# Haptic-Enabled Hand Rehabilitation in Stroke Patients: A Scoping Review
## 4 Discussion
This combination appears to best fulfill the rehabilitation needs as the robotic part enables strengthening the hand and upper limb. Virtual reality helps reproduce and practice the mental image of the task to be performed and the haptic biofeedback improves dexterity and fine motor skills retraining [55, 56, 57, 58, 59, 60, 61, 62, 63, 64, 65, 66]. Most of the studies reported on body functions (80% of the outcomes) compared to the other health domains, such as activity and participation as defined by the ICF framework, meaning that most interventions focused on hand functions without necessarily involving and evaluating the patient in meaningful daily tasks and occupations. This clinical direction would have to do with potential technical challenges. While it is expected that there will be endless possibilities for virtual environments, it is also likely that the provision of biofeedback in simulated daily tasks is a complex development. This complexity could be explained by the emergence of the use of haptics in hand therapy. The use of haptics to provide a patient with biofeedback is more developed in the rehabilitation of the arms [84, 85, 86, 87, 88]. Surprisingly, none of the articles included involved telerehabilitation as a model of rehabilitation. Although home-based telerehabilitation is an emerging trend [89] that has been shown to be needed in pandemic times, home-based telerehabilitation targeting hand therapy appears to be uncovered by research and development. Barriers to technology-enabled telerehabilitation services for hand therapy include the weakness of the patient's impaired upper limb and the complexity of applying a targeted passive range of motion tasks to patients who are not trained in the medical field (e.g., stretching impaired fingers with the unimpaired hand). Further research in this direction is needed to provide the general public with user-friendly and clinically approved digital platforms. Haptic devices have the potential to be implemented in the future as a diagnostic telerehabilitation tool used during clinical examination especially in palpation and special tests since in today's age this action is not possible [90]. This futuristic feature could help conduct a thorough patient assessment without the need for face-to-face visits and decrease by the same fact the cost and effort for both the clinician and patient. The inclusion of haptic-supported virtual examination could be an interesting solution for providing telerehabilitation in complex contexts, such as for patients living in rural, remote or underserved communities, or during pandemics (e.g., the COVID-19). User's perspectives on the use of haptic technology in hand rehabilitation need to be addressed in future research. This scoping review revealed that there was no information on how haptics specifically affected the patient-robot interaction as well as engagement in the practice and adherence to the therapy. Clinicians' perspectives on using haptic technology in hand rehabilitation and how it impacted their practice were not addressed either. Haptic technology can emit high force outputs, and users may suffer from decreased motor and functional levels allowing them to counteract this external mechanical stress. This risk of mechanical stress is worthy of exploration through continuous verbal questions throughout the therapy or the use of self-perceived scales (e.g., comfort, pain). Therefore, including user perspective in technology-enabled hand rehabilitation research is critical in promoting user-centred approaches to technology development and exploring novel therapeutic approaches. In the absence of validated questionnaires and consistent methodologies, it is recommended to integrate qualitative or mixed methods into the clinical trials to gather patients' and clinical views on their experience with the technology deployed as part of the therapy.