Virtual-reality and exergame rehabilitation

1. Introduction

Version followed: VR and interactive video gaming as defined in the Cochrane review Virtual reality for stroke rehabilitation (Laver et al.; 2017 version and the June 2025 update), with the Cochrane Parkinson's review (2016) for balance and gait, the FDA AR/VR medical-device list (as of October 2026; page content dated 4 September 2026) for regulatory status, and manufacturer health-and-safety warnings and specialist guidance for safety. Status checked October 2026.

What it is. Virtual-reality (VR) and exergame rehabilitation uses computer-generated environments and motion-controlled games to let people practise movement, balance and everyday tasks. Cochrane defines VR broadly as computer-based programs that simulate real-life objects and events, and includes interactive video gaming, including commercial gaming consoles that are increasingly used in clinics [source: Cochrane plain-language summary, 2025]. Systems differ along two axes:

Immersion: immersive VR replaces the user's view of their surroundings, usually with a head-mounted display (headset); non-immersive VR shows the virtual environment on a screen while a camera, sensor or controller tracks movement [source: FDA AR/VR page; Cochrane 2025]. Very few stroke trials used immersive headsets, so their effectiveness is unclear [source: Cochrane news, June 2025].
Purpose of design: off-the-shelf commercial consoles and games (e.g. Nintendo Wii and Wii Fit, used in most Parkinson's trials) versus specialised rehabilitation systems built and, in some cases, regulated as medical devices [source: Cochrane Parkinson's review; FDA AR/VR list].

It is a method of the rehabilitation professions, not a psychotherapy. It is selected, set up, dosed and supervised by the rehabilitation team: in practice physiotherapists and occupational therapists for motor and balance work, and occupational therapists, neuropsychologists or speech and language therapists for cognitive and communication tasks. In the UK physiotherapists, occupational therapists and speech and language therapists are registered with the Health and Care Professions Council (HCPC); in the US they are licensed by state boards, with professional bodies such as APTA, AOTA (and NBCOT certification for OTs) and ASHA [uncertain: not verified].

Core idea of change. The rehabilitation rationale is that recovery after stroke and other neurological conditions depends on large amounts of repetitive, goal-directed practice; VR and games make practice more engaging, give immediate feedback, can simulate tasks hard to practise in a clinic, and can increase total therapy time, sometimes with less direct supervision [source: Cochrane news, June 2025]. Some specialised systems add a specific mechanism, for example showing a virtual version of the affected limb that the patient moves with the working limb [source: MobiHealthNews 2017; pharmaphorum 2017]. The psychotherapist's work sits alongside this: helping the person engage, make informed choices, cope with what training reveals about their impairment, and stay safe, while all training decisions stay with the rehabilitation team [synthesis].

Related entries: VR used to deliver exposure therapy for anxiety, phobias or PTSD is a psychotherapy and is covered in 092 VR exposure therapy; this guide covers only rehabilitation uses.

2. Framework

There is no single published protocol; programmes are designed by the treating rehabilitation team and vary by system, condition and setting. The phases below describe the typical course as the sources imply it, with the psychotherapist's parallel tasks. Session counts, durations and progression rules are set by the rehabilitation team and are not given here. [synthesis, built on the sources cited per phase]

Referral and rehabilitation assessment. Goal: the team decides whether VR or gaming fits the person's goals (arm function, balance, walking, daily activities, cognition) and the setting (inpatient, outpatient, home). Cochrane frames VR as an add-on to usual care that raises therapy volume, not a replacement for conventional therapy [source: Cochrane news 2025]. Psychotherapist: share relevant psychological information (mood, anxiety, trauma history, psychosis, dissociation, seizure history reported in therapy) with consent [synthesis].
Safety screening and system selection. Goal: rule out or manage risks before first use (seizure history and photosensitivity, implanted medical devices, vision problems, psychiatric and heart conditions, pregnancy, older age, balance and fall risk, susceptibility to motion sickness), and choose immersive or non-immersive, commercial or medical system [source: Meta Quest 2 safety instructions; Epilepsy Society 2025; Fernández-Cañas et al. 2026]. Move on when the team has cleared the person and agreed the system.
Supervised familiarisation. Goal: the person learns the equipment in a cleared space, seated if possible, with short initial exposures and symptom checks; manufacturer guidance advises newcomers to start with comfortable content and short sessions and to take regular breaks [source: Meta Quest 2 safety instructions]. Cybersickness may be rated before, during and after exposure with a structured instrument [source: Fernández-Cañas et al. 2026]. Move on when the person tolerates sessions without significant symptoms and can use the system as instructed.
Graded training. Goal: repeated task practice with progression decided by the therapist from performance and tolerance. Cochrane reports benefits may be greatest when people use the programme for many hours and that larger arm-function gains were seen when VR was added to usual care [source: Cochrane 2025].
Transfer to home or telerehabilitation (where offered). Goal: continue practice with remote or reduced supervision; some medical systems have portable or home versions, for example MindMaze described MindMotion Go as an outpatient or home continuation of care (not FDA-cleared at the time of the 2017 report) [source: pharmaphorum 2017]. Move on when the person and family can set up a safe play space and use the system safely.
Review and discharge. Goal: the team reviews goals and decides on continuation, change or stopping. Psychotherapist: support the ending, the meaning of results, and maintenance of activity [synthesis].

