Restricted accessResearch articleFirst published online 2026-2
Influence of Demographic and Clinical Factors on Perceived Usability,Presence,Flow,Competence,Pleasant and Unpleasant Sensations,and Utility During Interaction with Virtual Reality Games for Motor and Cognitive Rehabilitation: An Observational Study in Patients with Stroke and Traumatic Brain Injury
User experience plays a crucial role in the interaction with virtual reality systems, especially in rehabilitation games for patients with brain injuries, who often face cognitive and motor challenges. User experience influences factors such as acceptance, engagement, and, importantly, the effectiveness of the intervention, all of which are key to achieving optimal recovery outcomes. While previous studies have examined the experiences of neurological populations, they have often focused on a single construct and used instruments that include irrelevant or confounding items. The objective of this study was to assess the perceived usability, presence, flow, competence, pleasant and unpleasant sensations, and utility of non-immersive virtual reality-based rehabilitation games targeting motor and cognitive functions in patients with stroke and traumatic brain injury.
Materials and Methods:
Thirty adults with stroke or traumatic brain injury interacted with three non-immersive virtual reality games targeting motor and cognitive skills, and then completed standardized instruments assessing the above constructs.
Results:
The results revealed high usability, strong presence, and a positive flow experience. Participants also reported high levels of competence and pleasant sensations, with low levels of unpleasant sensations, indicating a generally favorable user experience. Utility was positively perceived. Analysis of demographic and clinical factors showed no significant impact of sex on most constructs, although women reported higher flow and enjoyment. Etiology, however, had a significant effect, with patients with traumatic brain injury reporting more positive experiences across all constructs compared to patients with stroke. Neither age nor time since injury significantly influenced the results. These findings highlight the importance of understanding specific user experience constructs and the influence of demographic and clinical factors in designing effective and engaging virtual reality rehabilitation games.
Castellanos-PinedoF, Cid-GalaM, DuqueP, et al.; Grupo de Trabajo del Plan de Atención al Daño Cerebral Sobrevenido de Extremadura. [Acquired brain injury: A proposal for its definition, diagnostic criteria and classification]. Rev Neurol, 2012; 54(6):357–366.
2.
JohnsonCO, NguyenM, RothGA, et al.Global, regional, and national burden of stroke, 1990–2016: A systematic analysis for the Global Burden of Disease Study 2016. Lancet Neurol, 2019; 18(5):439–458; doi: 10.1016/S1474-4422(19)30034-1
3.
GreenwaldBD, BurnettDM, MillerMA. Brain injury: Epidemiology and pathophysiology. Arch Phys Med Rehabil, 2003; 84(3 Suppl 1):S3–S7; doi: 10.1053/apmr.2003.50052
4.
DewanMC, RattaniA, GuptaS, et al.Estimating the global incidence of traumatic brain injury. J Neurosurg, 2019; 130(4):1080–1097; doi: 10.3171/2017.10.JNS17352
5.
WinsteinCJ, SteinJ, ArenaR, et al.; American Heart Association Stroke Council, Council on Cardiovascular and Stroke Nursing, Council on Clinical Cardiology, and Council on Quality of Care and Outcomes Research. Guidelines for adult stroke rehabilitation and recovery: A guideline for healthcare professionals from the American Heart Association/American Stroke Association. Stroke, 2016; 47(6):e98–e169; doi: 10.1161/STR.0000000000000098
6.
KwakkelG, KollenB, LindemanE. Understanding the pattern of functional recovery after stroke: Facts and theories. Restor Neurol Neurosci, 2004; 22(3–5):281–299.
7.
NielsenJB, Willerslev-OlsenM, ChristiansenL, et al.Science-based neurorehabilitation: Recommendations for neurorehabilitation from basic science. J Mot Behav, 2015; 47(1):7–17; doi: 10.1080/00222895.2014.931273
MapouRL, SpectorJ. Clinical Neuropsychological Assessment: A Cognitive Approach. Springer; 1995.
10.
