sensors

Review
Smart Wearable Systems for Health Monitoring
Zhiyong Deng 1,2 , Lihao Guo 3, *, Ximeng Chen 1, * and Weiwei Wu 3, *

1 School of Nuclear Science and Technology, Lanzhou University, Lanzhou 730000, China
2 Nuclear Power Institute of China, Huayang, Shuangliu District, Chengdu 610213, China
3 School of Advanced Materials and Nanotechnology, Interdisciplinary Research Center of Smart Sensors,
Xidian University, Xi’an 710126, China
* Correspondence: [email protected] (L.G.); [email protected] (X.C.);
[email protected] (W.W.)

Abstract: Smart wearable systems for health monitoring are highly desired in personal wisdom
medicine and telemedicine. These systems make the detecting, monitoring, and recording of biosig-
nals portable, long-term, and comfortable. The development and optimization of wearable health-
monitoring systems have focused on advanced materials and system integration, and the number of
high-performance wearable systems has been gradually increasing in recent years. However, there are
still many challenges in these fields, such as balancing the trade-off between flexibility/stretchability,
sensing performance, and the robustness of systems. For this reason, more evolution is required
to promote the development of wearable health-monitoring systems. In this regard, this review
summarizes some representative achievements and recent progress of wearable systems for health
monitoring. Meanwhile, a strategy overview is presented about selecting materials, integrating
systems, and monitoring biosignals. The next generation of wearable systems for accurate, portable,
continuous, and long-term health monitoring will offer more opportunities for disease diagnosis
and treatment.

Keywords: smart sensors; wearable systems; health monitoring; advanced materials

1. Introduction
Citation: Deng, Z.; Guo, L.; Chen, X.;
Wu, W. Smart Wearable Systems for
In modern medicine, diagnosis, monitoring, and therapy methods mostly rely on
Health Monitoring. Sensors 2023, 23,
large-scale precise equipment, which is inconvenient and uncomfortable or even injurious
2479. https://doi.org/10.3390/
to patients. Meanwhile, due to limited medical resources, the diagnosis and monitoring
s23052479 processes have gradually tended to become portable and domiciliary, which necessitates
the development of miniaturized and portable equipment [1–8]. In recent years, numerous
Academic Editors: Susanna
flexible and wearable electronic devices have been designed with the advent of the Internet
Spinsante and Ki H. Chon
of Things (IoTs), and these novel devices can be also used in the medical domain to
Received: 4 January 2023 constitute diagnosis/monitoring/therapy systems that possess many advantages, such as
Revised: 19 February 2023 being non-invasive and lightweight, having skin conformability and portability [1–7], etc.
Accepted: 21 February 2023 Traditional devices and systems used to collect biosignals under normal life conditions are
Published: 23 February 2023 always strongly limited by large, repetitive deformations [8,9], such as joint movements
(at elbows, knees, wrists, etc.) and skin stretching. In order to use the obtained signals
as a basis for disease diagnosis and monitoring, the sensing performance of wearable
diagnosis/monitoring devices, i.e., sensitivity, selectivity, robustness, instantaneity, etc.,
Copyright: © 2023 by the authors.
should be improved under deformation.
Licensee MDPI, Basel, Switzerland.
For wearable devices and systems to diagnose disease and monitor health, electrodes
This article is an open access article
in wearable devices and systems need to have excellent conductivity and connect with an
distributed under the terms and
outstanding sensing platform during long-term use, while a stable skin–device conformable
conditions of the Creative Commons
surface is also indispensable to maintain real-time and continuous monitoring [10,11].
Attribution (CC BY) license (https://
creativecommons.org/licenses/by/
Meanwhile, wearable devices and systems are pursuing thin thickness and small sizes
4.0/).
for miniaturization and portability, which are necessary for improving conformability,

Sensors 2023, 23, 2479. https://doi.org/10.3390/s23052479 https://www.mdpi.com/journal/sensors

Sensors 2023, 23, 2479 2 of 36

but disadvantageous for their other properties such as conductivity, sensitivity, etc. For
example, according to Joule’s law, the severe fever issue is a common problem in integrated
circuits caused by smaller circuit sizes. Embracing this trade-off, then, is the kernel to
constructing high-performance wearable disease diagnosis/health-monitoring devices [10].
With the assistance of advanced materials, flexible electronics, and nano-/microfabrication,
there are many studies focused on sensing materials, flexible electrodes, or substrates in
wearable devices and systems, and through integrating promoted units, the performance
and size of wearable systems might be optimized simultaneously [12–17].
To date, many wearable devices and systems, e.g., smart watches, wristbands, head-
bands, eyeglasses, smart tattoos, and shoes, have been designed, fabricated, and commer-
cialized [18–23]. In wearable systems, functional units can be categorized into a substrate,
flexible electrodes, sensing materials, communication/energy units, and device-integrated
modes between these units [3,24–31]. As mentioned above, in order to ensure the per-
formance and comfort of wearable systems under deformation, design principles should
include: (1) each unit and system possess excellent structure robustness, and their structure
should not be easily destroyed under repetitive deformation, (2) the function of each unit
and the connection between them should be stable and insusceptible to deformation, (3) the
surface of wearable systems contacting with human skin should be conformable, nontoxic,
harmless, and comfortable. Based on the first and second principles, many measures have
been managed, which can be classified into two categories, i.e., materials and structures. As
for materials, there are many novel conductive nanomaterials and polymers that possess
inherent flexibility. These materials can maintain their performance under deformations
and can be used as sensing materials or flexible electrodes [26,28,32]. The stability and
robustness of wearable systems can also be achieved through adjusting the structure of
devices and systems, known as stretchable structures. Structures such as wave, serpentine,
helix, and kirigami have been demonstrated to provide effective strain release under de-
formations [23,33–37]. Moreover, integrated circuits, wireless transmission, and artificial
intelligence can be introduced to further enrich the functionality of wearable systems to
provide medical information, e.g., remote interaction and family practice [3,10]. Briefly,
the collected biosignals are transferred to the analysis terminal via wireless transmission
methods, such as Bluetooth, antenna, radio frequency identification devices (RFID), and
near-field communications (NFC), which releases the monitoring systems from an unwieldy
analysis terminal [38–42]. In addition, with the rise in wireless charging, energy can also be
wirelessly transferred to wearable systems to achieve self-powered systems, and in addition
to this, the energy supply process includes energy capture, conversion, and storage, includ-
ing triboelectric nanogenerators (TENG), (organic) photovoltaic cells, ion batteries, and
supercapacitors [43–47]. Machine learning, as a subset of artificial intelligence, has been
used to analyse biosignals in many fields, and this high throughput method can simulate
human brains in parallel information processing and enable wearable systems for signals
analysis or even disease diagnosis.
Nowadays, wearable systems are extensively used to monitor human basic physi-
ological signals, such as oxygen saturation, wrist pulse, blood pressure, and heart rate.
Researchers have demonstrated that wearable systems have great potential in disease
diagnosis, therapy, drug delivery, etc., as shown in Figure 1 [26,29,48,49]. For instance,
electrophysiology signals [23], i.e., electrocardiograph (ECG) [50], electroencephalograph
(EEG) [51], electromyography (EMG) [52], and electrooculogram (EOG) [53], are collected
via epidermal electronic devices, providing visual data for studies and treatment of car-
diovascular and cerebrovascular diseases, and anatomical body movements can also be
monitored by wearable systems. Moreover, the use of (bio)chemical biomarkers in body
fluids and breath as diagnostic information to analyse the physiological function of the
human body is a promising approach, and wearable (bio)chemical sensing systems have
been designed, fabricated, and used to diagnose diseases such as diabetes mellitus, cancer,
etc. Wearable diagnosis/monitoring/therapy systems can be utilized as a substitution for
Sensors 2023,23,
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38

large-scale
large-scaleprecise
preciseequipment
equipmentduring
duringearly diagnosis
early and
diagnosis monitoring
and of disease
monitoring because
of disease of
because
their painless, inexpensive, and portable advantages [54–57].
of their painless, inexpensive, and portable advantages [54–57].

Figure1.1. Wearable systems

Figure systems for for human
humanhealthhealthmonitoring,
monitoring,including
including(a)(a) breath
breath monitoring.
monitoring. Re-
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produced
duced with with permission
permission from from [58][58].
ref. ref. Copyright
. Copyright 20162016 Wiley-VCH.
Wiley-VCH. (b) Electroencephalogram
(b) Electroencephalogram mon-
monitoring. Reproduced
itoring. Reproduced withwith permission
permission fromfrom [59][59].
ref. ref. Copyright
. Copyright 2019
2019 Nature
Nature Publishing
Publishing Group.
Group. (c)
(c) Sound
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monitoring. Reproducedwith withpermission
permissionfrom ref.[60]
fromref. [60].. Copyright 2017
2017 Nature
NaturePublishing
Publishing
Group. (d)
Group. (d)Electrooculogram
Electrooculogram and andintraocular
intraocularpressure
pressuremonitoring.
monitoring.Reproduced
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permission
fromref.
from [61].Copyright
ref.[61]. Copyright20142014Nature
NaturePublishing
PublishingGroup.
Group.(e) (e)Electrocardiograph
Electrocardiographmonitoring.
monitoring. Repro-
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ducedwith
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fromref. [23].Copyright
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monitoring. Reproduced
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ref. [62]. Copyright2021
2021
The Royal Society of Chemistry. (g) Wrist pulse and blood pressure monitoring.
The Royal Society of Chemistry. (g) Wrist pulse and blood pressure monitoring. Reproduced with Reproduced with
permissionfrom
permission fromref. [63].Copyright
ref.[63]. Copyright2014 2014Wiley-VCH.
Wiley-VCH.(h) (h)Wound
Woundhealing
healingmonitoring.
monitoring.Reproduced
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with permission from ref. [64] . Copyright 2018 American Association
with permission from ref. [64]. Copyright 2018 American Association for the Advancement offor the Advancement of Sci-
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ence.(i)
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Science.

Withthe
With thechange
changeininliving
livingenvironment,
environment,the theincidence
incidenceages agesofofchronic
chronicdiseases,
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toring
and earlyand early diagnosis
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have gained gained increasing
attention andattention
demand.and The
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designedTheanddesigned
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cated wearable diagnosis/monitoring
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gradually gradually become multi-
multi-functional,
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cross-disciplinary, and advanced. and advanced.
Thus, Thus,
this review this review
focuses on the focuses
wearable ondiagnosis
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and
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systems and combssystems and combs
the design the design
strategy, includingstrategy,
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selection, structurese-
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lection, and systems
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also highlight We practical applications
also highlight practicalof wearable
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challengestheand future directions
challenges and future todirections
develop the performance
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for disease health monitoring.
and healthInmonitoring.
Scheme 1, we illustrate1,
In Scheme
the
we research
illustratedirections anddirections
the research current gaps,
and which
currentalso constitute
gaps, which alsothe main structure
constitute and
the main
scope of our review. Firstly, the materials used in wearable health-monitoring
structure and scope of our review. Firstly, the materials used in wearable health-monitor- systems are
summarized,
ing systems are including flexibleincluding
summarized, substrates,flexible
sensingsubstrates,
materials,sensing
and conducting
materials, electrodes.
and con-
Moreover, the integration
ducting electrodes. of monitoring
Moreover, systems
the integration is discussed,systems
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discussed, focus-
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ing on data energy supply
communication systems,
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and data Secondly,
analysiswearable
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health-monitoring
Secondly, wearablesystems applied to anatomical
health-monitoring systems applied movement monitoring,
to anatomical arterial
movement pulse
monitor-
pressure monitoring, electrophysiological signals monitoring, and
ing, arterial pulse pressure monitoring, electrophysiological signals monitoring, andbiochemical signals
 Sensors2023,
Sensors 23,x2479
2023,23, FOR PEER REVIEW 4 of3836
4 of

monitoring signals
biochemical are concluded. Finally,
monitoring concluding Finally,
are concluded. remarksconcluding
and an outlook for further
remarks and an study
out-
are presented.
look for further study are presented.

