Exoskeletons with virtual reality, augmented reality and gamification for stroke patients' rehabilitation : systematic review

Background: Robot-assisted therapy has become a promising technology in the field of rehabilitation of post-stroke patients with motor disorders. Motivation during the rehabilitation process is a top priority for a majority of stroke survivors. With the advancement in technology, there has been the introduction of Virtual Reality, Augmented Reality, customizable games or a combination thereof that aid robotic therapy in retaining or increasing the interests of patients to keep performing the exercises. However, there are gaps in evidence regarding the transition from clinical rehabilitation to home-based therapy and it calls for an updated synthesis of literature showcasing this trend. The present review proposes a categorization of these studies according to technologies used by them and also details research in upper limb and lower limb applications. Objective: The goal of this work was to review the practices and technologies implemented for the rehabilitation of post-stroke patients. It aims to assess the effectiveness of exoskeleton robotics in conjunction with any of the three technologies, Virtual Reality, Augmented Reality or Gamification for improving activity and participation in post-stroke survivors. Methods: A systematic search of the literature on exoskeleton robotics applied with any of the three technologies, Virtual Reality, Augmented Reality or Gamification, was performed in the databases namely; MEDLINE (Medical Literature Analysis and Retrieval System Online, or MEDLARS Online), EMBASE (Excerpta Medica database), Science Direct & The Cochrane Library. Exoskeleton based studies that did not include any VR, AR or gamification elements were excluded and publications from the year 2010 to 2017 were included. Results in the form of improvements in patients were also recorded and taken into consideration in finding the effectiveness of therapy on patients. Results: Thirty studies were identified based on the inclusion criteria that included randomised controlled trials as well as explorative research pieces. There was a total of around 385 participants across the studies. Use of technologies such as Virtual Reality/Augmented Reality/Gamification based Exoskeletons are capable of filling the transition from clinical to home-based settings. Our analysis showed that there were in general improvements in the motor deficiency for patients using the novel interfacing techniques with exoskeletons. This categorization of studies helps in understanding the scope of rehabilitation therapies that can be successfully arranged for home-based rehabilitation. Conclusions: Future studies are necessary to explore various types of customizable games required to retain or increase the motivation of patients going through the therapy individually.