VeerbeekJM, van WegenE, van PeppenR, et al.What is the evidence for physical therapy poststroke? A systematic review and meta-analysis. PLoS One, 2014; 9(2):e87987; doi: 10.1371/journal.pone.0087987
11.
GillespieDC, BowenA, ChungCS, et al.Rehabilitation for post-stroke cognitive impairment: An overview of recommendations arising from systematic reviews of current evidence. Clin Rehabil, 2015; 29(2):120–128; doi: 10.1177/0269215514538982
12.
CiceroneKD, DahlbergC, MalecJF, et al.Evidence-Based cognitive rehabilitation: Updated review of the literature from 1998 through 2002. Arch Phys Med Rehabil, 2005; 86(8):1681–1692; doi: 10.1016/j.apmr.2005.03.024
13.
ViruegaH, GaviriaM. After 55 years of neurorehabilitation, what is the plan? Brain Sci, 2022; 12(8):982; doi: 10.3390/brainsci12080982
14.
WulfG, LewthwaiteR. Optimizing performance through intrinsic motivation and attention for learning: The OPTIMAL theory of motor learning. Psychon Bull Rev, 2016; 23(5):1382–1414; doi: 10.3758/s13423-015-0999-9
15.
MaierM, BallesterBR, VerschurePFMJ. Principles of neurorehabilitation after stroke based on motor learning and brain plasticity mechanisms. Front Syst Neurosci, 2019; 13:74; doi: 10.3389/fnsys.2019.00074
16.
ParsonsTD. Neuropsychological Rehabilitation 3.0: State of the Science. Clinical Neuropsychology and Technology Springer International Publishing: Cham; 2016; pp. 113–132; doi: 10.1007/978-3-319-31075-6_7
17.
FluetGG, RoyD, LlorensR, et al.Basis and Clinical Evidence of Virtual Reality-Based Rehabilitation of Sensorimotor Impairments After Stroke. Neurorehabilitation Technology Springer International Publishing: Cham; 2022; pp. 429–466; doi: 10.1007/978-3-031-08995-4_20
18.
FariaAL, LatorreJ, Silva CameirãoM, et al.Ecologically valid virtual reality-based technologies for assessment and rehabilitation of acquired brain injury: A systematic review. Front Psychol, 2023; 14:1233346; doi: 10.3389/fpsyg.2023.1233346
19.
KaramiansR, ProffittR, KlineD, et al.Effectiveness of virtual reality- and gaming-based interventions for upper extremity rehabilitation poststroke: A meta-analysis. Arch Phys Med Rehabil, 2020; 101(5):885–896; doi: 10.1016/j.apmr.2019.10.195
20.
GeorgievD, GeorgievaI, GongZ, et al.Virtual reality for neurorehabilitation and cognitive enhancement. Brain Sci, 2021; 11(2):221; doi: 10.3390/brainsci11020221
21.
LaverKE, LangeB, GeorgeS, et al.Virtual reality for stroke rehabilitation. Cochrane Database Syst Rev, 2017; 11(11):CD008349; doi: 10.1002/14651858.CD008349.pub4
22.
XuY, NiJ, YangY, et al.Game-based visual feedback-guided dynamic balance training versus conventional training in patients with hemiplegia: A pilot randomized controlled trial. J Rehabil Med, 2025; 57:jrm41277; doi: 10.2340/jrm.v57.41277
23.
KorkusuzS, TaşkınG, KorkusuzBS, et al.Examining the effects of non-immersive virtual reality game-based training on knee hyperextension control and balance in chronic stroke patients: A single-blind randomized controlled study. Neurol Sci, 2025; 46(3):1267–1275; doi: 10.1007/s10072-024-07830-z
24.
RochatL, Van der LindenM, RenaudO, et al.Poor reward sensitivity and apathy after stroke. Neurology, 2013; 81(19):1674–1680; doi: 10.1212/01.wnl.0000435290.49598.1d
25.
MikamiK, JorgeRE, MoserDJ, et al.Incident apathy during the first year after stroke and its effect on physical and cognitive recovery. Am J Geriatr Psychiatry, 2013; 21(9):848–854; doi: 10.1016/j.jagp.2013.03.012
26.
