Co-Design Approaches in Immersive Virtual Reality for Upper Limb Stroke Rehabilitation: A Narrative Review

Stroke-related upper-limb impairment is a leading cause of long-term disability, and immersive virtual reality (IVR) has emerged as a promising tool to enhance rehabilitation intensity and engagement. However, the effectiveness of IVR systems depends not only on technological features but also on how they are designed with end-user involvement. This narrative review examines co-design approaches used in the development of IVR systems for upper-limb stroke rehabilitation and evaluates how stakeholders contribute to system design and outcomes. A literature search was conducted in PubMed, Scopus, and IEEE Xplore, and studies involving IVR upper-limb rehabilitation with participatory, user-centered, or human-centered design were included. Thirteen studies met the inclusion criteria. Most studies demonstrated intermediate levels of participation, with seven classified as Level 4 (Collaborate), three as Level 3 (Involve), one as Level 2 (Consult), one as Level 1 (Inform), and one as Level 5 (Co-create). Common design principles included task-specific training, gamification, personalization, adaptive difficulty, meaningful activities, and clinician involvement. Despite positive findings regarding usability, motivation, and acceptability, most studies remained at feasibility or prototype stages, with limited evidence of clinical effectiveness. Recurring barriers included technological complexity, fatigue, cognitive demands, infrastructure limitations, and challenges in clinical integration. Overall, co-design is increasingly incorporated into IVR stroke rehabilitation development. However, sustained stakeholder partnership throughout the innovation lifecycle remains uncommon. Future research should prioritize longitudinal co-design processes and rigorous clinical evaluation to support the translation of IVR systems into routine rehabilitation practice.