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Persistent upper limb impairment following stroke has a substantial impact on patients’ daily activities and quality of life [-]. Therapeutic exercises are necessary to restore motor function and independence. Patients commonly attend face-to-face therapy sessions at clinics and perform exercises under the supervision of therapists. However, this traditional approach has limitations, including high costs, scheduling conflicts, limited access to therapy services, and the need for patients to travel to clinics [,].
Technologies, such as immersive virtual reality (VR), have been applied to promote the accessibility and affordability of poststroke therapeutic exercises [-]. The effectiveness of immersive VR-based rehabilitation programs on upper limb motor recovery has been examined in previous studies [-]. Besides effectiveness, it is equally important to consider patients’ perceptions and acceptance of such programs because negative perceptions and nonacceptance of these technologies, which is a common challenge in practice, can lead to implementation failure, losses to stakeholders, and undesirable health care outcomes [,].
Several studies have examined the experiences of stroke survivors with immersive VR-based motor rehabilitation programs, evaluating various aspects such as perceived usefulness, discomfort, motivation, and intention to use these programs. Results have shown that the application of immersive VR is both feasible and acceptable among patients [,-]. However, these studies primarily relied on quantitative methods, specifically rating scales, to capture the experiences of patients. This approach, while valuable, fails to uncover the underlying factors that influence these experiences, leaving critical elements unexplored []. To address this gap, incorporating qualitative methods, such as in-depth interviews, is essential. Qualitative research can provide rich, detailed data that reveals the complexities of patients’ interactions with VR technology, their emotional responses, and the contextual factors that shape their experiences. By exploring these dimensions, researchers can identify barriers and facilitators to the formation of positive perceptions and subsequent acceptance and implementation. This will allow them to tailor interventions to meet the specific needs of patients with stroke and enhance the overall effectiveness of VR-based rehabilitation programs.
Currently, qualitative studies evaluating the experiences of stroke survivors with immersive VR-based rehabilitation programs are limited. Previous studies with small sample sizes have provided some insights but are insufficient to understand broader experiences and perceptions of such patients [,]. Therefore, this study aimed to conduct both quantitative and qualitative analyses of the perception of patients with stroke regarding an immersive VR-based exercise system for poststroke upper limb exercises. Through this mixed methods approach, we aim to obtain a better understanding of the factors influencing perceptions and identify areas for improvement in the design and implementation of VR-based rehabilitation programs.
The data source was a questionnaire survey and semistructured interviews conducted as part of a proof-of-concept randomized controlled trial (RCT) []. The trial examined the effectiveness and safety of an immersive VR-based exercise system for poststroke upper limb exercises. The exercise system comprised 5 games (-): dumbbell-lifting game for shoulder flexion and abduction, fishing game for elbow flexion, sheep-whacking game for forearm pronation and supination, apple-picking game for wrist flexion and extension, and balloon-popping game for reaching exercises. The details of the 5 games are presented in . A VR headset and a wireless handheld controller (HTC VIVE Pro, HTC Corporation) were used to display and interact with the virtual environments ().
Study participants were inpatients at a public hospital in China who have had a stroke. Patients were considered eligible for the study if they were aged 19 to 75 years; had their first ever unilateral stroke, as confirmed by their computed tomography or magnetic resonance imaging records; were experiencing motor impairments in one of the upper limbs, with Brunnstrom stages of stroke recovery of the arm of 3 to 5; had an active range of motion of at least 10° in the shoulder and elbow of the affected arm; could maintain autonomous upright seating for at least 45 minutes; and had normal or corrected-to-normal vision and hearing. Patients with injuries or other health conditions restricting their upper limb mobility, unilateral spatial neglect, unstable medical conditions, a history of seizures or epilepsy, communication difficulty, mood instability, or concurrent participation in any other ongoing investigational drug studies were excluded. Physicians and physical therapists in the rehabilitation medicine department initially introduced the study to their inpatients. Patients expressing interest in participation were invited to a screening session, during which they tried the study’s VR devices, and their eligibility was assessed. The researcher (JC) provided detailed explanations of the study to the patients initially determined eligible, confirmed their eligibility, and obtained their written informed consent for participation. In the RCT, participants were randomly assigned to one of the 2 study groups. The intervention group received the aforementioned exercise system and was instructed to use the system to perform upper limb exercises for 35 minutes each day, 6 days a week, for 2 weeks. The control group received commercial games downloaded from Steam (Valve Corporation) and was instructed to play them for the same duration and frequency []. These commercial games served as a sham VR program to conceal group assignments from participants. They were not directly aligned with the exercises provided in the exercise system and were used solely for entertainment. provides details of these commercial games. The control group used the same headset and handheld controller as the intervention group. All participants continued their prescribed stroke rehabilitation therapy in the hospital throughout the study period.