Format: individual sessions in hospital, clinic or home; some systems used in groups or with telemonitoring [uncertain: not verified]. Typical number of sessions: not standardised; set by the team [source: Cochrane news 2025 does not specify frequency or duration].

3. Guiding principles

Principles for the psychotherapist working alongside VR and exergame rehabilitation [synthesis unless a source is given]:

The rehabilitation team owns the intervention: you never set, change or recommend sessions, games, intensity or progression; route every such question to the treating physiotherapist, OT or neuropsychologist.
Describe evidence honestly: VR may slightly improve arm function and activity compared with conventional therapy and helps more when added to usual care; evidence for mobility, participation and quality of life is uncertain [source: Cochrane news, June 2025]. Practical meaning: help clients hold realistic hopes, neither "games cure stroke" nor "it's just a toy".
It is an add-on, not a substitute [source: Cochrane news 2025]. Practical meaning: if a client wants to drop conventional therapy for gaming, explore it and refer back to the team.
Commercial is not the same as medical: consumer consoles and headsets are sold for entertainment and carry manufacturer warnings; some rehabilitation systems are regulated medical devices [source: FDA AR/VR list; Meta Quest 2 safety instructions]. Practical meaning: ask which system the client uses and whether the team chose it.
Safety screening comes first: seizures, implanted devices, psychiatric conditions, falls and cybersickness are known risks [source: Meta Quest 2 safety instructions; FDA AR/VR page; Epilepsy Society 2025]. Practical meaning: pass relevant history to the team before first use, with consent.
Psychological factors drive engagement: mood, fatigue, anxiety and self-efficacy shape whether people keep practising. Practical meaning: treat adherence as a joint problem to explore, not a compliance issue.
Performance feedback is emotional data: scores and on-screen avatars show deficits starkly. Practical meaning: invite reactions to scores and help the client separate the score from self-worth.
Immersion can trigger psychological reactions: headsets remove the real surroundings, which can provoke disorientation, panic or trauma-related reactions in some people; the manufacturer advises people with psychiatric disorders to consult a doctor first [source: Meta Quest 2 safety instructions]. Practical meaning: prepare clients with anxiety, PTSD, psychosis or dissociation and agree a stop signal with the team.
Age limits and development matter: one consumer headset manufacturer states its product is not for children under 13 and asks adults to monitor teenagers' use [source: Meta Quest 2 safety instructions]; FDA lists unknown side effects in children as a risk [source: FDA AR/VR page]. Practical meaning: with children, check the system's age labelling and that use is supervised by the paediatric rehab team.
Privacy is part of safety: FDA lists cybersecurity and privacy as AR/VR device risks [source: FDA AR/VR page]. Practical meaning: help clients understand what data accounts, cameras and apps collect and who sees it.
Integrate, don't duplicate: link therapy goals to rehabilitation goals so psychological work supports practice and daily-life transfer.
Status changes: product clearances and evidence change; date-stamp what you tell clients and check the current source.

4. Intervention inventory

Part A describes how the rehabilitation team delivers VR and exergame rehabilitation, at a descriptive level only, so you can talk about it accurately. Part B gives the psychotherapist's own interventions. Nothing here is a training prescription.