RebokGW, CarlsonMC, LangbaumJBS. Training and maintaining memory abilities in healthy older adults: Traditional and novel approaches. J Gerontol B Psychol Sci Soc Sci, 2007; 62 (Special_Issue_1):53–61; doi: 10.1093/geronb/62.special_issue_1.53
27.
Chang-HyungL 2, Ye-SoonK, Jin-HwaJ. Effectiveness of virtual reality based cognitive rehabilitation on cognitive function, motivation and depression in stroke patients. Medico-Legal Update, 2020; 20(1):1880–1886.
MeyerJT, GassertR, LambercyO. An analysis of usability evaluation practices and contexts of use in wearable robotics. J Neuroeng Rehabil, 2021; 18(1):170; doi: 10.1186/s12984-021-00963-8
30.
HamY, ShinJ-H. Efficiency and usability of a modified pegboard incorporating computerized technology for upper limb rehabilitation in patients with stroke. Top Stroke Rehabil, 2023; 30(4):333–341; doi: 10.1080/10749357.2022.2058293
31.
WinterC, KernF, GallD, et al.Immersive virtual reality during gait rehabilitation increases walking speed and motivation: A usability evaluation with healthy participants and patients with multiple sclerosis and stroke. J Neuroeng Rehabil, 2021; 18(1):68; doi: 10.1186/s12984-021-00848-w
32.
CâmaraJ, FerreiraL, FariaAL, et al.Feasibility, acceptability, and preliminary impact of full-body interaction on computerized cognitive training based on instrumental activities of daily living: A pilot randomized controlled trial with chronic psychiatric inpatients. Games Health J, 2022; 11(6); doi: 10.1089/g4h.2021.0228
33.
De LucaR, MaggioMG, NaroA, et al.Can patients with severe traumatic brain injury be trained with cognitive telerehabilitation? An inpatient feasibility and usability study. J Clin Neurosci, 2020; 79:246–250; doi: 10.1016/j.jocn.2020.07.063
34.
Fernandes MonizY, Toshio Gomes GunjiB, SilvaAPd, et al.Moniz game: Usability and user experience evaluation of a musical game for motor coordination. Games Health J, 2024; 13(4):252–257; doi: 10.1089/g4h.2023.0133
35.
CostaV, RojoA, López-LópezS, et al.Evaluating the usability and safety of virtual reality application combined with the swalker for functional gait rehabilitation. Games Health J, 2024; 13(5):397–405; doi: 10.1089/g4h.2023.0172
36.
Villada CastilloJF, Montoya VegaMF, Muñoz CardonaJE, et al.Design of virtual reality exergames for upper limb stroke rehabilitation following iterative design methods: Usability study. JMIR Serious Games, 2024; 12:e48900; doi: 10.2196/48900
37.
GerberSM, MuriRM, MosimannUP, et al.Virtual Reality for Activities of Daily Living Training in Neurorehabilitation: A Usability and Feasibility Study in Healthy Participants. In: 2018 40th Annual International Conference of the IEEE Engineering in Medicine and Biology Society (EMBC) IEEE; 2018; pp. 1–4; doi: 10.1109/EMBC.2018.8513003
38.
NaqviWM, NaqviI, MishraGV, et al.The dual importance of virtual reality usability in rehabilitation: A focus on therapists and patients. Cureus, 2024; 16(3):e56724; doi: 10.7759/cureus.56724
39.
LombardM, DittonT. At the heart of it all: The concept of presence. J Computer-Mediated Comm, 2006; 3(2):0–0; doi: 10.1111/j.1083-6101.1997.tb00072.x
40.
WiederholdBK, WiederholdMD. The effect of presence on virtual reality treatment. In: Virtual Reality Therapy for Anxiety Disorders: Advances in Evaluation and Treatment. American Psychological Association: Washington; 2005; pp. 77–86; doi: 10.1037/10858-006
41.
LoureiroSMC, CorreiaC, GuerreiroJ. Mental imagery, product involvement and presence at virtual reality supermarket. J Creative Communications, 2023; 18(1):79–92; doi: 10.1177/09732586221086655
42.
