinal cord injury at the T6 level or higher, there is a risk of autonomic dysreflexiaThis is an exaggerated response of the nervous system to harmful stimuli below the level of the injury, which can cause a sudden rise in blood pressure and other dangerous symptoms. Any discomfort caused by the exoskeleton, even if the patient doesn't feel it, can be the trigger.
From a functional point of view, it must be understood that the CAE does not always lead to an independent march without devices; in many cases the goal is to improve health, function and quality of life, rather than completely abandoning the wheelchair.
Another important limitation is the high cost of the devices and the necessary trainingThis means that for now few insurers or public systems finance the purchase for home use, and that access is mainly concentrated in reference centers or research projects.
In practical terms, current exoskeletons are heavy, bulky and with certain restrictions: lower than normal walking speed, difficulty turning, incompatibility with stairs in most models, need for large and relatively smooth surfaces, and battery limited to a few hours of use.
Furthermore, in the vast majority of cases the device must be used always accompanied by a trained person that can assist in case of a fall, loss of balance or technical failure, which limits the spontaneity of its use on a daily basis.
Regulations, technical trials and clinical validation
Exoskeletons intended for clinical rehabilitation and therapeutic assistance are considered Medical devices regulated under MDR 2017/745This involves demonstrating that the product is safe and delivers the intended performance through a comprehensive program of trials, clinical evaluation, and follow-up.
From a technical point of view, manufacturers must overcome structural strength and fatigue tests that guarantee the durability of the joints, actuators and structure even after thousands or millions of cycles of intensive use.
They are also made load and weight distribution tests to analyze how the device transfers forces to the limbs and spine, and thus avoid overloading the knee, hip or lumbar region that could harm the user.
The stability tests They evaluate the system's behavior in response to imbalances, unexpected thrusts, or sudden changes in posture. They verify that the combination of structure, control software, and external supports responds safely under realistic conditions.
On the other hand, the following is being studied: thermal comfort and ergonomicsPressure points, heat accumulation, adaptability to different morphologies, ease of placement and removal, etc. All of this influences both safety and patient acceptance.
At a clinical level, they are necessary studies with real users that measure outcomes in mobility, independence, physiological parameters, and quality of life, as well as the occurrence of adverse effects. The scientific literature already includes randomized trials, systematic reviews, and qualitative studies that document the experience with exoskeletons in spinal cord injury and other pathologies.
Advanced biomechanical analysis and the role of artificial intelligence
Validating and optimizing a modern exoskeleton requires going beyond static testing. That's why centers like Med-Lab IBV use advanced motion analysis techniques to study in detail how the device interacts with the body during actual walking.
Through systems of three-dimensional (3D) motion captureThe trajectory of the limbs, the symmetry of the step, the joint range of motion and possible compensations (e.g., excessive hip tilts or abnormal trunk movements) induced by the exoskeleton are recorded.
Force platforms and inertial sensors are used to calculate joint forces and moments in ankle, knee, hip and spine, quantifying the loads that the anatomical structures support and verifying that they remain within safe limits.
Surface electromyography (EMG) allows the analysis of muscle activity during exoskeleton useIdentifying whether the device's assistance reduces fatigue, whether the appropriate muscles are activated, or whether undesirable activation patterns appear that would need to be corrected.
In addition, parameters are assessed for motor control and postural stability, verifying that the exoskeleton control algorithms respond correctly to real disturbances (small bumps, changes in speed, turns) and help the patient maintain balance.
The gradual incorporation of artificial intelligence and machine learning It allows the device to "learn" from the user: it adjusts in real time the level of assistance, the rigidity of the robotic joints or the step length based on performance, opening the door to increasingly personalized therapies.
Notable clinical experiences and specific models
In Spain, there are already centers that can be considered benchmarks in the clinical use of exoskeletons. Teknon Clinic in Barcelona, through TraumaunitNeurorehabilitation with exoskeletons is part of a comprehensive approach to the patient with neurological injury, combining conventional physiotherapy, robotic physiotherapy and personalized technical aids.
In the field of brain injury, specialized hospitals work with models such as the HANK lower limb exoskeleton, developed by GOGOAThis system stands out for offering a constant gait pattern, something that is difficult to achieve manually and is demonstrating clear improvements in the re-education of the different phases of walking.
The first clinical results with HANK point to significant reductions in the time required to achieve objectives compared to traditional rehabilitation, as well as additional improvements in the quality of the gait pattern compared to classic therapies.
Beyond the clinical setting, companies like GOGOA are positioning themselves as Leaders in the design, development and marketing of MedTech exoskeletonsintegrating into the same ecosystem product design, therapy and a modern research laboratory where technology is continuously tested and redesigned based on the real experience of patients and professionals.
Internationally, devices such as Ekso Bionics or FDA-approved personal exoskeletons They are allowing some users to take the exoskeleton home. In the United States, the Department of Veterans Affairs is even considering funding these systems for veterans with spinal cord injuries who meet the criteria and complete the required training.
Access, training programs and the future of exosuits
To begin using an exoskeleton, the usual entry point is a hospital or outpatient rehabilitation program where there is a trained team and a clear protocol. Sometimes its use begins in the subacute phase, while the patient is still hospitalized, and continues later on an outpatient basis.
Outside of the clinical setting, some models allow the supervised home use once the user has completed extensive training and demonstrated safe handling of the device, always accompanied by a trained family member or assistant.
To acquire a personal exoskeleton, it is usually necessary that a Have a qualified healthcare provider perform the assessment and coordinate the prescription, also assessing financing options through insurance, public systems, specific programs (such as those for veterans) or even fundraising campaigns and grants.
As for the future, everything points to us seeing exosuits. lighter, more comfortable and affordablewith longer-lasting batteries, more sophisticated sensors, and increasing integration with virtual reality and artificial intelligence to create immersive training environments and ultra-personalized therapies.
The trend is for both hospitals and private rehabilitation centers to increasingly incorporate this technology into their protocols, supported by biomechanical reference laboratories that guarantee safety, efficacy, and proper certification under MDR regulations. With the maturity of the sector and the accumulation of clinical evidence, rehabilitation exoskeletons are becoming established as one of the most promising tools for improving mobility, overall health, and quality of life for people with neurological injuries and complex musculoskeletal disorders.