Schemaofofthe
Scheme1.1.Schema
Scheme themain
mainstructure
structureofofthis
thisarticle.
article.TheTheaim
aim(core)
(core)ofofthis
thisreview
reviewisiswearable
wearable
systems
systems for health monitoring and disease diagnosis (first ring). The practical applications ofwear-
for health monitoring and disease diagnosis (first ring). The practical applications of wear-
able
ablesystems
systemsin inhealth
health monitoring
monitoring are divided into
are divided into four
fourparts,
parts,i.e.,
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anatomicalmovement
movementmonitoring,
monitor-
ing, arterial
arterial pulse
pulse pressure
pressure monitoring,
monitoring, electrophysiological
electrophysiological signalssignals monitoring,
monitoring, and biochemical
and biochemical markers
markers monitoring (second ring). The components of smart wearable health-monitoring systems
monitoring (second ring). The components of smart wearable health-monitoring systems are summa-
are summarized, including flexible substrates, sensing materials, conducting electrodes, data com-
rized, including flexible substrates, sensing materials, conducting electrodes, data communication
munication systems, energy supply systems, and data analysis systems.
systems, energy supply systems, and data analysis systems.
2.2.Materials
Materialsand andSystem
SystemFabrication
Fabrication
Wearable
Wearable diagnosis/monitoringdevices
diagnosis/monitoring devicesand andsystems
systemsare arecomplex
complexand andhighly
highlyinte-
inte-
grated. To fabricate promising wearable systems, materials selection
grated. To fabricate promising wearable systems, materials selection and structureand structure designde-
are
signvery
are critical [26,66].
very critical Generally,
[26,66]. the functional
Generally, unitsunits
the functional of wearable systems
of wearable include
systems (1)
include
stretchable substrate,
(1) stretchable (2) sensing
substrate, materials,
(2) sensing (3) flexible
materials, electrodes,
(3) flexible and (4)and
electrodes, systems integra-
(4) systems in-
tion [29]. Moreover,
tegration the performance
[29]. Moreover, of systems
the performance is determined
of systems by the by
is determined function and inter-
the function and
actions of each
interactions ofindividual unit, so
each individual we must
unit, so weconsider individual
must consider units asunits
individual well as
as well
the entire
as the
system.
entire system.

2.1.Flexible
2.1. FlexibleSubstrates
Substrates
Traditionalrigid
Traditional rigidsubstrate
substratematerials,
materials,such
suchas
asSiO
SiO2,2 ,Si,
Si,and
andITO/FTO,
ITO/FTO,only onlyshow
showme-me-
chanicalflexibility
chanical flexibilitywhenwhenthethethickness
thicknessofofthese
thesematerials
materialsreduces
reducestotodozens
dozensofofnanometres.
nanometres.
However, the
However, the mechanical
mechanicalstrength
strengthis also weakened
is also weakenedsimultaneously
simultaneously[67]. Therefore, stretch-
[67]. Therefore,
able substrates that possess excellent mechanical flexibility and strength
stretchable substrates that possess excellent mechanical flexibility and strength are de- are demanded
to maintain
manded the stability
to maintain of systems
the stability under complicated
of systems under complicateddeformation [68,69].[68,69].
deformation ManyManyelastic
polymers,
elastic e.g., polyethylene
polymers, terephthalate
e.g., polyethylene (PET) [70], polydimethylsiloxane
terephthalate (PDMS) [71],
(PET)[70], polydimethylsiloxane
polyethylene
(PDMS) naphthalate (PEN)
[71], polyethylene [72], polyimide
naphthalate (PEN) [72],(PI) [73], poly(styrene-ethylene-butylene-
polyimide (PI) [73], poly(styrene-eth-
styrene) (SEBS) [74], etc.,
ylene-butylene-styrene) have[74],
(SEBS) been widely
etc., have chosen as flexible
been widely chosen substrates
as flexible forsubstrates
wearable
systems due to their intrinsic mechanical flexibility. Moreover, most
for wearable systems due to their intrinsic mechanical flexibility. Moreover, most elasticelastic polymers are
easily processable and nontoxic, which reduces the risks in biomedical
polymers are easily processable and nontoxic, which reduces the risks in biomedical use use [75].
[75]. The choice in substrate mainly depends on the target physiological signals and the
placement
The choiceof flexible devices.
in substrate When
mainly monitoring
depends on thedifferent target physiological
target physiological signals andsignals,
the
flexible substrates
placement of flexibleneed to possess
devices. Whendifferent properties.
monitoring For example,
different flexibility andsignals,
target physiological stretch-
Sensors 2023, 23, 2479 5 of 36

ability are the most crucial properties of flexible substrates used in movement-monitoring
systems, but permeability is the chief property which needs to be considered when wear-
able systems are used to monitor biochemical markers contained in breath or body fluids.
Moreover, non-stretchable substrates are preferable in some monitoring systems (such as
biomarker-monitoring systems) since stretchable substrates may induce the mechanical
destruction of sensing layers. In addition, wearable systems always suffer serious deforma-
tion, which may cause them to break down when they are placed near joints (e.g., elbows,
wrists, knees), so some special properties should be endowed to flexible substrates, such as
self-healing. Accordingly, the common flexible substrates are categorized here based on
their characteristics.
PI and PET are two commercial polymers with high tensile strength, excellent bend-
ability, low cost, and great chemical stability. Since PI can withstand high temperature (up
to 452 ◦ C), weak acid, alkalis, and organic solvents, this material is widely used in Micro-
Electro-Mechanical Systems (MEMS). A mass of flexible devices based on PI substrates
have also been fabricated for pressure and bend sensing [76,77]. However, the yellow
colour of PI hinders its use in many applications, including solar cell and flexible display,
where high light transparency is required [73]. PET, which also offers satisfactory physical
and chemical stability, is a transparent flexible substrate that allows more than 85% of light
to pass through. This material can be used as a substrate for solar cells or flexible displays
to replace PI [72,78]. In general, PET and PI can only be bent but not stretched. There are
two strategies for fabricating stretchable substrates: constructing stretchable topological
shape structures (described in the subsequent section) and using stretchable materials.
The stretchability of PVA and PDMS makes them popular as stretchable substrates
in wearable systems, which can be stretched over a 1000-fold stretch [79]. Moreover,
due to the liquid state before solidification, PDMS and PVA can be easily processed into
various shapes with different moulds, e.g., hemispheric, pyramid, ripple, etc. [66,80–82],
and these moulds are not only delicate moulds produced by lithography but also common
microstructured items such as abrasive paper and lotus leaves [63,83]. Microstructured
substrates can effectively improve the sensing performance of wearable systems [66,84–86].
For example, Cheng et al. imitated the microspine receptors in human skin and spin-
coated MXene on microstructured PDMS, which was constructed using abrasive paper
as a mould, and the sensitivity and detected limitation of the obtained pressure sensor
were related to the roughness of the abrasive paper, so the optimized flexible pressure
sensor could achieve high sensitivity (151.4 kPa−1 ) and low detected limitation (4.4 Pa) [83].
The morphology, size, and density of microstructures on a substrate all influence the
performance of wearable systems. These factors should be precisely controlled using
MEMS technology, e.g., lithography and reactive ion beam etching. More interestingly, the
special microstructured PDMS substrate can detect pressure direction, which is significant
but difficult because the pressure always coexists with shear forces [87]. This method will
be discussed in the subsequent section.
Furthermore, PVA has a self-healing property due to abundant hydrogen bonds inside,
which makes wearable systems with PVA substrate resistant to damage [88]. Mechan-
ical failure is inevitable and fatal during the use of wearable systems, but like human
skin, substrates using self-healing materials can self-heal when they are mechanically
broken [89,90]. The self-healing mechanisms of these materials include hydrogen bonds,
chelation, and electrostatic interaction. Advanced self-healing materials have been pro-
posed to lengthen the lifespan of wearable systems. For instance, Huynh et al. provided a
flexible self-healing device based on polyurethane (PU) and gold nanoparticles for pres-
sure, temperature, and gas sensing, and the performance of the device can be maintained
even after 4–5 scratch/healing cycles [89,91]. A PVA-functionalized single-walled CNT-
polydopamine sensor was explored by Wan and coworkers, which has high self-healing
efficiency (99%) and fast ability (<2 s), and this sensor has an excellent performance in
healthcare monitoring [92].
Sensors 2023, 23, 2479 6 of 36

Fibres and textiles possess excellent breathability that the abovementioned substrate
materials lack, so they are supposed to be the natural materials closest to human skin.
Silk has been widely reported as a substrate in flexible and wearable electronic products
owing to its many benefits [93,94], including biocompatibility, transmissivity, mechanical
robustness, etc. As common fibres and textiles are insulating, they need to be function-
alized when used as a substrate in wearable systems [95,96]. Two methods are mainly
used to functionalize the textiles: integrating external devices (sensors, power sources,
conductive pathways/electrodes, etc.) on textiles and spinning conductive or sensing fibres
in textiles [97–99]. Both methods have their advantages; there are various smart wearable
substrates developed on textile substrates, and functionalized textiles bring traditional
cloths to the smart, high-tech, and multi-functional stages [100].

2.2. Sensing Materials and Conducting Electrodes

2.2.1. Metals and Traditional Inorganic Materials
Sensing materials and conducting electrodes are two of the most crucial components
in wearable systems. The selective principle of electrode materials mainly focuses on their
conductivity and robustness, but the sensing materials should be chosen according to the
aim function [26,28,101]. The conductivity and function of both the two units have to be
stable under repeated deformation to ensure the stable performance of systems, and to
avoid the interference of sensing signals, the electrode resistance should be insensitive
to deformation.
Metals, e.g., Au, Ag, Cu, Pt, and some traditional inorganic materials, e.g., indium tin
oxide (ITO) and fluorine doped tin oxide (FTO), have been utilized as conducting electrodes
because of their excellent conductivity [102,103]. In terms of sensing materials, the materials
vary depending on their purpose of use, such as transition metal oxide (semiconductor) for
optical sensing [104], Pt and Mg (metal) for temperature sensing, and Au and Ag for force
sensing [105,106]. These metals and traditional inorganic materials have been widely used
in rigid devices but due to the inherent rigidity of these materials, they are easily broken
under deformation. Even though some metals are soft, there is still permanent cumulative
damage, i.e., cracks and breakage, under cyclic stress or strain [107–109]. In wearable
systems, rigid devices and electrodes are attached to or buried in flexible substrates, but via
theoretical simulation and experimental test, the modulus disparity of devices and flexible
substrate causes stress concentration, which aggravates the deformation and damage of
rigid devices [52,110–112]. Metals and rigid inorganic materials can be made more flexible
in two ways: by reducing the thickness of the materials or by constructing stretchable
structures [23,38,113]. The strain energy per area can be effectively brought down by
reducing the thickness of materials. This strategy makes materials more flexible, and the
special stretchable structures, such as serpentine, sigmate, and wave, can disperse stress
distribution, thereby avoiding stress concentration caused by deformation [38,67].
Recently, Kim et al. designed a GaN surface acoustic wave device (Figure 2a) [38], and
they proposed that the contact mode between thick GaN and substrate is non-conformal
contact because of high strain energy per area, whereas when GaN is thinner than 200 nm,
the strain energy can be reduced to less than 3 N/m (work of adhesion) and the contact
converts to conformal contact (Figure 2b). As shown in Figure 2c, the surface acoustic wave
of a 200 nm GaN sheet which conformally contacts with PI substrate and skin replica is
exceedingly sensitive to skin deformation, and this GaN is also sensitive to ultraviolet light
and Na+ ion because of its inherent semiconducting property. This GaN sensor is connected
to an antenna that is wireless for signals and energy transmission, and the conducting
pathway and antenna are composed of serpentine Au, which represents another method
mentioned above.
Sensors 2023,23,
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38