PaesD, IrizarryJ, BillinghurstM, et al.Investigating the relationship between three-dimensional perception and presence in virtual reality-reconstructed architecture. Appl Ergon, 2023; 109:103953; doi: 10.1016/j.apergo.2022.103953
43.
GibbsJK, GilliesM, PanX. A comparison of the effects of haptic and visual feedback on presence in virtual reality. Int J Hum Comput Stud, 2022; 157:102717; doi: 10.1016/j.ijhcs.2021.102717
44.
ZhouZ, LiJ, WangH, et al.Upper limb rehabilitation system based on virtual reality for breast cancer patients: Development and usability study. PLoS One, 2021; 16(12):e0261220; doi: 10.1371/journal.pone.0261220
45.
EsfahlaniSS, ThompsonT, ParsaAD, et al.ReHabgame: A non-immersive virtual reality rehabilitation system with applications in neuroscience. Heliyon, 2018; 4(2):e00526; doi: 10.1016/j.heliyon.2018.e00526
46.
VilleneuveM, OgourtsovaT, Deblock-BellamyA, et al.Development of a virtual reality-based intervention for community walking post stroke: An integrated knowledge translation approach. Disabil Rehabil, 2024; 46(19):4428–4438; doi: 10.1080/09638288.2023.2277397
47.
BorregoA, LatorreJ, AlcañizM, et al.Embodiment and presence in virtual reality after stroke. a comparative study with healthy subjects. Front Neurol, 2019; 10:1061; doi: 10.3389/fneur.2019.01061
48.
CsikszentmihalyiM. Beyond Boredom and Anxiety. Jossey-Bass Publishers: United States; 1975.
49.
RutrechtH, WittmannM, KhoshnoudS, et al.Time speeds up during flow states: A study in virtual reality with the video game thumper. Timing Time Percept, 2021; 9(4):353–376; doi: 10.1163/22134468-bja10033
50.
BodzinA, JuniorRA, HammondT, et al.Investigating engagement and flow with a placed-based immersive virtual reality game. J Sci Educ Technol, 2021; 30(3):347–360; doi: 10.1007/s10956-020-09870-4
51.
KuilMVD, Visser-MeilyJMA, EversAWM, et al.A usability study of a serious game in cognitive rehabilitation: A compensatory navigation training in acquired brain injury patients. Front Psychol, 2018; 9:846; doi: 10.3389/fpsyg.2018.00846
52.
SpreijLA, Visser-MeilyJMA, SibbelJ, et al.Feasibility and user-experience of virtual reality in neuropsychological assessment following stroke. Neuropsychol Rehabil, 2022; 32(4):499–519; doi: 10.1080/09602011.2020.1831935
53.
McAuleyE, DuncanT, TammenVV. Psychometric properties of the intrinsic motivation inventory in a competitive sport setting: A confirmatory factor analysis. Res Q Exerc Sport, 1989; 60(1):48–58; doi: 10.1080/02701367.1989.10607413
54.
GarcíaJA, CarcedoRJ, CastañoJL. The influence of feedback on competence, motivation, vitality, and performance in a throwing task. Res Q Exerc Sport, 2019; 90(2):172–179; doi: 10.1080/02701367.2019.1571677
55.
VenkatesanMDPS, ShankarP. Perceived competence influencing academic performance of students at the under-graduate level. J Positive School Psychology, 2022; 6(6):10855–10863.
56.
FluetGG, QiuQ, PatelJ, et al.Autonomous use of the home virtual rehabilitation system: A feasibility and pilot study. Games Health J, 2019; 8(6):432–438; doi: 10.1089/g4h.2019.0012
57.
LimI, ChaB, ChoDR, et al.Safety and potential usability of immersive virtual reality for brain rehabilitation: A pilot study. Games Health J, 2023; 12(1):34–41; doi: 10.1089/g4h.2022.0048
58.
RebhiM, Ben AissaM, TannoubiA, et al.Reliability and validity of the Arabic version of the Game Experience Questionnaire: Pilot questionnaire study. JMIR Form Res, 2023; 7:e42584; doi: 10.2196/42584
59.