Figure 1. Dumbbell-lifting game for shoulder exercise. 
Figure 2. Fishing game for elbow exercise. 
Figure 3. Sheep-whacking game for forearm exercise. 
Figure 4. Apple-picking game for wrist exercise. 
Figure 5. Balloon-popping game for reaching exercise. 
Figure 6. A participant performing exercises using the virtual reality device. The participants’ demographic and clinical characteristics, including age, sex, education level, stroke type, time from stroke onset, Brunnstrom stage of the affected arm, and previous experience with VR, were collected at baseline. The effectiveness and safety of the immersive VR-based exercise system were measured at baseline and the 1-week and 2-week follow-up assessments. Owing to the exclusive use of the exercise system by the intervention group, perceptions of the exercise system were only evaluated in this group. A questionnaire survey and semistructured interviews were conducted during the participants’ last follow-up assessments; the details are provided in the Questionnaire and Interview sections.
Ethics ApprovalThe RCT was approved by The University of Hong Kong–Shenzhen Hospital Human Research Ethics Committee (approval number [2021]137) and Dingzhou People’s Hospital (approval number hx-2021-04) in China. It has been registered in the Chinese Clinical Trial Registry (registration number ChiCTR2100047150). All the participants provided written informed consent before participating in the RCT. No cash compensation was provided. All data used were deidentified.
QuestionnaireA questionnaire was adapted from technology acceptance models and relevant studies examining individuals’ and patients’ perceptions of various technologies [-]. It was used to assess participants’ perceptions of the exercise system, including perceived usefulness, perceived ease of use, attitude, intrinsic motivation, and behavioral intention. presents the measurement items. The items were rated on a 7-point Likert scale ranging from 1 (very strongly disagree) to 7 (very strongly agree), with higher values indicating more positive perceptions.
Textbox 1. Perception outcomes and measurement items.Perceived usefulness (PU)
PU 1: using the immersive virtual reality (VR)–based exercise system to perform upper limb exercises would improve upper limb motor function.PU 2: using the immersive VR-based exercise system to perform upper limb exercises would increase exercise efficiency.PU 3: using the immersive VR-based exercise system to perform upper limb exercises would enhance exercise effectiveness.PU 4: you found the immersive VR-based exercise system useful for performing upper limb exercises.Perceived ease of use (PEOU)
PEOU 1: learning to use the immersive VR-based exercise system was easy for you.PEOU 2: you found it easy to get the immersive VR-based exercise system to do what you wanted to do.PEOU 3: it was easy to become skillful at using the immersive VR-based exercise system.PEOU 4: you found the immersive VR-based exercise system easy to use.Attitude (ATT)
ATT 1: using the immersive VR-based exercise system to perform upper limb exercises is a good idea.ATT 2: using the immersive VR-based exercise system to perform upper limb exercises is a wise idea.ATT 3: you like the idea of using the immersive VR-based exercise system to perform upper limb exercises.ATT 4: using the immersive VR-based exercise system to perform upper limb exercises was a pleasant experience.Intrinsic motivation (IM)
IM 1: you found using the immersive VR-based exercise system to perform upper limb exercises enjoyable.IM 2: the actual process of using the immersive VR-based exercise system to perform upper limb exercises was pleasant.IM 3: you had fun using the immersive VR-based exercise system to perform upper limb exercises.Behavioral intention (BI)
BI 1: you intend to continue using the immersive VR-based exercise system to perform upper limb exercises.BI 2: You plan to continue using the immersive VR-based exercise system to perform upper limb exercises.InterviewAs the RCT was a proof-of-concept trial, individual, face-to-face, and semistructured interviews were conducted to learn more about the participants’ experiences with the exercise system, allowing us to improve it further. Open-ended questions were asked regarding the exercise system’s comfort, comprehensibility, usefulness, and the participants’ preferences and intention to use the system. presents the details of the interview questions. During the interview, a researcher (JC) reformulated and clarified questions to ensure the participants’ complete comprehension. Probing questions, such as “What do you mean by that?” and “Could you be more specific?” were also asked to obtain deeper insights into the participants’ responses when necessary.