Figure2.2.The
Figure Thetypical
typicaldesign
designstrategies
strategiesof ofconducting
conductingmetals
metalsand
andtraditional
traditionalinorganic
inorganicmaterials
materialsin in
wearable systems. (a) Schematic of the wearable system with rigid devices and chip-less wearable
wearable systems. (a) Schematic of the wearable system with rigid devices and chip-less wearable
system. (b) Estimation of minimum sensing material thickness required for conformal lamination
system. (b) Estimation of minimum sensing material thickness required for conformal lamination
on human skin. (c) SEM image of conformal contact between material and skin. Reproduced with
on human skin.
permission from(c)ref.
SEM [38]image of conformal
. Copyright contact between
2021 American material
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for the skin. Reproduced with
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permission
(d) Optical from ref. [38].
micrograph of Copyright
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skin (EES) withfor the Advancement
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thean FS-EES. Reproduced
Advancement of Science.with permissionand
(h) Illustration from
SEM ref. [23]. ofCopyright
image an island–
bridge fabrication strategy. Reproduced with permission from ref. [114]. Copyright 2008 Nature
2021 American Association for the Advancement of Science. (h) Illustration and SEM image of an
Publishing Group. (i) Response of kirigami structure to stretching in the axial
island–bridge fabrication strategy. Reproduced with permission from ref. [114]. Copyright 2008 direction. Reproduced
with permission
Nature Publishing from ref. [115]
Group. . Copyright
(i) Response of 2015 Nature
kirigami Publishing
structure Group. (j)in
to stretching Schematic
the axialillustration
direction.
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with permission with the ref.
from Ferris wheel-shaped
[115]. island
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Nature array in Ecoflex
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(j) Schematic
sus strain for
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of stretchable island
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stress with permission
versus strain from ref. [116]
for the circle-shaped island . Copyright
(red trace)2022 American
and FWI (blue Association
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under
vancement of Science. (k) Two-dimensional diagram showing a representative
stretching. Reproduced with permission from ref. [116]. Copyright 2022 American Association for transistor structure.
(l) Optical microscope images of one transistor under 0% (left) and 100% (right global strain). (k, l)
the Advancement of Science. (k) Two-dimensional diagram showing a representative transistor
Reproduced with permission from ref. [117]. Copyright 2021 Nature Publishing Group.
structure. (l) Optical microscope images of one transistor under 0% (left) and 100% (right global
strain). (k,l) Reproduced with permission from ref. [117]. Copyright 2021 Nature Publishing Group.
Rogers et al. provided an epidermal electronics skin (EES) [23], and the interconnect
line Rogers
in this system was formed
et al. provided into a large-amplitude
an epidermal electronics skin serpentine
(EES) [23],shape, shown
and the in Figure
interconnect
2b, referring to the open-mesh structures [118,119]. The effective
line in this system was formed into a large-amplitude serpentine shape, shown in Figure modulus (E EES) and
2b,
bending stiffness were proved to be paramount, rather than the range
referring to the open-mesh structures [118,119]. The effective modulus (EEES ) and bending in stretchability,
and the effective
stiffness were proved modulus
to bewas approximately
paramount, ratherexpressed
than the as EEES in
range = Estretchability,
int(1 + Ld/Ls), where
and theEint
corresponds
effective to thewas
modulus effective modulus ofexpressed
approximately the interconnect
as EEES line,
= EintLd,(1and+ LLds/L
is sthe size ofEde-
), where int
vices and distance
corresponds between modulus
to the effective devices, respectively. Introducing
of the interconnect line, Ladfilamentary
, and Ls is the serpentine
size of
interconnect
devices line reduced
and distance betweenthe effective value of Ld, and
devices, respectively. with thinner
Introducing devices, the
a filamentary effective
serpentine
modulus of EES was minimized, which also reduced the driving forces
interconnect line reduced the effective value of Ld , and with thinner devices, the effective of this EES for
interface delamination
modulus and avoided
of EES was minimized, device
which failure
also under
reduced thedeformation.
driving forces Through
of thisfinite
EES ele-
for
ment modelling,
interface delaminationthe stress
and on interconnect
avoided devicewas evenly
failure scattered
under over the Through
deformation. sinuosity finite
of the
serpentine
element interconnect
modelling, line, minimizing
the stress the stress
on interconnect concentration,
was evenly scatteredwhichover themay cause me-
sinuosity of
chanical
the breakage.
serpentine Based online,
interconnect these serpentinethe
minimizing interconnect lines, multiple
stress concentration, which devices were
may cause
fabricated, such
mechanical as an electrophysiological
breakage. sensor (Figure
Based on these serpentine 2e), a temperature
interconnect lines, multiple sensor (Fig-
devices
ure 2f),
were a photo-detector,
fabricated, such as an and AlInGaP LEDs (Figure
electrophysiological sensor 2g).(Figure
By integrating these sensors
2e), a temperature and
sensor
devices, a flexible multi-functional system was obtained, which can be used for long-term
Sensors 2023, 23, 2479 8 of 36

(Figure 2f), a photo-detector, and AlInGaP LEDs (Figure 2g). By integrating these sensors
and devices, a flexible multi-functional system was obtained, which can be used for long-
term electrophysiological (ECG, EEG) monitoring. A similar island–bridge interconnect
strategy is also used in non-plane devices [120], such as a hemispherical electronic eye
camera demonstrated by Rogers et al. Rigid silicon devices (p–n diode photodetector)
islands were interconnected by compressed Au electrodes (Figure 2h) [114]. The stress
caused by deformations was induced to distribute on flexible interconnect lines, easing the
strain on rigid devices and reducing the risk of damage.
As mentioned above, some flexible substrates cannot be stretched, which limits their
applications. Inspired by Chinese traditional paper art, i.e., origami and kirigami, which
transform two-dimensional (2D) paper into a three-dimensional (3D) structure, designing
the substrates in special patterns can endow them with stretchable property [30]. When the
axial strain is applied to non-stretchable substrates such as PI, PET, and paper, the stress is
concentrated inside the substrate, but by transforming these substates into kirigami struc-
tures, stress and stretching energy can be dissipated by opening the kirigami pattern, thus
allowing the flat substrate to bend out of the plane (transform 2D into 3D) [35,37,113,121].
As shown in Figure 2i, kirigami patterns of substrates can be elaborately designed via finite
element modelling, and the substrate pattern parameters, e.g., incision length Lc , incision
horizontal separation distance x, and vertical distance y, determine the length, width, and
feature angle of opening substrates; in another word, stretchability [115]. By optimizing the
kirigami structure, the substrate and electronics can achieve a tensile strain of 215% [37].
Embedding rigid devices into soft polymer substrates (e.g., Ecoflex, PDMS, and Ecoflex
Gel) is a strategy to minimize the lateral strain on the devices, because soft polymers with
low elastic modulus are generally stretchable under deformation [34,74,122]. However, the
mismatched elastic modulus of soft polymer substrates and embedded rigid devices is a
double-edged sword that can both protect rigid devices and lead to crack propagation along
the interface between the substrate and the devices [111,112]. More recently, Yang et al.
presented geometrically engineered rigid islands which were fabricated into Ferris wheel
patterns to suppress cracks at the interface between soft polymer substrates and embedded
rigid islands (Figure 2j) [116]. Theoretical simulations and experimental observations
showed that the interlocking Ferris wheel structure of the rigid devices anchored the soft
polymer and improved failure strain under stretching, thus extending the fatigue life of
wearable systems under practical usage. Moreover, another way to integrate devices and
substrates is to attach the devices above the substrate [11,123,124]. However, when the
system is stretched, the applied strain causes the stress to concentrate on the devices because
the rigid devices and soft polymer substrates have different elastic moduli. Consequently,
the performance of such wearable systems is invariably compromised by mechanical strain
during use, limiting their practical applications, such as in physiological signal monitoring
and analysis. This limitation was addressed by Bao and coworkers with a strain-insensitive,
stretchable transistor array by introducing a stiff layer (named elastiff layer) between rigid
devices and soft substrates (Figure 2k) [117]. The elasticity of the introduced stiff layer was
controlled by varying the crosslinking density of elastomer substrates in special areas, and
the stress induced by mechanical strain concentrated on the elastiff layer under stretching,
but due to the stiffness of the elastiff layer, the stress could not be delivered to the above
devices [125–129]. The mechanical strain distribution on the substrate and devices was
simulated by finite element modelling. The simulation showed that under the protection
of the stiff layer, the strain on the active device area was reduced to less than 5%, even
when the system was stretched up to 100%. To confirm the theoretical result, stretchable
device arrays were fabricated as shown in Figure 2l. As a result, when stretched to 100%
strain, the local strain was 7%, making this strain-insensitive stretchable system suitable for
monitoring electrophysiological signals.
Sensors 2023, 23, 2479 9 of 36

Sensors 2023, 23, x FOR PEER REVIEW 9 of 38

2.2.2. Conductive Polymers

usedCompared
as electrodeswithbecause
metals and traditional
of their inorganic materials,
poor conductivity polymers possess
[32]. All-polymer devices inherent
have at-
flexibility/stretchability, biocompatibility, and stability. However, polymers
tracted much attention in long-term health-monitoring and wearable systems, and improv- are usually not
used as electrodes because of their poor conductivity [32]. All-polymer
ing the conductivity of the polymer used in functional units is key. Conductive polymers devices have at-
tracted much attention in long-term health-monitoring and wearable systems,
can be divided into two types: intrinsically conductive polymers and conductive polymer and improv-
ing the conductivity
composites (describedof the polymer
in the used insection)
subsequent functional units isHowever,
[130,131]. key. Conductive
wearablepolymers
systems
can be divided into two types: intrinsically conductive polymers
based on intrinsically conductive polymers, such as poly(ethylenedioxythio- and conductive polymer
composites (described in the subsequent
phene):poly(styrenesulfonate) section)
(PEDOT:PSS), [130,131].
perform poorlyHowever,
and arewearable
unstable systems
because
based
many on intrinsically
intrinsically conductive
conductive polymers,
polymers such as poly(ethylenedioxythiophene):poly
are insufficiently stretchable/flexible and adherent
(styrenesulfonate) (PEDOT:PSS), perform poorly and are unstable because many intrinsi-
[132].
cally conductive polymers are insufficiently stretchable/flexible and adherent [132].
Greco et al. introduced ethyl cellulose into PEDOT:PSS to obtain an adhesive ethyl
Greco et al. introduced ethyl cellulose into PEDOT:PSS to obtain an adhesive ethyl
cellulose/PEDOT:PSS bilayer EMG monitoring system, but this bilayer sensor is still non-
cellulose/PEDOT:PSS bilayer EMG monitoring system, but this bilayer sensor is still non-
stretchable, which results in the EMG signals being susceptible to mechanical strain
stretchable, which results in the EMG signals being susceptible to mechanical strain caused
caused by muscle movement [133]. For long-term health monitoring, Zhang et al. devel-
by muscle movement [133]. For long-term health monitoring, Zhang et al. developed a
oped a full-polymer dry electrode by adding waterborne polyurethane (WPU) and D-sor-
full-polymer dry electrode by adding waterborne polyurethane (WPU) and D-sorbitol to
bitol to PEDOT:PSS to create a self-adhesive (Figure 3a), biocompatible, and stretchable
PEDOT:PSS to create a self-adhesive (Figure 3a), biocompatible, and stretchable blend [132].
blend [132]. The conductivity of the obtained blend film depends on PEDOT:PSS, which
The conductivity of the obtained blend film depends on PEDOT:PSS, which builds con-
builds conductive networks in the elastic component WPU, so the dry film electrode is
ductive networks in the elastic component WPU, so the dry film electrode is stretchable
stretchable and conductive in its entirety. This film can achieve firm adhesion to human
and conductive in its entirety. This film can achieve firm adhesion to human skin (ad-
skin (adhesive
hesive forceN/cm),
force > 0.41 > 0.41 N/cm), and a stable
and a stable monitoring
monitoring system system
for 1 for 1 month
month of contin-
of continuous
uous ECG signal monitoring can be assigned (Figure 3b). The same
ECG signal monitoring can be assigned (Figure 3b). The same strategy was used by strategy was used
Wangby
Wang et al. (Figure 3c), and the polymer films based on PEDOT:PSS exhibit
et al. (Figure 3c), and the polymer films based on PEDOT:PSS exhibit high conductivity of high conduc-
tivityS/cm
3100 of 3100 S/cm
(over (over
4100 S/cm 4100 S/cm100%
under understrain),
100% strain),
which can which
be can be maintained
maintained at 3600atS/cm
3600
S/cm after 1000 cycles to 100%
after 1000 cycles to 100% strain [134]. strain [134].

Figure 3.
Figure 3. The
The conductive
conductive polymer
polymer and
and nanowire
nanowire networks
networks used
usedin inwearable
wearablesystems.
systems. (a)
(a) Chemical
Chemical
structures of PEDOT:PSS, WPU, and D-sorbitol. (b) Schematic illustration and optical photoofofa
structures of PEDOT:PSS, WPU, and D-sorbitol. (b) Schematic illustration and optical photo
blend film dry electrode. Reproduced with permission from ref. [132]. Copyright 2020 Nature Pub-
a blend film dry electrode. Reproduced with permission from ref. [132]. Copyright 2020 Nature
lishing Group. (c) Chemical structure of PEDOT:PSS and schematic diagram of PEDOT:PSS film
Publishing Group. (c) Chemical structure of PEDOT:PSS and schematic diagram of PEDOT:PSS film
with stretchability and electrical conductivity enhancers. Reproduced with permission from ref.
with stretchability and electrical conductivity enhancers. Reproduced with permission from ref. [134].
[134]. Copyright 2017 American Association for the Advancement of Science. (d) Chemical struc-
Copyright 2017 American Association for the Advancement of Science. (d) Chemical structure and
ture and schematic illustration of polymer under stretching and release state. Reproduced with per-
schematic
mission fromillustration of. polymer
ref. [135] under
Copyright 2016stretching and release
Nature Publishing state. (e)
Group. Reproduced
Flow chartwith permission
of the self-sup-
from ref. [135]. Copyright 2016 Nature Publishing Group. (e) Flow chart of the self-supporting
porting PANI film fabrication process. (f) Photograph of a freestanding PANI film. Reproduced PANI
with permission from ref. [136]. Copyright 2017 Wiley-VCH. (g) Molecular structures of DPP-2T
Sensors 2023, 23, 2479 10 of 36

film fabrication process. (f) Photograph of a freestanding PANI film. Reproduced with permission
from ref. [136]. Copyright 2017 Wiley-VCH. (g) Molecular structures of DPP-2T and DPP-g2T
polymers and optical (top) and SEM (bottom) images of honeycomb DPP-2T and DPP-g2T films.
(h) Illustration of ECG recording setup and spontaneous heart activity measured on a volunteer with
honeycomb films under different strains. Reproduced with permission from ref. [137]. Copyright
2022 Nature Publishing Group. (i) SEM image of randomly stacked electrospun nanofibres and
photograph of an integrated sensor array attached to the surface of a soft balloon. Reproduced
with permission from ref. [138]. Copyright 2016 Nature Publishing Group. (j) SEM image of ATO
nanofibres and directions of the tensile strains applied to the ATO strain sensor. (k) The unidirectional
sensing mechanism of the ATO strain sensor. Reproduced with permission from ref. [139]. Copyright
2022 Elsevier B.V.

