AdaptRehab VR: Development of an Immersive Virtual Reality System for Upper Limb Stroke Rehabilitation Designed for Low- and Middle-Income Countries Using a Participatory Co-Creation Approach

Stroke remains a significant global health challenge, particularly in low- and middle-income Countries (LMICs), where two-thirds of stroke-related deaths occur, and disability-adjusted life years are seven times higher compared to high-income Countries (HICs). The majority of stroke survivors suffer from upper limb impairment, severely limiting their daily activities and significantly diminishing their overall quality of life. Rehabilitation plays a critical role in restoring function and independence, but it faces challenges such as low engagement, limited customization, difficulty tracking progress, and accessibility barriers, particularly in LMICs. Immersive virtual reality (imVR) has shown promise in addressing these challenges, but most commercial imVR systems lack therapeutic design and cultural adaptation. This study aimed to develop culturally adaptable imVR games for upper limb stroke rehabilitation (ULSR) in the context of LMICs, with a particular focus on Ethiopia. The AdaptRehab VR system was developed including six imVR games (Basket Bloom, Strike Zone, TapQuest, FruitFall Frenzy, Precision Pitch, and Bean Picker Pro) through co-creation approaches involving Ethiopian and Belgian physiotherapists, stakeholders, and patients, incorporating game development mechanics in rehabilitation, such as therapeutic aims, cultural factors, feedback, automatic progression recording, task variety, and personalized rehabilitation. It was designed with the Unity 3D engine and Oculus Quest headsets, supporting controllers and hand tracking. This culturally tailored imVR platform has demonstrated significant potential to enhance ULSR accessibility, patient motivation, and outcomes in resource-constrained settings, addressing critical gaps in stroke rehabilitation solutions. In conclusion, the AdaptRehab VR system was successfully developed as a culturally contextualized imVR platform tailored to tackle ULSR challenges in LMICs, with a specific focus on Ethiopia.