Textbox 2. Interview questions.Comfort
Do you feel any discomfort when using the immersive virtual reality (VR)–based exercise system?Do virtual environments make you feel uncomfortable?Does the headset or the handheld controller make you feel uncomfortable?(Ask if the participants reported discomfort) What makes you feel uncomfortable?Comprehensibility
Is it easy for you to understand the exercise tasks?Is it easy for you to use the headset or the handheld controller?(Ask if the participants reported difficulties) What do you find difficult to understand or use?Usefulness
Do you think that the immersive VR-based exercise system is useful for your upper limb rehabilitation?What makes you think the immersive VR-based exercise system is useful for your rehabilitation?What makes you think that the immersive VR-based exercise system is useless for your rehabilitation?Preference
Do you like the immersive VR-based exercise system?What aspects of the immersive VR-based exercise system do you like?What aspects of the immersive VR-based exercise system do you dislike?Intention to use
Do you intend to use the immersive VR-based exercise system for rehabilitation in the future?What motivates you to use the immersive VR-based exercise system for rehabilitation?What fails to make you intend to use the immersive VR-based exercise system for rehabilitation?ProceduresWritten informed consent was obtained from each participant before enrollment into the RCT. Before starting, the researcher (JC) explained the objectives of the questionnaire and interview. The participants then completed the questionnaire to indicate their perceptions of the exercise system. Next, the researcher interviewed the participants. Verbal consent for audio recording was verified again before the start of the interviews. During the interviews, the participants were encouraged to express their experience with the exercise system as much as possible. The interview was audio recorded for subsequent transcription. The interviews were conducted in Chinese. The administration of the questionnaire and interview lasted approximately 20 minutes for each participant.
Data AnalysisQuestionnaireDescriptive statistics, including the mean, SD, median, and rating distribution of the measurement items, were calculated.
InterviewThe interview audiotapes were transcribed verbatim by the researcher (JC). Two researchers (JC and TC) with backgrounds in human factors and health care informatics were involved in the analysis. The interview transcripts were analyzed using a qualitative content analysis approach with 3 steps []. Step 1: the interview transcripts were read several times before being independently analyzed by the 2 researchers. During the initial reading, the 2 researchers read through the interview transcripts while listening to the interview audiotapes to verify the accuracy of the transcripts and to gain an overall sense of the interview content. During the subsequent reading, the 2 researchers read through the interview transcripts in detail to gain a thorough understanding of the interview content. Step 2: an inductive approach was used to analyze the data because this approach allows the identification of codes and themes that answer the research question []. During the data analysis process, the first interview transcript was independently analyzed by the 2 researchers. Relevant statements from the interview transcript were identified, and codes were generated, which were then refined and developed into themes. The same process was repeated for each interview transcript, with the codes and themes added, revised, or developed each time. In addition, the frequencies of the statements expressed by the participants were recorded. Step 3: after all the interview transcripts were analyzed, the codes and themes were compared between the 2 researchers. In case of discrepancies, the original interview transcripts were checked, and the discrepancies were resolved through discussion between the 2 researchers until a consensus was reached.
NVivo (version 12; Lumivero) was used for content analysis, which was based on a checklist of consolidated criteria for reporting qualitative research [].
Of the 25 intervention group participants, 3 were discharged from the hospital in advance and 1 withdrew from the study, leaving 21 participants who completed the questionnaire and interviews. The demographic and clinical characteristics of the 21 participants are presented in . The mean age was 55.3 (SD 12.9) years, and the participants were predominantly male (15/21, 71%). Two-thirds of the participants had completed their secondary school education (14/21, 67%). Two-thirds of the participants had an ischemic stroke (14/21, 67%), with a mean time from stroke onset until study enrollment of 37.2 (SD 25.9) days. More than half of the participants (13/21, 62%) were at Brunnstrom stage 3. Most participants had no experience using a VR device (20/21, 95%).