Furthermore, attempts are made to modulate the conductivity of stretchable polymers

for diverse usage requirements [140–142]. The fully flexible polymer thin-film field-effect
transistor is frequently used in stretchable electronic devices for wearable systems, and the
semiconductor is an element in the field effect transistor (FET) which relies on an intrinsic
semiconducting stretchable polymer [143]. Oh et al. proposed that the stretchability of
polymers can be enhanced by infusing more flexible molecular building blocks into con-
jugated polymers containing modified side-chains and segmented backbones, and thus
they developed an intrinsically stretchable semiconducting polymer transistor [135]. As
shown in Figure 3d, stretchability is conferred with intrinsically semiconducting polymers
by designing a dynamic non-covalent crosslink moiety that dissipates energy through
breaking bonds under strain. The FET based on this stretchable polymer maintains stably
high field-effect mobility performance even after 100 cycles to 100% strain. Hence, regu-
lating the chain component and structure of the polymer is a feasible way to improve the
stretchability of intrinsically conductive polymers and to introduce an elastic component
to them.
An ultra-thin polymer film is also flexible like inorganic thin-film materials, so by
reducing the thickness of the polymer they can become more flexible. However, the
ultra-thin polymer film deposited or spin-coated on a rigid substrate is difficult to be
peeled off, and, thus, the choice of substrate is limited [144–146]. Wu et al. reported
a scalable fabrication approach to synthesize freestanding, transparent, and ultra-thin
(190 nm) flexible polymer films [136]. The synthesis process is shown in Figure 3e, and an
ingenious peeling method was designed for the transfer of the polyaniline (PANI) polymer
to any substrates, including PET, PE, and even human skin. Moreover, the conductivity
and band gap of the obtained PANI film can be easily tuned by doping, and due to the
ultra-thin thickness, the conductivity of the flexible film is uninfluenced by a mechanical
strain. As a demonstration, a volatile organic compounds (VOCs) sensor was built using
this ultra-thin PANI film, and this flexible sensing system could detect and distinguish
various VOCs with different acid-doped PANI films even under bending/strain states.
Recently, Chen et al. reported a highly stretchable organic electrochemical transistor
(OECT) device, in which a honeycomb morphology film is combined with a semiconducting
polymer. The poly(2,5-bis(2-octyldodecyl)-3,6-di(thiophen-2-yl)-2,5-diketo-pyrrolopyrrole-
alt-2,5-bis(3-triethyleneglycoloxy-thiophen-2-yl) (DPP-g2T) can self-form a honeycomb
structure during the solvent evaporation process because of its amphiphilic property
(Figure 3g), and this honeycomb structure film possesses excellent stretchability with negli-
gible performance degradation, even under stress strain up to 140% [137]. Finite element
analysis revealed that in the honeycomb structure, the strain distribution is dispersed and
weakened (maximum principal strain <60% under 89% strain) compared with uniform stain
distribution in dense films, and this phenomenon is similar to sponge behaviour in real
life. Due to its stable structure, the electrical pathway and response of this architecture are
suitable for the amplification and monitoring of electrophysiology signals (Figure 3h) [147].
In addition, the breathability of this porous architecture is obviously superior to that of
Sensors 2023, 23, 2479 11 of 36

dense films, which improves wearing comfort and reduces rejection. The strategy can also
be adapted to the design of wearable body fluid analysis systems. Many other impactful
approaches to enhance the flexibility/stretchability of conductive polymers have also been
put forward, such as using an out-of-plane strategy and a kirigami structure. Margari-
tondo et al. constructed 3D PEDOT:PSS nanoarches with 270% stretchability [148]. Similar
porous sponge structures can also be obtained via a sugar template, and Lo et al. used
PDMS as a flexible substrate and constructed a PEDOT:PSS conductive network [149]. Due
to the ample contact with the gel, this wearable device is accurate in recording patients’
electrophysiology signals.

2.2.3. 1D Nanowire/Fibre/Tube Networks

Compared with bulk materials, 1D nanowires/fibres/tubes have excellent flexibil-
ity/stretchability [150,151]. The 1D materials can disperse stress and/or slip under strain
to reduce mechanical damage, which makes them a suitable candidate for wearable sys-
tems [152]. Numerous 1D material networks have been applied, including metal (e.g., Au,
Ag, Cu) nanowires, carbon nanofibres/tubes (CNF/CNT), electrospun polymer fibres, and
other 1D materials which satisfy multifarious application needs [49,153]. The 1D material
network is similar to natural fabrics and has great application potential in wearable de-
vices/systems [154]. Moreover, 1D materials can stack and form a porous network that is
lightweight, air permeable, and flexible, allowing wearable devices/systems based on 1D
nano-wires/fibres/tubes to possess better comfort and mechanical robustness [155].
For instance, as shown in Figure 3i, a pressure sensor was fabricated by Lee and
coworkers using CNT. This sensor is flexible, transparent, and bending-hyposensitive [138].
The low bending sensitivity of this sensor is due to the nanoporous structure built by 1D
CNTs because they slip under bending-induced strain, while under pressure, the contact
area of each nanotube changes, maintaining high pressure sensitivity. A wearable bending-
insensitive pressure sensing device was designed using 1D CNT network film to accurately
measure the distribution of pressure (Figure 3i right), and the properties of the sensor
remained unchanged even though the sensor was bent to a large extent (bending radius
<80 µm). This simple strategy inspired many other researchers concerning wearable systems
based on 1D nanowire/fibre/tube devices and their health monitoring applications. A
similar piezoresistive sensor was fabricated using carbon-decorated fabric fibre as the
sensing material. Once the conductive fibre was pressed under pressure, the conductive
pathway changed [156]. The fantastic performance of this sensor is comparable to that in
clinical settings and commercial devices in health monitoring.
Electrospinning is a handy way to process polymers into nanofibre networks, and
many novel electrospinning methods have been investigated to make polymer nanofibre
networks with different kinds of structures [157]. The good insulation of many polymers
makes them suitable as dielectric materials. Lin et al. reported a tactile sensor based on
core–shell PDMS ion gel/ PVDF-HFP nanofibre mats, and this sensor responded to static
and dynamic pressure via a piezocapacitive mechanism [158]. The thickness of nanofibre
mats changed their capacitance under mechanical deformation, making this sensor capable
of measuring pressure. Furthermore, the core–shell PDMS ion gel/PVDF-HFP nanofibre
sensor was also self-powered. Finally, a demonstration of using the wearable pulse rate
detector as a heart rate indicator was carried out.
In addition to piezoresistive and piezocapacitive sensing, the breakage process of
nanofibres can also be used to sense strain. For instance, Yang et al. recently proposed an
antimony-doped tin oxide (ATO)-oriented nanofibre film strain sensor [139]. The prepared
ATO nanofibre is flexible and highly conductive, and the oriented nanofibrous structure
can distinguish strain direction, i.e., the strain sensor exhibits high a gauge factor (GF)
(up to 250) along nanofibre orientation direction with negligible GF (1.2) in the transverse
direction. Briefly, when a mechanical strain was applied along the nanofibre orientation
direction, the nanofibres easily broke, inducing evident resistance change, while in the
transverse direction, the flexible nanofibres could slip under strain and the conductivity
Sensors 2023, 23, 2479 12 of 36

was maintained [159–161]. Moreover, this strain sensor was used as a wearable electronic
for monitoring sophisticated human body motions.

2.2.4. Composite Materials

Depending on the purpose of use, the different units of wearable devices/systems are
generally composed of different materials, but the divergent physical properties of these
materials (e.g., elasticity modulus, stiffness, and stretchability) can lead to severe problems
that may interfere with their proper functioning [34,74,122]. As recommended above, for
example, the mismatched elasticity modulus of sensing materials or electrodes and flexi-
ble substrates always results in an abominable interface separation. This invalidates the
function of wearable systems [117]. Adding an adhesive layer can minimize the mismatch
between the active layer and the flexible substrate. However, material selection for an
adhesive layer should reconcile the properties of both two layers, which is challenging.
Therefore, composite materials are put forward to ameliorate the matter [162]. Compared
with intrinsically conductive polymers, composites applied in wearable systems are con-
stituted by flexible/stretchable polymer matrices (e.g., PDMS, PVA, paper, hydrogel) and
conductive material additives (e.g., metal nanoparticles, liquid metal, 1D/2D materials),
which are equipped with better conductivity and flexibility/stretchability [163].

Metal Composites
Takei et al. reported a highly sensitive composite film electronic whisker [164]. The
composite film is based on CNTs, silver nanoparticles, and polymers, as illustrated by
Figure 4a. The conductive network matrix formed by nanotubes and nanoparticles has
excellent conductivity, while the polymer binder ascertains the stability of the network
matrix under deformations (Figure 4b). The resistivity and sensitivity of these composite
films are controllable through modulating the ratio of components, which can achieve
ultra-high sensitivity up to 8%/Pa, and the composite film was fabricated into a whisker
form, further aggravating the strain and enhancing its sensitivity (Figure 4c). The elastic
matrix based on polymer binders can not only bond the sensing inorganic components,
but also stabilize the adhesion between the sensing layer and substrate, improving the
flexibility/stretchability of systems. This flexible ultra-highly sensitive pressure sensor
may possess wide potential applications in human–machine interfacing and wearable
health-monitoring systems.
 ultra-high sensitivity up to 8%/Pa, and the composite film was fabricated into a whisker
form, further aggravating the strain and enhancing its sensitivity (Figure 4c). The elastic
matrix based on polymer binders can not only bond the sensing inorganic components,
but also stabilize the adhesion between the sensing layer and substrate, improving the
flexibility/stretchability of systems. This flexible ultra-highly sensitive pressure sensor
Sensors 2023, 23, 2479 13 of 36
may possess wide potential applications in human–machine interfacing and wearable
health-monitoring systems.

Figure4.
Figure 4. Design
Designstrategies
strategiesofofcomposite
compositematerials
materialsused in wearable
used systems.
in wearable (a) Schematic
systems. of a CNT-
(a) Schematic of a
Ag nanoparticle composite film patterned on a PDMS substrate. (b) Cross-sectional SEM image of
CNT-Ag nanoparticle composite film patterned on a PDMS substrate. (b) Cross-sectional SEM image
of the CNT-Ag composite film. (c) Optical image of a fully fabricated e-whisker array. (d) Circuit
diagrams of the e-whiskers. Reproduced with permission from ref. [164]. Copyright 2013 Proceedings
of the National Academy of Sciences of the United States of America. (d) Schematic illustration of the
stretchable composite membrane cross-section. (e) Photographs of a free-standing membrane under
500% strain. (f) SEM and TEM images of closely packed nanowires in the membrane. Reproduced
with permission from ref. [65]. Copyright 2021 American Association for the Advancement of Science.
(g) Schematic illustration of the Ag polymer composites with in situ-synthesized Ag nanoparticles.
(h) Structure and photograph of wearable system based printable Ag polymer composite material.
Reproduced with permission from ref. [131]. Copyright 2017 Nature Publishing Group. (i) Photo-
graph of composite material consisted with liquid metal and PVA. (j) Different kirigami patterns of
composite material paper. Reproduced with permission from ref. [165]. Copyright 2022 American
Chemical Society. (k) Schematic illustration of soft thermal responsive materials. (l) SEM image
of thermal responsive materials with 20 wt% of CNT to polymers. Reproduced with permission
from ref. [166]. Copyright 2016 Wiley-VCH. (m) Schematic illustration of the fabrication of a MXene
nanocomposite hydrogel (MNOH). (n) SEM image of the freeze-dried MNH. (o) Photographs of the
anti-freezing (left) and long-lasting moisture retention (right) performance of MNOH. Reproduced
with permission from ref. [88]. Copyright 2019 Wiley-VCH.