WilbournB, HowellTH, CastelAD, et al.Development, refinement, and acceptability of digital gaming to improve HIV testing among adolescents and young adults at risk for HIV. Games Health J, 2020; 9(1):53–63; doi: 10.1089/g4h.2018.0162
60.
XuW, LiangH-N, ZhangZ, et al.Studying the effect of display type and viewing perspective on user experience in virtual reality exergames. Games Health J, 2020; 9(6):405–414; doi: 10.1089/g4h.2019.0102
61.
WilksCR, YinQ, ZuromskiKL. User experience affects dropout from internet-delivered dialectical behavior therapy. Telemed J E Health, 2020; 26(6):794–797; doi: 10.1089/tmj.2019.0124
62.
NavarroMD, LlorensR, BorregoA, et al.Competition enhances the effectiveness and motivation of attention rehabilitation after stroke. A randomized controlled trial. Front Hum Neurosci, 2020; 14:575403; doi: 10.3389/fnhum.2020.575403
63.
WongEY, HuiRT, KongH. Perceived usefulness of, engagement with, and effectiveness of virtual reality environments in learning industrial operations: The moderating role of openness to experience. Virtual Real, 2023; 27(3):1–17; doi: 10.1007/s10055-023-00793-0
TysonSF, DeSouzaLH. Development of the Brunel Balance Assessment: A new measure of balance disability post stroke. Clin Rehabil, 2004; 18(7):801–810; doi: 10.1191/0269215504cr744oa
66.
GregsonJM, LeathleyMJ, MooreAP, et al.Reliability of measurement of muscle tone and muscle power in stroke patients. Age Ageing, 2000; 29(3):223–228; doi: 10.1093/ageing/29.3.223
67.
Meseguer-HenarejosA-B, Sánchez-MecaJ, López-PinaJ-A, et al.Inter- and intra-rater reliability of the modified ashworth scale: A systematic review and meta-analysis. Eur J Phys Rehabil Med, 2018; 54(4):576–590; doi: 10.23736/S1973-9087.17.04796-7
68.
RomeroM, SánchezA, MarínC, et al.Utilidad clínica de la versión en castellano del Mississippi Aphasia Screening Test (MASTsp): Validación en pacientes con ictus. Neurología, 2012; 27(4):216–224; doi: 10.1016/j.nrl.2011.06.006
69.
LlorénsR, NoéE, ColomerC, et al.Effectiveness, usability, and cost-benefit of a virtual reality–based telerehabilitation program for balance recovery after stroke: A randomized controlled trial. Arch Phys Med Rehabil, 2015; 96(3):418–425.e2; doi: 10.1016/j.apmr.2014.10.019
70.
ÁlvarezI, LatorreJ, AguilarM, et al.Validity and sensitivity of instrumented postural and gait assessment using low-cost devices in Parkinson’s disease. J Neuroeng Rehabil, 2020; 17(1):149; doi: 10.1186/s12984-020-00770-7
71.
LatorreJ, ColomerC, AlcañizM, et al.Gait analysis with the Kinect v2: Normative study with healthy individuals and comprehensive study of its sensitivity, validity, and reliability in individuals with stroke. J Neuroeng Rehabil, 2019; 16(1):97; doi: 10.1186/s12984-019-0568-y
72.
GrierRA, BangorA, KortumP, et al.The System Usability Scale. Proceedings of the Human Factors and Ergonomics Society Annual Meeting, 2013; 57(1):187–191; doi: 10.1177/1541931213571042
CalvoTG, CastueraRJ, RuanoF-R, et al.Psychometric properties of the Spanish version of the Flow State Scale. Span J Psychol, 2008; 11(2):660–669; doi: 10.1017/S1138741600004662
75.
IjsselsteijnWA, KortD, PoelsYAW. Game Experience Questionnaire. 2013.
76.
WuenschKL, EvansJD. Straightforward statistics for the behavioral sciences. J Am Stat Assoc, 1996; 91(436):1750; doi: 10.2307/2291607
77.