Table 1. Characteristics of the participants (N=21).CharacteristicsValuesAge (y)aVR: virtual reality.
Questionnairepresents the distribution, mean (SD), and median of the participants’ ratings for each measurement item on the questionnaire. The mean values of the overall ratings for perceived usefulness, perceived ease of use, attitude, intrinsic motivation, and behavioral intention were 6.20 (SD 0.69), 6.33 (SD 0.80), 6.25 (SD 0.74), 6.37 (SD 0.75), and 6.31 (SD 0.84), respectively. The median ratings for each measurement item were 6 or 7.
Table 2. Distribution, mean (SD), and median of the participant’s responses to the measurement items (N=21).OutcomesRating distribution, n (%)Mean (SD)MedianaPU: perceived usefulness.
bPEOU: perceived ease of use.
cATT: attitude.
dIM: intrinsic motivation.
eBI: behavioral intention.
InterviewsOverviewA total of 87.23 minutes of interview audiotapes were recorded. The interviews lasted between 2.43 and 8.30 (mean 4.15; median 3.88) minutes. The results of the content analysis were categorized into positive and negative perceptions of the exercise system. The details of the qualitative data are presented in the following sections.
Positive Perceptions of the Exercise SystemOverviewA total of 73 statements derived from 21 participants were coded as positive perceptions. Of these, 25 (34%) statements were related to ease of use, 20 (27%) to benefits, 9 (12%) to enjoyment, 7 (10%) to assistance, 7 (10%) to accessibility, and 5 (7%) to game design. The findings are summarized in .
Table 3. Positive perceptions of the exercise system (N=21).Themes, subthemes, and statementsParticipants who made the statement, nEase of useaVR: virtual reality.
Ease of UseOf the 21 participants, 20 expressed that the games were easy to understand. One of them felt that it was difficult to play the games the first time because of unfamiliarity, although it became easy after a few trials. A total of 5 participants reported that the headset and handheld controller were easy to use. Some participants stated the following:
[I] know how to play each [game].Some participants reported that their upper limb motor function had improved. Specifically, 5 out of 21 participants expressed that their muscle strength had increased, 3 reported that their range of motion had improved, 3 expressed that their affected upper limb became more stable, 2 expressed that their overall upper limb movement performance had improved, and 1 said that their hand became more flexible. Some examples of the participants’ statements are as follows:
Muscle strength is a little better. There is no obvious [feeling] when putting the weight [on the wrist]. [It is] not tiring.One participant observed improvements in their ability to perform self-care eating activities:
I can easily pick up and hold the food now. [I needed to] break it [into small pieces] before. I was afraid that [I] could not hold it and dropped it. Now I do not need to break it [into small pieces], I can hold it and eat it directly. I can also hold the cup when brushing [my] teeth and cleaning [my] mouth.Two participants mentioned that playing games improved their reaction speed to the computer, and 1 participant expressed that playing games could promote thinking:
To the computer...I feel that [my] reaction is faster.Two participants expressed that they were in a good mood when immersed in the virtual environments.
I have been kind of stressed since I got this disease, but once I listen to that music, [my] mood turns good....I feel like I am alive again, walking into that wood and picking apples like [in] real [life], and being immersed into that environment. I feel like ... my mind broadens.Of the 21 participants, 9 described their feelings of enjoyment and fun when performing VR exercises. For example, some participants stated as follows:
At least performing [exercises] with it [the immersive VR-based exercise system] is not that annoying, not that boring.Of the 21 participants, 7 expressed that they might not know how to perform some movements in the real world; however, the virtual objects in the games guided and helped them to learn and encouraged them to try to perform the movements. Some participants stated as follows:
You know [I] could not do that movement [elbow extension] before. I feel it [the immersive VR-based exercise system] is useful. [The elbow] could extend when [I] put the fishing rod down.Of the 21 participants, 7 reported that the exercise system provided more opportunities for exercise. Some examples of the participants’ statements are as follows:
[I like using the immersive VR-based exercise system because I] can exercise. I can always exercise.Several participants expressed interest in the game design. Two out of 21 participants stated that the virtual environments were attractive, 2 stated that the games provided a sense of immersion, and 1 stated that the games were innovative. Some participants stated as follows:
[It is] just like being in a wonderland, right? It is also very clear, just like the 3D movies. I like looking around and performing the exercises.A total of 15 statements derived from 8 participants were identified as negative perceptions. Of those, 8 (53%) statements were related to difficulty in handling VR devices, 6 (40%) statements to uncomfortable experiences when using VR devices, and 1 (7%) statement to monotony. The findings are summarized in .