It is common for conductive materials in an elastic matrix to be disordered, and the

properties (e.g., conductivity) of the composite to be isotropic. More recently, Jung et al. pro-
posed a new idea for fabricating a conducive and elastic nanomembrane with aligned Ag
nanowires using a floating assembly method [65]. The originally disordered Ag nanowires
were dragged by Marangoni flow induced by a surface tension gradient (Figure 4d). In
brief, water-immiscible solvents (i.e., toluene) and water-insoluble elastomers were spread
on water/ethanol mixtures containing amphiphilic ligands [e.g., polyvinyl pyrrolidone
(PVP)], which reduced the interfacial energy between toluene–elastomer and water–ethanol.
With the dissolution of ethanol, the local surface tension gradually decreased, resulting in
a surface tension gradient and Marangoni flow. This float assembly phenomenon occurs
commonly in nature, which can be applied to fabricate various elastic nanocomposite mem-
branes, and the conductive materials include Ag nanowires, Au-Ag core–shell nanowires,
Ag nanoparticles, and Au nanoparticles, while the elastomers can be SEBS, thermoplas-
Sensors 2023, 23, 2479 14 of 36

tic polyurethane (TPU), and poly(styrene-isoprene-styrene) (SIS). As a consequence, this

approach effectively distributes the strain on the membrane, which improves its elasticity
under high loading conditions (Figure 4e), and the cold-welding stage thereafter ensures
excellent conductivity (Figure 4f). In addition, a directional strain sensor can be designed
based on this elastic membrane with aligned nanowires. As mentioned above [139], re-
sistance changes under deformation in parallel and vertical directions differ by order of
magnitude. This anisotropy of conductivity can also be eliminated through perpendicularly
stacking two membranes. Based on this highly elastic, conductive, and multifunctional
composite membrane, a multifunctional epidermal sensor can be fabricated, and this
wearable system can measure temperature, humidity, strain, and electrophysiological
signals simultaneously.
Matsuhisa et al. used Ag flakes and in situ formed Ag nanoparticles as conductive
additives, and fluorine rubber and methylisobutylketone (MIBK) as elastic polymer matri-
ces in constituting printable elastic conductors (Figure 4g) [131]. The Ag flakes dispersed
in fluorinated elastomer had excellent conductivity even under high strain, while the
introduced Ag nanoparticles possessed a sensitive response to the surroundings (e.g., me-
chanical strain), enabling the initial conductivity of this composite to reach 6168 S/cm,
which remains 935 S/cm at 400% strain [52,167,168]. The printable fluorinated elastomer
enables the composite to be processed into various patterns to meet the needs of applica-
tions, and a fully printed sensor was demonstrated for pressure and temperature sensing
(Figure 4h) [169]. Furthermore, the stretchable sensor can keep accurate sensing even when
the applied strain is up to 250%. As a result, the favourable flexibility and stretchability of
composite make the material a suitable basis for manufacturing wearable systems that can
monitor human motions even in flexible areas such as elbows and knees.
Liquid metal (LM) [e.g., Ga-In eutectic alloy (EGaIn)] can serve as a conductive
material in wearable devices/systems. Since LM behaves like a liquid, it rarely suffers from
a broken issue under deformation [170]. However, precisely because of its flow behaviour,
the usage of liquid metal is inconvenient, and requires extra equipment or methods, such as
microfluidic channels and supplied bottom fibre [171]. Li et al. reported a way to prepare
LM paper. In brief, the LM was ultrasonically dispersed into a CNF solution and blended
with PVA, and then the composites were cast on paper (Figure 4i) [165]. The established LM
conductive pathway was stabilized by the CNF/PVA matrix, and via kirigami-structure
design (as mentioned above), the LM paper became stretchable, self-supporting, stable,
conductor-exposing, and recyclable (Figure 4j). Moreover, the high conductivity endowed
by LM enables this LM paper to be fabricated to monitor high-quality electrophysiological
signals, (i.e., ECG, EEG, and EMG), and it can also be used as a self-powered wearable
sensor after integrating with TENG.

Non-Metal Composite Materials

The combination of different materials increases the functionality of composite mate-
rials. Inspired by natural organisms, materials with excellent flexibility and self-healing
ability are widely used as the elastic matrix to endow wearable systems with self-healing
capacities [90,172,173]. However, elastic polymer materials rarely possess great conduc-
tivity and self-healing properties at the same time. Adding the conductive additives to
form a conductive network in the elastic matrix can improve conductivity and maintain
self-healing properties simultaneously [89]. Yang et al. combined CNT with mechanically
adaptable polymers, and the CNT was functionalized with carboxyl groups which can
interact with hydrogen bonds in the polymer matrix (Figure 4k) [166]. Briefly, the adapt-
able polymers can self-heal after cutting and the internal conductive network can be also
repaired due to the strong interaction between additive and matrix (Figure 4l). In addition,
the composite material consisting of conductive CNT and elastic polymer matrix possesses
good electrical conductivity, and a soft thermal sensor can be fabricated based on this
composite. The resistance of this thermal sensor decreases with increasing temperature
because the segments of polymers which have low glass-transition temperature disentan-
Sensors 2023, 23, 2479 15 of 36

gle from CNT upon heating and the intercontact of CNT becomes better, reducing the
resistance of the thermal sensor [174]. This flexible self-healing thermal sensor effectively
improves the service life of the sensor and has great potential in artificial intelligence robots
or wearable systems.
Many flexible and wearable devices have been designed using conductive hydrogels
in recent years due to their excellent conductivity, mechanical properties, and biological
characteristics [175–177]. Because of the abundant hydrogen bonds, many hydrogels are
mechanically adaptable, such as polyacrylamide (PAAM) and polyvinyl alcohol (PVA).
However, the inevitable loss of water is a huge obstacle for their applications, and with
water evaporation, the function of the structure of devices/systems based on hydrogels
suffers from catastrophic collapse [178,179]. Liao et al. provided a facile solvent displace-
ment method to prepare a flexible, anti-freezing, conductive wearable hydrogel sensor [88].
The hydrogel polymer matrix consists of PVA and PAAm, and the conductive additive is
MXene nanosheets (Figure 4m,n). Composite materials were soaked in ethylene glycol (EG)
solution to partially replace the water in hydrogel polymer networks, enhancing moisture
retention (8 days), and thereby resolving water loss problems. Moreover, benefiting from
the hydrogen bonds between PVA chains, PAAm chains, and MXene nanosheets, the com-
posites have self-healing capability, i.e., the conductivity quickly (within 3.1 s) recovers to
the original standard after cutoff. The high conductivity of MXene makes the prepared
sensor highly sensitive to strain, so the wearable system can be used as a strain sensor to
monitor human motion. Additionally, the hydrogel composite exhibits a low-temperature-
tolerant behaviour which is anti-freezing even at extremely low temperatures (−40 ◦ C)
(Figure 4o) [180,181], and this strong anti-freezing capability allows this wearable system
to be used in extreme environments, expanding its potential applications [182].

2.3. Other Parts in Wearable Systems

Advanced wearable systems for health monitoring are generally equipped with wire-
less signal transmission systems, energy supply systems, and terminal signal analysis
systems, and these systems enrich the function of wearable systems [3,24,29,31]. Fully
integrated wearable systems have gradually been commercialized. In addition, advanced
wearable health-monitoring systems have a profound influence on developing personalized
medical and treatment research.

2.3.1. Data Communication System

Communicating data wirelessly is a key technology in the broader use of wearable
systems, and conventional wireless data communication systems such as NFC, RFID,
antenna, and analogue-to-digital converters (ADCs) have matured in rigid electronic
devices [38]. However, applying these data communication systems to wearable systems
requires additional considerations, such as the flexibility and robustness decay problem,
because of the rigid integrated circuit (IC) chips used in these systems. Niu et al. reported a
bodyNET system which was separated into two parts, i.e., the flexible reader with Bluetooth
on clothes and a stretchable sensor tag on the skin (Figure 5a) [40]. The data collected
by stretchable sensor tags could be transmitted via RFID to flexible readers, and then
via Bluetooth to terminals. All the rigid components (i.e., IC chips and batteries) were
removed to prevent rigid–stretchable interfaces caused by direct contact with skin, the stress
concentration was restrained and the robustness of the wearable system was improved.
This bodyNET system based on RFID communication can be used to monitor and analyse
pulse, breath, and body motion simultaneously and continuously.
 tooth on clothes and a stretchable sensor tag on the skin (Figure 5a) [40]. The data collected
by stretchable sensor tags could be transmitted via RFID to flexible readers, and then via
Bluetooth to terminals. All the rigid components (i.e., IC chips and batteries) were re-
moved to prevent rigid–stretchable interfaces caused by direct contact with skin, the stress
concentration was restrained and the robustness of the wearable system was improved.
Sensors 2023, 23, 2479 16 of 36
This bodyNET system based on RFID communication can be used to monitor and analyse
pulse, breath, and body motion simultaneously and continuously.

Figure5.5.The
Figure Thenovel
noveldata
datacommunication
communicationsystem,
system,energy
energysupply
supplysystem,
system,and
anddata
dataanalysis
analysissystem
system
in wearable systems. (a) Schematic illustration and photograph of a bodyNET sensor system.
in wearable systems. (a) Schematic illustration and photograph of a bodyNET sensor system. Re- Re-
producedwith
produced withpermission
permissionfrom
fromref. [40]Copyright
ref.[40]. . Copyright2019
2019Nature
NaturePublishing
PublishingGroup.
Group.(b)
(b)Schematic
Schematic
illustration of a wearable NFC resonator unit (left) and photograph of NFC network integrated on
illustration of a wearable NFC resonator unit (left) and photograph of NFC network integrated on
shirt and pants. Reproduced with permission from ref. [42]. Copyright 2021 Nature Publishing
shirt and pants. Reproduced with permission from ref. [42]. Copyright 2021 Nature Publishing
Group. (c) Schematic illustration of a light–machine interface platform. (d) Optical image of weara-
Group. (c) Schematic illustration of a light–machine interface platform. (d) Optical image of wearable
ble photodetector (top) and SEM image of Te@TeSe assembled with carbon fibre fabric textile and
photodetector (top) and SEM image of Te@TeSe assembled with carbon fibre fabric textile and Ag
nanowires (bottom). (e) Optical image of wearable photodetector textile on clothes. Reproduced with
permission from ref. [183]. Copyright 2021 Wiley-VCH. (f) Schematic illustration of a magnetoelastic
system and its application in health monitoring. Reproduced with permission from ref. [184]. Copy-
right 2021 Nature Publishing Group. (g) A wearable TENG biomechanical energy-harvesting system.
Reproduced with permission from ref. [185]. Copyright 2019 Wiley-VCH. (h) Schematic diagram
of a self-powered photoplethysmograpm sensor on human hands. Reproduced with permission
from ref. [186]. Copyright 2021 Nature Publishing Group. (i) Three-dimensional surface plot for
continuous angular movement of finger. Reproduced with permission from ref. [187]. Copyright
2021 Wiley-VCH.

Recently, Hajiaghajani et al. proposed that the RFID and Bluetooth approaches need a
high power supply and the data security level is low [42]. Thus, to address this issue, the
authors limited the operational range of communication links (i.e., NFC), and a network
using a surface plasmon-like metamaterial was made and attached to clothes (Figure 5b).
Then, a textile-integrated NFC multibody area network was reported, which can realize
long-distance communication between multiple objects through overlaying NFC arrays
which are discrete, anisotropic, and magneto-inductive. Due to the advantages of modu-
larity, this network is tuneable and expands according to the user’s needs, and the energy
consumed, which is low, can be supplied using NFC, liberating this NFC network from the
constraint of batteries [188,189]. The temperature and human motion are accurately moni-
tored and accorded by this NFC wearable system, providing a new method for advanced
wearable system design.
Different from traditional communication methods, Li et al. proposed an optical
communication system using near-infrared (NIR) light as a medium of transmission [183].
A self-powered wearable system can be built based on the Te@TeSe photodetector textile,
and the wearable system can manipulate robotic arms’ actions, following instructions which
Sensors 2023, 23, 2479 17 of 36

are commanded by NIR light. Although this wearable system realizes mechano-optical
communication, the data transmission is non-reversing, but the data feedback process is a
still challenge for using light as a wireless communication way.

2.3.2. Energy Supply Systems

The energy supply of conventional rigid electronic devices/systems generally depends
on batteries or an external alternating current (AC) power source, but in wearable sys-
tems, the rigid batteries and circumscribed electric wire impair the flexibility/stretchability
and portability to a great extent. Moreover, the charging or replacement process and
safety problems make traditional rigid batteries unsuitable in wearable systems. There-
fore, flexible, sustainable, and portable energy supply systems are desirable for wearable
systems [190,191]. The above-mentioned data communication systems simultaneously
have energy supply functions, and besides these examples, the wearable systems can also
harvest mechanical, light, or thermal energy from the ambient environment. Solar cells,
TENG, piezoelectric nanogenerators (PENG), and supercapacitors are common flexible
energy supply systems in wearable systems at present, and self-powered wearable systems
can be applied to long-term health monitoring [43].
As shown in Figure 5f, Zhou et al. designed a stretchable magnetoelastic generator and
used this generator as a wearable system’s power generator and biomedical sensor [184].
The micromagnets are dispersed in a silicon matrix and a giant magnetoelastic effect
inside a stretchable system is established with a high magneto–mechanical coupling factor.
According to the wavy chain model built by authors, mechanical stress can change the
spacing of the micromagnet and dipole alignment, which induces magnetic field altering,
and this altering enables biomechanical-to-electrical energy conversion [192]. Wearable
systems always work in a complex environment that contains strain, deformation, and/or
press, thus this mechanical-induced generator can provide a stable energy supply. The
short-circuit current intensity can reach 3.27 mA/cm2 and the 20.17 W/m2 power can
be collected from body movement. Furthermore, this magneto–mechanical generator is
used as a self-powered, water-resistant, wearable wrist pulse-monitoring system, and the
swimmer’s wrist pulse is accurately recorded.
TENG and PENG are also two kinds of generators converting mechanical energy
into electric energy. TENG energy supply systems have several advantages, such as low
cost, great reliability, high efficiency, etc., and these merits let TENG provide high and
steady output power to systems [193]. Due to the wide use of elastic polymers in TENG,
the flexible and stretchable TENG is distinctly better than rigid batteries. Therefore, the
research focusing on TENG has been epidemic currently, and multifarious wearable systems
based on TENG are devoted to human health monitoring [194]. Medeiros et al. described
a self-powered wearable system based on TENG [185]. The energy is harvested from
human motion and the power density can reach 600 µW/cm−2 . The wearable system was
fabricated on cloth as exhibited in Figure 5g, and the self-powered, breathable, waterproof
system is also highly sensitive to touch.
Solar energy is an abundant green power, and wearable systems can be actuated
by solar energy through photovoltaic devices. Jinno and coworkers reported an ultra-
flexible photonic skin powered by organic photovoltaic, realizing biosignal detection and
monitoring (Figure 5h) [186]. The fully flexible organic photovoltaic modules are connected
to flexible organic light-emitting diodes (OLED) and photodiodes (OPD). The integrated
optical sensing system performs impressive sensing performance, and the blood pulse
signals are detected on human hands.