TyburskiE, KarabanowiczE, MakM, et al.Color Trails Test: A new set of data on cognitive flexibility and processing speed in schizophrenia. Front Psychiatry, 2020; 11:521; doi: 10.3389/fpsyt.2020.00521
78.
WildeNJ, StraussE, TulskyDS. Memory span on the Wechsler scales. J Clin Exp Neuropsychol, 2004; 26(4):539–549; doi: 10.1080/13803390490496605
79.
GrossiD, MatareseV, OrsiniA. Sex differences in adults’ spatial and verbal memory span. Cortex, 1980; 16(2):339–340; doi: 10.1016/S0010-9452(80)80071-2
80.
Bullinger H-J. Human Aspects in Computing: Design and Use of Interactive Systems and Work with Terminals. (BullingerH-J. ed). Elsevier; 1991.
81.
NorthMM, NorthSM. A comparative study of sense of presence of virtual reality and immersive environments. Ajis, 2016; 20; doi: 10.3127/ajis.v20i0.1168
82.
CummingsJJ, BailensonJN. How immersive is enough? A meta-analysis of the effect of immersive technology on user presence. Media Psychol, 2016; 19(2):272–309; doi: 10.1080/15213269.2015.1015740
83.
PaceS. Immersion, Flow and the Experiences of Game Players. 2008.
84.
ThompsonM, Uz-BilginC, TutwilerMS, et al.Immersion positively affects learning in virtual reality games compared to equally interactive 2d games. Ils, 2021; 122(7/8):442–463; doi: 10.1108/ILS-12-2020-0252
85.
LangeBP, WührP, SchwarzS. Of time gals and mega men: Empirical findings on gender differences in digital game genre preferences and the accuracy of respective gender stereotypes. Front Psychol, 2021; 12:657430; doi: 10.3389/fpsyg.2021.657430
86.
BakerRS, RicheyJE, ZhangJ, et al.Gaming the system mediates the relationship between gender and learning outcomes in a digital learning game. Instr Sci, 2025; 53(2):203–238; doi: 10.1007/s11251-024-09679-3
87.
HoeftF, WatsonCL, KeslerSR, et al.Gender differences in the mesocorticolimbic system during computer game-play. J Psychiatr Res, 2008; 42(4):253–258; doi: 10.1016/j.jpsychires.2007.11.010
88.
ZhangY, LiangQ, WangF. Influence of competition-outcome feedback in video games on players’ flow experience. Curr Psychol, 2023; 42(21):17583–17594; doi: 10.1007/s12144-022-02935-0
89.
JinS-AA. “Toward integrative models of flow”: Effects of performance, skill, challenge, playfulness, and presence on flow in video games. J Broadcast Electron Media, 2012; 56(2):169–186; doi: 10.1080/08838151.2012.678516
90.
DesdentadoL, MiragallM, LlorensR, et al.Identifying and regulating emotions after acquired brain injury: The role of interoceptive sensibility. Front Psychol, 2023; 14:1268926; doi: 10.3389/fpsyg.2023.1268926
91.
SahaG, ChakrabortyK, PattojoshiA. Management of psychiatric disorders in patients with stroke and traumatic brain injury. Indian J Psychiatry, 2022; 64(Suppl 2):S344–S354; doi: 10.4103/indianjpsychiatry.indianjpsychiatry_34_22
92.
MarkusHS. Emotions and behavior after stroke. Int J Stroke, 2020; 15(3):243–243; doi: 10.1177/1747493020913772
93.
CastorN, El MassiouiF. Traumatic brain injury and stroke: Does recovery differ? Brain Inj, 2018; 32(13–14):1803–1810; doi: 10.1080/02699052.2018.1508748
BunzU, CorteseJ, SellersN. Examining younger and older adults’ digital gaming habits and health measures. Gerontechnology, 2020; 19(4):1–10; doi: 10.4017/gt.2020.19.04.381
98.
Pinazo-HernandisS, RedolatR, MartinAV, et al.Older adults and use of video games. Innovation: European J Social Sci Res, 2024:1–17; doi: 10.1080/13511610.2024.2367992
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