Table 4. Negative perceptions of the exercise system (N=21).Themes, subthemes, and statementsParticipants who made the statement, nDifficulty in handling VRadevicesaVR: virtual reality.
Difficulty in Handling VR DevicesOf the 21 participants, 3 indicated that the headset was heavy, 3 mentioned that wearing the headset made them feel sweaty and stuffy, 1 stated that the cable connecting the headset and laptop constrained their head movement, and 1 mentioned that the handheld controller was heavy to hold. Some participants stated the following:
I feel that the headset is a little heavy.Two out of the 21 participants mentioned that wearing the headset led to dizziness, 2 reported that they experienced fatigue during the VR exercises, 1 highlighted that wearing the headset caused eyestrain, and 1 reported experiencing pain in the upper limb during the VR exercises. Some of the participants stated as follows:
[I] felt a little dizzy after taking off [the headset].One participant reported that repeating the same exercises every day was boring, but the participant kept doing the exercises to recover faster.
For my own health, [I] mean to recover faster, the exercises must be performed, right? ...It is, of course, boring, always repeating the same movement.This study aimed to investigate the perceptions of stroke survivors regarding the use of an immersive VR-based exercise system for poststroke upper limb exercises. Quantitative and qualitative analyses were used to explore these perceptions. The questionnaire results revealed that the participants recognized the exercise system’s usefulness for rehabilitation, found the exercise system easy to use, maintained a positive attitude toward the exercise system, enjoyed using the exercise system for exercises, and expressed their intention to continue using the exercise system. The interviews further uncovered the following 6 themes related to positive perceptions of the exercise system: (1) ease of use, (2) benefits, (3) enjoyment, (4) assistance, (5) accessibility, and (6) game design. Conversely, 3 themes were associated with negative perceptions: (1) difficulty in handling VR devices, (2) uncomfortable experiences when using VR devices, and (3) monotony. The interview findings may help interpret the results obtained from the questionnaire and provide further understanding of the factors influencing the patients’ acceptance and use of VR-based rehabilitation programs. For example, some patients expressed interest in the highly immersive game scenarios, which might have attracted them to use the exercise system to perform exercises. In contrast, some patients expressed undesirable feelings about wearing the headset, which might have led to a negative perception regarding the exercise system and impeded its use. Moreover, our findings serve as a concrete illustration of established technology acceptance models, such as the Technology Acceptance Model and Unified Theory of Acceptance and Use of Technology model. For example, previous research has underscored perceived usefulness as a key determinant of technology acceptance by users [,,,]. Our study further elucidated that motor function, daily living skills, cognitive ability, and mood were the main aspects of usefulness valued by the participants. In the following sections, we delve into the questionnaire and interview findings in greater detail.
Perception RatingsIn contrast to previous studies reporting that individuals with limited prior technology experience are less inclined to accept the technology [,,-], our findings indicated that a lack of experience with VR may not impede patients’ positive feelings about using the exercise system. The interview responses, which are discussed in the following sections, may help explain this. However, the highly positive perceptions might be a result of selection bias, meaning that participants who were satisfied with the exercise system were more likely to adhere to the VR exercises, whereas those who were unsatisfied with it could have withdrawn from the study. Therefore, the patients’ perceptions of the exercise system might have been overestimated.