2.3.3. Data Analysis Systems

With the rise in artificial intelligence, the sensing systems no longer just sense but are
able to “feel” the stimulus. The machine learning process trains the sensor with a mass of
sensing data, and then the sensor systems can distinguish and recognize the type of stimu-
lation [195]. The advanced wearable system, which is equipped with high-performance
Sensors 2023, 23, 2479 18 of 36

sensor systems and data analysis systems, exhibit accurate recognition functions. For
example, Horev et al. have used a short-term fast Fourier transformation method to extract
the characteristic value from original sensing signals (Figure 5i), and the frequency at
maximum amplitude is viewed as a classification basis using principal component analysis
(PCA) as a classification method [187]. The 3D spectrogram surface plot is shown for con-
tinuous angular movements (1–180◦ ), which can be used in real life to precisely determine
the different complex body movements.
There is a typical characteristic for sensing signals: the obtained signals always follow
time series, whatever the type of signals. The methods to process and analyse sensing data
that follow time series can be mainly classified into two categories, named step-by-step and
end-to-end [196,197]. The above mentioned example is a responsive step-by-step method,
and using a step-by-step method to analyse the sensing signals usually relies on feature
vectors/values. Via a specific algorithm, the feature vectors are extracted from original
sensing signals to form hypervectors, which can be used as a classification standard for
comparing with training sample databases by the algorithm (such as PCA and discriminate
factor analysis (DFA)), and then the state of the sample is recognized. The advantages
of the step-by-step method are apparent, e.g., the algorithm target of each step is clear
and a small number of hypervectors in each step effectively decreases the calculated
amount; the extracted feature vectors possess actual meaning (such as the frequency in the
aforementioned example), facilitating analysis process; fewer training samples are needed
using this method. However, the parameter of the algorithm needs to be adjusted in each
step, causing tedious work, and the feature vectors should be designed by specialists due
to their actual meaning, hindering their development to some extent.
The end-to-end analysis method is a deep learning method in which a Convolutional
Neural Network (CNN) is used to directly process sensing signals, and the results are
contrasted with a training sample database to identify the signal state [198]. Compared
with step-by-step, the end-to-end method, with no requirement for feature vectors, is
a more automatic method to analyse data like a “black box”. Even though the end-to-
end method can automatically learn a relatively ideal feature network structure, many
samples are needed to ensure the correctness of the CNN. Moreover, the construction
of CNN also requires the assistance of a specialist, and due to the learned feature factor
being hard to explain, the analysis and adjustment process of an end-to-end method is
nonrepresentational compared with a step-by-step method.
Thus, how to select the data analysis method determines the recognition quality of
wearable systems, and ensures the correctness of results; the effective, sufficient, and real
training samples are the most important principle to observe. A satisfactory data analysis
system can endow wearable systems with “wisdom”, and smart wearable systems will
become the main force in health monitoring in the next generation.

3. Wearable Health-Monitoring Systems

3.1. Anatomical Movement Monitoring
Developing high-performance wearable movement-monitoring systems plays an essential
role in action recognition, motor function assessment, and dexterous human–machine inter-
action, which is significant for rehabilitation and intelligent prosthetics [10,199,200]. A sensor
for monitoring anatomical movements of the human body must be sensitive to the ap-
plied force in three major planes (i.e., sagittal, coronal, and axial) and three major axes
(i.e., sagittal, coronal, and vertical). The anatomical movements can be classified into two
categories, i.e., slight movements (e.g., muscle movements with no joint rotation) and full
range movements (e.g., joint rotation). The traditional movement-monitoring methods
rely on machine vision (or optical) systems or angle encoders, but these methods suffer
from the limitation of freedom leading to discomfort, even joint injury in long-term applica-
tion [201,202]. The flexible/wearable sensors/systems (i.e., force-based sensors, soft strain
sensors, micro inertial sensors, and surface electromyography sensors) may overcome this
Sensors 2023, 23, 2479 19 of 36

problem, and these sensors have been commonly used due to their ability to gain direct
measurement of body segment movement [49].
To monitor all kinds of anatomical movements, the sensitivity and detection range is
equally important. However, usually, only one property (sensitivity or detection range)
is improved while another is ignored, rather than being achieved simultaneously. Guo
et al. proposed that the sensitivity and detection range of piezoresistive monitoring de-
vices are strongly related to the microstructures, and the pressure sensor with surface
microstructure may have high sensitivity and the internal microstructure can improve the
detection range [62]. Thus, the authors designed a dual-microstructure pressure sensor for
synchronous anatomical movement monitoring. The surface and internal microstructures
were constructed by removing the sacrificial template, and the final pressure sensor can
simultaneously achieve high sensitivity (401.01 kPa−1 , 0–12 kPa) and wide detection range
(1.96 Pa to 100 kPa) with real-time performance (responses within 103 ms) and great sta-
bility over 6000 cycles (Figure 6a). The wearable device based on this high-performance
pressure sensor enables the detection of a wide range of movements (e.g., flexion and
extension of the elbow, wrist, and fingers) and highly sensitive detection (e.g., movements
of masticatory muscle, deltoid, and forearm extensor). With the assistance of data mining
methods, such as machine learning, the gesture behavioural information is also extracted
by a wearable gesture recognition system (Figure 6b) [196,197]. The multiple physiological
signals (e.g., movements, respiration, and carotid artery) can be synchronously monitored
and decoupled using a Fourier transform filter.
Strain sensors are always used to detect mechanical strain and can be also applied to
monitor human movements. However, when using the strain sensor to monitor anatomical
movements, the off-axis deformations, such as bending, torsion, and pressure deformation,
are disruptive to strain sensing [203,204]. Meanwhile, there are many adverse conditions
during health monitoring, e.g., impacts, overextension, and punctures, which are also
undesirable; thus, the ability of wearable strain sensors to decouple or reject these off-axis
deformations is advantageous. Recently, Araromi et al. presented a highly sensitive strain
detection mechanism, based on strain-mediated contact in anisotropically resistive struc-
tures (SCARS) (Figure 6c) [205]. The sensing layer is made of anisotropic-resistive material
and patterned into periodic microstructure, which can be compressed or extended under
mechanical strain. The high sensitivity (GF > 85000) was achieved, and using high-strength
conductors, the strain sensing system was resilient to adverse off-axis loading. The low
resistance pathway contacts/separates with adjacency under compression/extension, and
the resistance of the sensing layer changes and the Ohmic resistance shows a linear change
under applied strain with negligible bending or twisting deformation (Figure 6d). The
discrete gestures and continuous hand motions can be predictively tracked and classi-
fied via the detection of small muscle movements in the arm using this wearable strain
sensing system.
The ability of wearable systems to measure and discriminate normal and shear forces
is essential to provide texture and slip information [85,206,207]. Normal and shear forces
and the direction of pressure are needed for health monitoring or auxiliary machinery,
which are feedback data required for many activities such as holding goods or inserting a
key in a lock. However, the shear force direction of applied pressure is difficult to obtain
and recognize. Inspired by biological skin, Boutry et al. reported a soft system composed of
an array of capacitors, which can measure and discriminate normal and tangential forces in
real-time [87]. The capacitors array was designed into a specific microstructure (i.e., the top
layer is a pyramid shape and the bottom layer is a hemispherical shape) (Figure 6e), and
the micro-structured sensor array is sensitive to normal pressure, shear force, the composite
force, and bending. As shown in Figure 6f, a robot arm holding a hand gripper equipped
with this device can imitate human tactile sense to shear force feedback.
 using high-strength conductors, the strain sensing system was resilient to adverse off-axis
loading. The low resistance pathway contacts/separates with adjacency under compres-
sion/extension, and the resistance of the sensing layer changes and the Ohmic resistance
shows a linear change under applied strain with negligible bending or twisting defor-
mation (Figure 6d). The discrete gestures and continuous hand motions can be predic-
Sensors 2023, 23, 2479 20 of 36
tively tracked and classified via the detection of small muscle movements in the arm using
this wearable strain sensing system.

Figure 6.
Figure 6. The
Thewearable
wearablesystems
systemsforfor
human
human movement
movement monitoring.
monitoring.(a) Photograph of a dual-micro-
(a) Photograph of a dual-
structure MXene-based piezoresistive pressure sensor and its performance in muscle
microstructure MXene-based piezoresistive pressure sensor and its performance in muscle movement, movement,
respiration, and carotid artery monitoring. (b) Gesture recognition system based on this wearable
respiration, and carotid artery monitoring. (b) Gesture recognition system based on this wearable
sensor. Reproduced with permission from ref. [62]. Copyright 2021 The Royal Society of Chemistry.
sensor. Reproduced with permission from ref. [62]. Copyright 2021 The Royal Society of Chemistry.
(c) The operation principle of a strain-mediated contact in anisotropically resistive structures
(c) The operation principle of a strain-mediated contact in anisotropically resistive structures (SCARS)
(SCARS) sensor (top) and schematic illustration of the sensor. (d) Demonstration of sensor resilience
sensor (top) and
to punctures schematic
(left) and high illustration
loads (right).of Reproduced
the sensor. with
(d) Demonstration
permission from of ref.
sensor resilience
[205] to
. Copyright
punctures (left) and high loads (right). Reproduced with permission from ref. [205].
2020 Nature Publishing Group. (e) Schematics showing the comparation of two different structures Copyright
2020 Nature Publishing
in detecting Group.
the direction (e) Schematics
of applied showing
pressure. (f) the comparation
Experiments with sensor ofmounted
two different
on a structures
robot arm.
in detecting the
Reproduced direction
with of applied
permission from ref.pressure. (f) Experiments
[87]. Copyright with Association
2021 American sensor mounted onAdvance-
for the a robot
arm.
ment Reproduced
of Science. with permission from ref. [87]. Copyright 2021 American Association for the
Advancement of Science.
The ability of wearable systems to measure and discriminate normal and shear forces
3.2. Arterial Pulse Pressure Monitoring
is essential to provide texture and slip information [85,206,207]. Normal and shear forces
and Arterial pulsation
the direction is caused
of pressure areby the ejection
needed of blood
for health from the
monitoring orleft ventricle
auxiliary into the
machinery,
aorta, travelling to arteries throughout the whole body [48]. The blood
which are feedback data required for many activities such as holding goods or insertingflows back to thea
heart with the aorta contracting when the ventricles diastole, and when
key in a lock. However, the shear force direction of applied pressure is difficult to obtainthe ventricles
systole, the blood
and recognize. is sentbytobiological
Inspired the rest of theBoutry
skin, body, caused by the arelaxation
et al. reported soft system of composed
the aorta.
The arterial pulse can be detected by a form of pressure fluctuation
of an array of capacitors, which can measure and discriminate normal and tangential contributed by the
blood movement. During the diastole and systole, the change in blood flow,
forces in real-time [87]. The capacitors array was designed into a specific microstructure caused by the
concentration
(i.e., the top layer is a pyramid shape and the bottom layer is a hemispherical shape) then
and dilation of the blood vessel, can influence the blood volume, and (Fig-
change
ure 6e),the
andintravascular pressure pulsation
the micro-structured [208,209].
sensor array The blood
is sensitive is pumped
to normal throughout
pressure, the
shear force,
body by vasoconstriction, and the arterial vessels are straightened and
the composite force, and bending. As shown in Figure 6f, a robot arm holding a handnarrowed, increasing
arterial
gripperpulse pressure,
equipped withwhich is inverse
this device when the
can imitate arterial
human vessels
tactile sensedilate. Blood
to shear is feedback.
force the most
important body fluid, which carries essential substances and passes through all organs,
supplying
3.2. Arterialoxygen and nutrients.
Pulse Pressure Meanwhile, the blood flowing through the organs can
Monitoring
carry out waste and regulate temperature, and the blood circulatory system is connected
to most of the organs, which can reflect the healthy condition of other organs [210–212].
For example, cardiovascular diseases, as serious and fatal diseases, can be monitored and
prevented through proactively and continuously monitoring blood pressure (BP) [213].
Nowadays, cuff sphygmomanometers are the most commonly used method to measure BP,
but due to the discomfort and bulkiness, this method is unable to continuously monitor in
daily life [214,215].
As a form of physiological movement, the essence of arterial pulse monitoring is
sensing pressure change, so the high-performance pressure sensor mentioned above can
also be used to monitor human BP. Chun et al. reported a self-powered mechanoreceptor
sensor which can accurately record the radial artery pulse (Figure 7a) [216]. The collected
sensing signals show a typical shape which reveals three pulse waveforms [i.e., percussion
 (BP) [213]. Nowadays, cuff sphygmomanometers are the most commonly used method to
measure BP, but due to the discomfort and bulkiness, this method is unable to continu-
ously monitor in daily life [214,215].
As a form of physiological movement, the essence of arterial pulse monitoring is
sensing pressure change, so the high-performance pressure sensor mentioned above can
Sensors 2023, 23, 2479 also be used to monitor human BP. Chun et al. reported a self-powered mechanoreceptor 21 of 36

sensor which can accurately record the radial artery pulse (Figure 7a) [216]. The collected
sensing signals show a typical shape which reveals three pulse waveforms [i.e., percus-
sion wave
wave (P-wave),
(P-wave), tidal tidal
wavewave (T-wave),
(T-wave), and and diastolic
diastolic wave wave (D-wave)],
(D-wave)], andand physiologi-
physiological
information
cal information can becanobtained from from
be obtained these these
signals, such as
signals, radial
such artery artery
as radial augmentation index
augmentation
(AI r ), radial
index (AIr),diastolic augmentation
radial diastolic index (DAI),
augmentation indexpulse interval,
(DAI), round-trip
pulse interval, time (a reflected
round-trip time (a
wave from
reflected hand
wave periphery)
from (Tr ), etc.,(Tamong
hand periphery) which the
r), etc., among AIrthe
which , DAI,
AIr, and
DAI,Tandr areTrcommon
are com-
parameters to diagnose arterial stiffness [217]. Moreover, the waveform
mon parameters to diagnose arterial stiffness [217]. Moreover, the waveform of signals of signals is
different at rest and after exercise, meaning the state of the artery pulse is
is different at rest and after exercise, meaning the state of the artery pulse is changed duechanged due to
the different
to the heart
different rates
heart (Figure
rates 7b).7b).
(Figure

Figure7.7.The
Figure Thewearable
wearablesystems
systemsapplied
appliedin inarterial
arterialpulse
pulsepressure
pressuremonitoring.
monitoring.(a)
(a)Photograph
Photographofofaa
patchable sensor attached on a wrist to measure the radial artery (left) and three typical types
patchable sensor attached on a wrist to measure the radial artery (left) and three typical types in in
radial artery measurements. (b) Two characteristic signals before and after exercise and magnified
curve of pulse wave signal of heart rate and type of blood pressure. Reproduced with permission
from ref. [216]. Copyright 2018 Wiley-VCH. (c) Photograph of a device for detection of wrist pulses
and (d) original wrist pulses signals of a non-pregnant person and a pregnant woman. Reproduced
with permission from ref. [63]. Copyright 2014 Wiley-VCH. (e) A wireless pulse measurement
using GaN SAW wearable system. Reproduced with permission from ref. [38]. Copyright 2021
American Association for the Advancement of Science. (f) Illustration of bioimpedance blood pressure
measurement. (g) Correlation between arterial blood pressure and bioimpedance. (h) Recognition
performance of bioimpedance-monitoring system. Reproduced with permission from ref. [218].
Copyright 2022 Nature Publishing Group. (i) Illustration of piezoelectric dynamic response to
arterial pulse and typical waveform. Reproduced with permission from ref. [219]. Copyright 2022
Wiley-VCHv.

The physiological information conveyed by pulse can be used as a reference to di-

agnose cardiovascular disease. For instance, atherosclerosis leads to pathologic change
in arterial pulse and affects BP even in the very early stage, which is asymptomatic in
other symptoms. Wang et al. presented a microstructured PDMS/CNT pressure sensor
with excellent sensitivity, and this sensing device provides a noninvasive way to diagnose
cardiovascular diseases (Figure 7c,d) [63]. The pulse signals from non-pregnant people and
a pregnant woman were measured, and through extracting feature information in pulse
signals (e.g., pulse frequency, P-, T-, and D-wave), the pregnant woman could be accurately
distinguished from those not pregnant.
In daily life monitoring, the comfort and robustness of pulse sensing systems are
indispensable, and the wearable system should fit the body as closely as possible, which
Sensors 2023, 23, 2479 22 of 36

may cause skin inflammation. Thus, breathability is always needed for long-term monitor-
ing [48]. The aforementioned GaN surface acoustic wave wearable system possesses high
sensitivity and is comfortable to wear (Figure 7e), and this wearable system can also record
human pulse [38]. Remarkably, the system can be worn for 17 h/day and the monitoring
can maintain over 7 days, which demonstrates the reusability and long-term service capac-
ity of this wearable system. This outstanding wearable system offers a versatile biomedical
sensing platform for health monitoring and disease diagnosis.
The existing cuffless BP-monitoring methods can also rely on optical or bioimpedance
besides pressure [220,221]. A commonly used optical method is photoplethysmography
(PPG), which consists of a light emitter and detector. The light with a certain wavelength
is emitted from the emitter and directed towards the skin surface, and then the detector
monitors transmission light and reflected light. Due to the damping intensity caused by
skin, bones, veins, muscles, and other tissues being essentially constant, the absorption of
detected light is only influenced by the change in blood volume and arterial systole and
diastole, in other words [48]. However, the sensing depth of optical-monitoring methods
are limited to capillary regions by shallow penetration of light. Moreover, the tonometry
methods relying on pressure sensors require a bone presence which localizes the placement
area of wearable systems. Kireev and coworkers introduced a wearable bioimpedance
BP-monitoring system that is made of graphene electronic tattoos (Figure 7f) [218]. The
bioimpedance-monitoring method has the capability to sense buried arteries’ pulse using
electrical currents with deep penetration. The change in pressure during arteries’ systolic
and diastolic phases is revealed by the amplitude change in bioimpedance. Briefly, the blood
vessels, containing rich ionic solution, possess better conductivity than surrounding fat and
muscle cells, and the arterial volume is correlated with BP, which determines the impedance.
The characteristic features (e.g., systolic pressure, diastolic pressure, interbeat interval,
and pulse transit time) are precisely monitored and recorded (Figure 7g). Furthermore,
the machine learning model was created with these characteristic features, enabling this
wearable system successfully to monitor the BP of volunteers under a different state of
motion (Figure 7h).
It is worth noting that there is an exceptional case where, when using piezoelectric
devices to monitor arterial pulse, the accuracy of BP evaluation is limited. Because of the
distance error of located sensors and time synchronization error, the waveforms of signals,
obtained by piezoelectric devices, are disturbed and anamorphic compared with true BP
signals (Figure 7i) [222–224]. Thus, the use of piezoelectric methods for BP monitoring is
controversial. In order to eliminate this problem, the reason causing distortion should be
found and resolved. Yi et al. elucidated the relationship between BP waveforms and the
thickness of the piezoelectric functional layer and eliminated the signal distortion [219].
Via integration, transition correction, and direct correlation, the arterial pulse signals can
be truly monitored and recorded using piezoelectric wearable devices. This approach
eliminates the controversy over using piezoelectric devices to monitor arterial pulse and
can potentially be used to achieve daily health monitoring.

3.3. Electrophysiological Signals Monitoring

Electrophysiological signals, as a vital information medium, are exchanged between
the nerve systems and various motor and sensory end-plates. Most of our living activities
are controlled by the nervous system through electrophysiological signals, such as ad-
vanced cognitive activities (e.g., thinking and memory) and daily movements (e.g., muscle
movements), and meanwhile, the sensory information is transferred back to the nervous
systems [30]. Hence, through monitoring electrophysiological signals, the neurological
status of patients can be observed in real-time, which is needful for many diseases such
as Parkinson’s disease, epilepsy, heart failure, and hypertension. Electroencephalography
(EEG), electrocorticography (ECG), and electromyography (EMG) are the most representa-
tive electrophysiological signals noticed by people [10].
Sensors 2023, 23, 2479 23 of 36

At present, the clinical methods to monitor electrophysiological signals rely on tradi-

tionally rigid metal electrodes and gel electrolytes, which are typically attached to the skin
via tapes, mechanical clamps, or straps. However, there are many issues during long-term
application using rigid electrodes and gel electrolytes as monitoring devices, e.g., the unsta-
ble electrode–tissue interface, gel electrolyte dehydration, and poor wearing comfort, which
may lead to a decrease in signal-to-noise ratio [175,225]. In addition, electrophysiological
signal monitoring is always confined to a hospital bed by bulk power supplies and commu-
nication components. Thus, advanced wearable systems are exploited to provide long-term
stable monitoring methods and ameliorate wearing comfort. The above-mentioned epider-
mal wearable system (Figure 1e) reported by Kim et al. possesses an electrophysiological
monitoring function, and the ECG, EMG, and EEG can be continuously monitored for as
many as 6 h [23]. The favourably conformal contact of the wearable system and skin enables
this system to maintain satisfactorily stable monitoring performance even when the system
is mounted in challenging areas (e.g., elbow). The ECG signals are recorded from the chest,
revealing all phases of the heartbeat and including the cardiac wave’s rapid depolarization
phenomenon (Figure 8a) [226]. Moreover, the obtained EMG signals are compared with
conventional monitoring methods based on gel electrolyte, and the signal quality of the
wearable system is remarkably good with commercial electrodes. The EMG signals can
be illustrated alternatively, appearing as the spectral content in a colour contour plot, and
the speech command is recorded and recognized by a wearable system with EMG signals
from the throat, which creates opportunities for human/machine interfaces and controls
a computer strategy game (Figure 8b). In addition, the alpha rhythms, as an EEG signal,
are only apparent when the eyes close, and the recorded EEG signals show an obvious
Sensors 2023, 23, x FOR PEER REVIEW 23 of 38
difference at 10 Hz frequency, which corresponds to alpha rhythm, revealing the excellent
performance of this wearable system in electrophysiology monitoring (Figure 8c) [59].

Figure8.8.The
Figure Thewearable
wearablesystems
systems used
used in in electrophysiological
electrophysiological signals
signals monitoring.
monitoring. (a) ECG
(a) ECG (top)(top) sig-
signals
nals measured with a wearable EES and obtained EMG (bottom) signals compared with conven-
measured with a wearable EES and obtained EMG (bottom) signals compared with conventional
tional sensors. (b) Spectrogram of the EMG data mounted on the neck during vocalization of four
sensors. (b) Spectrogram of the EMG data mounted on the neck during vocalization of four different
different words (left) and simulated video game control by EMG data. (c) EEG alpha rhythms meas-
words (left) and simulated video game control by EMG data. (c) EEG alpha rhythms measured
ured by EES. Reproduced with permission from ref. [23]. Copyright 2011 American Association for
by
theEES. Reproduced
Advancement of with permission
Science. from van
(d) Skin−gate ref. [23]. Copyright
der Waals 2011 on
transistor American Association
human skin for the
under different
Advancement of Science. (d) Skin − gate van der Waals transistor on human skin under
deformation. (e) The ECG signals measured by the skin−gate transistor (rad line) and Ag/AgCl elec- different
deformation. (e) The
trode (black line) ECG
(left) andsignals
recordedmeasured
EEG signalsby the skin−eyes
(closed gate and
transistor (rad line)
open eyes) andReproduced
(right). Ag/AgCl
electrode (black line)
with permission from(left)
ref.and recorded
[227] EEG 2022
. Copyright signals (closed eyes
American and open
Association eyes)
for (right). Reproduced
the Advancement of Sci-
ence. (f) Representative frequency ranges of human mechanical and electrophysiological biosignals.
(g) Schematic illustration of selective biophysiological signal detection through the hydrogel
damper and the selective damping mechanism. (h) The ECG and EEG signals measured with the
hydrogel damper. Reproduced with permission from ref. [228]. Copyright 2022 American Associa-
Sensors 2023, 23, 2479 24 of 36

with permission from ref. [227]. Copyright 2022 American Association for the Advancement of
Science. (f) Representative frequency ranges of human mechanical and electrophysiological biosignals.
(g) Schematic illustration of selective biophysiological signal detection through the hydrogel damper
and the selective damping mechanism. (h) The ECG and EEG signals measured with the hydrogel
damper. Reproduced with permission from ref. [228]. Copyright 2022 American Association for the
Advancement of Science.