Ease of UseEase of use is a critical perceptual aspect affecting technology acceptance [,,,]. Most patients who have experienced stroke are older adults who often have limited experience with technology and may face declining physical or cognitive functions, as well as technology anxiety [-]. Therefore, ensuring that VR-based rehabilitation exercises are easy to use is particularly important for this demographic to promote acceptance and adoption. In this study, almost all participants reported that it was easy to understand how to play the rehabilitation exercise games and use the VR devices. Although 1 participant initially found the games difficult due to unfamiliarity, the participant quickly adapted and found the games easier after practicing several times. This may be because the games were related to daily life (eg, fishing), and there were no complicated tasks or complex operations with the handheld controller. Consequently, participants could easily become familiar with the rules of the games and the use of the VR devices without much training or practice. Another possible explanation may be that most participants were able to perform the exercises independently. Necessary assistance was provided only to ensure their safety and prevent the development of abnormal movements (eg, shrugging the shoulders) by the researcher (JC), with the guidance of physical therapists []. These findings suggest several specific implications for VR-based rehabilitation programs. First, the simplicity of game design, mimicking daily life activities, can significantly enhance usability for patients with stroke. Second, minimal training and practice requirements make it feasible for older adults with limited technology experience to quickly adapt to the exercises. Third, providing tailored support to prevent incorrect movements can further improve patient engagement and safety. Consequently, designing technology-based rehabilitation exercises with these considerations can foster greater acceptance, enhance patient adherence, and ultimately improve rehabilitation outcomes for stroke survivors.
BenefitsParticipants perceived improved upper limb motor function and daily living skills after using the exercise system. Although this exercise system was initially designed for motor rehabilitation, participants perceived improvements in reaction speed, thinking, and mood. Such gains have rarely been reported in previous studies. One possible explanation may be that the repetitive practice led to familiarity with the exercises, thereby helping the participants increase their reaction speed. Furthermore, the setup of the games in the exercise system, such as the 1-minute countdown and real-time feedback on task performance (refer to details of the games in - and ), might provide participants with a sense of tension and competition. This, in turn, might “facilitate your thinking and make the brain work hard,” as 1 participant expressed. Another reason may be the advantages of immersive VR; that is, wearing the headset isolated the participants from the physical world, so they could fully focus on the tasks in the games. Moreover, being able to complete the tasks in the games provided the participants with a sense of achievement, which might have elicited positive emotions. As 1 participant described, being able to play games made the participants feel “useful,” and thus, “the feeling of pessimism” has been alleviated. Furthermore, the natural scenes and relaxing background music in the games might have helped relieve the participants’ negative emotions due to the stroke. A participant stated as follows:
I have been kind of stressed since I got this disease, but once I listen to that music, [my] mood turns good... walking into that wood and picking apples like [in] real [life], and being immersed into that environment. I feel like... my mind broadens.The results indicate that the positive experiences associated with these games can help reduce the psychological burden of rehabilitation, making the process feel less like a chore and more like a recreational activity. These findings also suggest that the exercise system possesses the potential to influence multiple dimensions of stroke rehabilitation, which should be considered when designing and implementing such VR-based interventions.
EnjoymentConsistent with previous studies that used video games for rehabilitation [-], performing exercises by playing the games in the exercise system was described as “exciting” and “fun” in this study. These findings suggest that the exercise system offers an enjoyable possibility for performing upper limb exercises. The enjoyment factor has specific implications for VR-based rehabilitation programs. First, enjoyable exercises can increase patient motivation and adherence and can consequently lead to more consistent participation in the rehabilitation regimen. This is particularly important for stroke survivors, as sustained engagement is crucial for recovery. Second, incorporating enjoyable elements into the exercise design can help alleviate technology anxiety, making patients more willing to try and continue using the system. Motivational and enjoyable elements can include reward systems that provide a sense of accomplishment, features that facilitate social interaction, and real-time positive feedback and encouragement.
AssistanceSome participants expressed that the virtual objects in the games guide and encourage them to perform movements that they might not be able to perform in the real world. For example, 1 participant said, “That apple-picking [game], together with that bird, could guide my hand to perform the movements.” The rationale behind this effect may be that learning a motor task is more effective when learners’ attention is focused on achieving specific goals (ie, focusing on external cues) rather than focusing on performing specific movements (ie, focusing internally on the movements themselves) [-]. For example, the apple-picking game was designed for wrist flexion and extension exercises. It required the participants to extend their wrists to pick a red apple and flex their wrists to drop it. Picking up and dropping the apple (ie, external focus) was relatively easy for the participants to
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