To ensure the conformal contact between wearable systems and skin, Yan et al. re-
ported the design of a wearable system based on van der Waals thin films (Figure 8d) [227].
The stretchability, malleability, and breathability are ensured simultaneously because the
staggered nanosheets can freely slide and rotate under deformations. Moreover, the stretch-
ability of thin films allows the necessary deformation of the sensing layer to adapt to the
local surface topography. A conformal contact between thin sensing film and skin is shown
in Figure 8d, and there is still no separation, even under compressing and stretching. The
excellent contact condition guarantees stable interface impedance, and the applied FET can
exactly monitor electrophysiological signals. After attaching this wearable FET system to
the human skin, the ECG and EEG signals (i.e., alpha rhythms) are monitored and recorded
in real-time (Figure 8e). The ECG signals measured by wearable systems show better anti-
interference to mechanical motion compared with traditional Ag/AgCl-monitoring devices.
The electrophysiological signals are seriously disturbed by the unexpected movements
of patients. As for the human body, mechanical motions are perennial and superimposed
on electrophysiological signals [229]. The current methods to avoid disturbing movements
rely on signal processes such as bandpass filters, which may result in signal loss [230].
Park et al. were inspired by the viscoelastic cuticular pad in nature (e.g., spider) and
presented a wearable electrophysiological signal-monitoring system based on a bandpass
filter material [228]. The unexcepted movements are in a low-frequency range, such as
walking and respiration are under 30 Hz, but the electrophysiological signals are high-
frequency signals (Figure 8f). The bio-inspired material exhibits frequency-dependent
phase transition, which leads to the bandpass filter function. In brief, the hydrogel can
change from a rubbery to a glassy state when the frequency of applied signals is above
30 Hz and the high-frequency vibration signals (e.g., electrophysiological signals) can be
transmitted while filtering low-frequency unexcepted movement signals (Figure 8g) [231].
As a result, the wearable system based on band-pass filter hydrogel serves as a high-quality
health monitoring system, and the electrophysiological signals such as ECG and EEG are
exactly monitored (Figure 8h).
As long-term, daily, and wearable monitoring equipment, the wearable systems
used to monitor electrophysiological signals are always beset by wet conditions, such
as sweat or rainwater, which cause signal distortion or damage to devices. Thus, the
performance of wearable systems for electrophysiological signal monitoring should be
reliable in either dry or wet conditions [232]. Noh et al. have reported a novel copper-
meshed carbon black/PDMS electrode which can be used to monitor ECG signals in all
water immersion conditions with a superior performance, showing an advisable way to
design water-resistant electrodes [233]. Based on this strategy, more eminent electrodes
have been designed, and these electrodes ensure the stability of wearable systems used to
detect electrophysiological signals, granting them more potential and making them useful
in daily monitoring [232,234,235].

3.4. Biochemical Monitoring

Wearable biomedical sensing systems have been developed for disease diagnosis and
health monitoring, and unlike traditional diagnostic methods (i.e., in vivo/vitro patho-
logical and clinical examinations), the wearable systems are portable, comfortable, and
low-cost [101]. Various diseases have been studied and recognized by wearable biochemical-
monitoring systems, such as cancer (e.g., lung cancer, colorectal cancer, bladder cancer, etc.),
neuropathic disease (e.g., atypical parkinsonism, idiopathic Parkinson’s disease, multiple
sclerosis), and chronic disease (e.g., chronic kidney disease, preeclampsia, hypertension,
Sensors 2023, 23, 2479 25 of 36

hyperglycaemia) [3,236,237]. The biomarkers are commonly detected as monitoring pa-

rameters of wearable biochemical-monitoring systems, and the biomarkers which are
specifically associated with diseases can be found in skin odour, breath, and body fluids
(e.g., sweat, tears, saliva, blood, etc.) [101,238,239].
As shown in Figure 9a,b, the special (bio)chemical molecular biomarkers contained in
body fluid can be sensed and back-fed by sensors in wearable systems, and then the data
analysis systems diagnose the diseases [10,240]. Moreover, disease diagnosis via biomark-
ers is difficult because of the small sample volumes, external interference, and dilution of
biomarkers, and, thus, the performance of wearable monitoring systems determining the
diagnosis results should be continually improved. Recent advances in artificial intelligence
are helpful for (bio)chemical physiological signal monitoring using wearable systems. In
short, a great deal of (bio)chemical sensing information can be collected from volunteer
patients and healthy people to set up a database (as mentioned in Section 2.3.3), and the dif-
ferent health state of people is diagnosed by referring to the sensing information database.
A sensor array, proposed by Jin et al., consists of five kinds of gas sensors based on
functionalized gold nanoparticles, and the sensor array can detect 11 kinds of volatile
organic compounds (VOCs) (Figure 9c) [241]. In addition, this wearable sensor array is
self-healing to enable extended usage periods. As a result, the wearable sensor array
possesses a low detection limit, high sensitivity, and excellent stability, which can be
maintained after self-healing. The PCA algorithm was used to discriminate the biochemical
information contained in the sensing signals, and the different health states of volunteers
were diagnosed (Figure 9d). The satisfactory discrimination features of these wearable
Sensors 2023, 23, x FOR PEER REVIEW 25 of 38
systems presage a new type of wearable biochemical signal-monitoring system, with great
prospects in smart wearable health-monitoring systems.

Figure 9. The wearable systems used in biochemical biomarkers monitoring. (a) Schematic of breath
Figure 9. The wearable systems used in biochemical biomarkers monitoring. (a) Schematic of breath
diagnosis. Reproduced with permission from ref. [240]. Copyright 2019 Wiley−VCH. (b) Schematic
diagnosis. Reproduced with permission from ref. [240]. Copyright 2019 Wiley−VCH. (b) Schematic
of the VOC−based disease monitoring with wearable systems. Reproduced with permission from
of the VOC −based2022
ref. [10]. Copyright disease monitoring
The Royal Society with wearable
of Chemistry. (c)systems.
SchematicReproduced withVOCs
of a self−healable permission from
ref. [10]. Copyright 2022 The Royal Society of Chemistry. (c) Schematic of a self−healable VOCs
sensor array and (d) PCA of sensing response from this sensor array to 11 types of VOCs emitted
from healthy
sensor arrayvolunteers’
and (d) PCAskin.of
Reproduced with permission
sensing response from this ref. [241]
from sensor . Copyright
array 2016 Amer-
to 11 types of VOCs emitted
ican Chemical Society. (e) Schematic of a VOCs−monitoring wearable device and (f) boxplot of the
from healthy volunteers’ skin. Reproduced with permission from ref. [241]. Copyright 2016 American
canonical score of DFA model of sensing signals obtained from this wearable device recognizing
Chemical Society. (e)
patients. Reproduced withSchematic
permissionof a VOCs
from −monitoring
ref. [242] wearable
. Copyright 2021 device
Wiley−VCH. (g)and (f) boxplot of the
Schematic
canonical score
of a wearable of DFA model systems
nutrient-monitoring of sensing
and (h)signals obtained
boxplot fromLeu
of measured this wearable
levels in sweatdevice
meas- recognizing
ured by this
patients. wearable chemical
Reproduced sensor. Reproduced
with permission from ref.with permission
[242]. Copyright ref. [57]
from 2021 . Copyright
Wiley −VCH.2022(g) Schematic of
Nature Publishing Group.
a wearable nutrient-monitoring systems and (h) boxplot of measured Leu levels in sweat measured
by thisA wearable chemical
sensor array, sensor.
proposed by Reproduced with of
Jin et al., consists permission
five kindsfromof gasref. [57]. Copyright
sensors based on 2022 Nature
Publishing Group.
functionalized gold nanoparticles, and the sensor array can detect 11 kinds of volatile or-
ganic compounds (VOCs) (Figure 9c) [241]. In addition, this wearable sensor array is self-
healing to enable extended usage periods. As a result, the wearable sensor array possesses
a low detection limit, high sensitivity, and excellent stability, which can be maintained
after self-healing. The PCA algorithm was used to discriminate the biochemical infor-
mation contained in the sensing signals, and the different health states of volunteers were
Sensors 2023, 23, 2479 26 of 36

In another example, the functionalized gold nanoparticles were also used to detect
the VOCs in human skin odour, enabling the diagnosis of tuberculosis. The sensors were
integrated into a wearable device, and the tuberculosis-specific VOCs were detected by
these sensors from the skin’s headspace [242]. The sensing information was collected from
29 healthy volunteers and 18 confirmed active pulmonary tuberculosis patients (Figure 9e,f),
and the Discriminate Factor Analysis (DFA) algorithm, the database of which included
475 samples’ information (299 healthy volunteers and 176 confirmed active pulmonary
patients), was introduced to evaluate the health state of the target. The results showed that
the diagnostic accuracy of this wearable system reached 89.4% with an 86.2% specificity and
a 94.4% sensitivity, meaning that tuberculosis can be accurately detected and monitored
with this wearable system.
The biochemical information of the human body is not only contained in VOCs but
also in body fluid, which can be also monitored by wearable systems. Recently, Wang
et al. designed a wearable electrochemical biosensor to monitor metabolites and nutrients
(Figure 9g,h) [57]. The authors tactfully presented a biosensor based on graphene electrodes
that can be repeatedly regenerated and functionalized with an antibody which is specific to
metabolite, distinguishing it from classic single-use biocompatible sensors with molecularly
imprinted polymer or antibodies. With the help of a microfluidic sampling way, the sweat
was analysed by the wearable system, and the results showed that the amino acid levels in
serum and sweat in healthy volunteers and patients with obesity and T2DM were different,
which assessed the risk of metabolic syndrome.

4. Conclusions and Perspectives

In this review, we summarized some representative achievements and recent progress
of wearable systems for health monitoring, and the overview was focused on materials,
systems integrating, and (bio)physiological signal monitoring. We also elaborated on
the materials selection strategies of each unit in wearable systems, including flexible
substrate, sensing materials, and conductive electrodes, and then the other integrated units
used to transmit data and energy were also introduced. In addition, the applications of
wearable systems in health monitoring, e.g., anatomical movement, arterial pulse, and
electrophysiological and (bio)chemical physiological signals, were described in detail.
However, there are still some remaining challenges in developing wearable systems, and
we outline several issues with our perspectives as follows.
(1) Materials. Recent advances in nanomaterials facilitate the development of wearable
systems. As mentioned above, different characteristics are needed for materials used in
different parts of wearable systems, so the technological trends of materials in wearable
systems are various, including flexibility/stretchability, conductivity, sensitivity, etc. Using
composite materials is a feasible way to multidimensionally improve the performance of
wearable systems, but the compatibility issue between different materials is an obstacle, so
the optimal combination mode is critical to exploit advanced composite materials which
can be used in wearable systems. Even though regulating the percolation threshold of
materials and functionalizing are two effective ways to improve compatibility, a sound
strategy is still highly required to solve this issue.
(2) Systems integrating. Wearable systems have been endowed with more and more
functions, and these advanced technologies, such as self-power/solar cell systems, wireless
interaction, and artificial intelligence, elevate the portability, practicability, and intelligence
of wearable systems. However, signal interference is a common problem when many func-
tion parts are integrated into a wearable system, which may influence the authenticity of
signals obtained by wearable systems. Moreover, the position of the human body or clothes
of different units in wearable systems should be prudently arranged, and a reasonable
layout can minimize the influence caused by mechanical deformation while maintaining
the sensing performance. Last but not least, novel systems with unique functions are
focused on now, such as sensing signal amplification or pretreatment systems and auto-
matic alarms, and, thus, more special systems are needed towards various applications. In
Sensors 2023, 23, 2479 27 of 36

addition, during the machine learning process, it should avoid excessive artificial correction
in data analysis.
(3) Health monitoring. Conformability, safety, and stability are the most essential
properties of wearable systems for health monitoring, so the inter-contact between wearable
systems and human skin must be safe, nontoxic, and comfortable. Moreover, artificial
intelligence is a terrific auxiliary means for wearable systems, which has been widely used
to diagnose the health state of people by analysing the sensing data. Due to the result of
the algorithm being directly concerned with sample capacity, the database must contain
effective, sufficient, and real training samples to ensure the reliability of the learned model,
so collecting sample data is a long way from setting up a satisfactory database. In addition,
excessive artificial data correction should be avoided when artificial intelligence is used to
analyse data.
In conclusion, smart wearable systems for health monitoring are meaningful in dis-
ease diagnosis, monitoring, and treatment. Using our advanced materials and high-tech
methods to develop wearable systems may open the next generation’s lifestyle, and good
health monitoring can effectively improve the quality of life of the human race.

Author Contributions: Writing—original draft preparation, L.G.; writing—review and editing, Z.D.,
X.C. and W.W. All authors have read and agreed to the published version of the manuscript.
Funding: Key Research and Development Program of Shaanxi [Grant Nos. 2022ZDLSF01-04 and
2020GXLH-Y-012].
Conflicts of Interest: The authors declare no conflict of interest.

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