A1. How VR and exergame rehabilitation is delivered (team procedure, descriptive)

Purpose: to understand what the client is doing in rehabilitation sessions so you can discuss it accurately and spot problems.
Steps (as sources describe; delivered by the rehab team):
1. The team sets functional goals and chooses a system. Options range from commercial consoles and games (in the Parkinson's review, six of eight trials used commercial systems such as Wii Fit) to custom rehabilitation programmes [source: Cochrane Parkinson's review 2016].
2. The system tracks the person's movement with a camera, sensors or controllers and maps it to a game or virtual task; specialised systems may show a virtual version of the affected limb, controlled by the working limb, for pointing, reaching and grasping tasks [source: MobiHealthNews 2017; pharmaphorum 2017].
3. Tasks are mostly movement training (arm, balance, stepping) rather than functional tasks such as dressing or cooking [source: Cochrane news 2025]; cognitive tasks may be embedded in some systems [uncertain: not verified for specific products].
4. The therapist sets difficulty and progression and monitors tolerance; some medical systems are designed for hospital use as early as the first weeks after stroke [source: pharmaphorum 2017; MobiHealthNews 2017].
5. Practice may continue at home or via telerehabilitation, raising total therapy time [source: Cochrane news 2025; pharmaphorum 2017].
Example language (illustrative): "Can you show me or tell me what a typical session looks like: what you see, what you do with your arm, and how the therapist decides when to make it harder?"
Watch for: confusion about who decides progression; the client practising on a home console without the team knowing; tasks that never connect to daily-life goals (raise with the team).

A2. Regulatory and evidence status (descriptive)

Purpose: to answer clients' questions about whether a product is "approved" and whether it works, without overstating.
Steps:
1. Regulatory status, as of October 2026 per the FDA AR/VR medical-device page (content dated 4 September 2026): FDA lists AR/VR devices that met premarket requirements and notes the list is not comprehensive. Entries in the Physical Medicine panel include MindMotionPRO (MindMaze, 2017, K162748), Virtual Occupational Therapy Application (Barron Associates, 2017, K163245), YuGo System (Biogaming, 2016, K151955) and REAL Immersive System (Penumbra, 2019, K183296). K numbers indicate 510(k) clearance [source: FDA AR/VR page]. The list does not state indications for most devices, so check the device's own clearance summary for its exact indication [source: FDA AR/VR page]. MindMotion Pro was reported as cleared for upper-body rehabilitation after stroke and traumatic injury [source: pharmaphorum 2017; MobiHealthNews 2017]. EU (CE/MDR), UK (UKCA/MHRA) and NICE status for these products: [uncertain: not verified]. Commercial gaming consoles and consumer headsets are entertainment products, not cleared rehabilitation devices [synthesis].
2. Evidence status, stroke: the Cochrane review (Laver et al., update published 20 June 2025; 190 trials, 7,188 participants; searches to September 2023) found that, compared with conventional therapy, VR may slightly improve arm function and activity; larger gains in arm function occurred when VR was added to usual care; VR may help balance; effects on mobility, participation and quality of life are uncertain; most trials used simple, low-cost systems and few studied immersive headsets [source: Cochrane news 2025; Cochrane plain-language summary]. The Cochrane plain-language summary page also shows abstract figures (72 trials, 2,470 participants) that do not match the main count [uncertain: check the full review before quoting numbers]. The 2017 version found moderate-certainty evidence of a small benefit for activities of daily living versus conventional therapy and low-certainty evidence elsewhere [source: Cochrane 2017 record].
3. Evidence status, Parkinson's disease: Cochrane (8 trials, 263 participants; searches to November 2016) found low-quality evidence of a short-term benefit of VR exercise on step and stride length, and that VR and physiotherapy may have similar effects on gait, balance and quality of life [source: Cochrane Parkinson's review 2016].
4. Evidence status, cognitive rehabilitation: Cochrane 2025 found evidence on cognition insufficient for conclusions in stroke [source: Cochrane plain-language summary]; for other populations: [uncertain: not verified].
Example language (illustrative): "The research so far suggests these programmes can add a little extra benefit, mainly for the arm, especially when they add to your usual therapy rather than replace it. Your therapists are the best people to say how it fits your plan."
Watch for: marketing claims ("rewires your brain", "clinically proven") that go beyond the sources; clients buying devices on that basis; outdated status statements. Date-stamp what you say.

A3. Safety screening and monitoring as published (descriptive)

Purpose: to know the documented risks so you can pass on relevant history and recognise warning signs.
Steps (what sources state):
1. Who should consult a doctor before headset use: pregnant people, older adults, people with binocular vision abnormalities, psychiatric disorders, heart conditions or other serious medical conditions; people with a history of seizures, loss of awareness or epilepsy-related symptoms; people with pacemakers or other implanted devices, who should also check with the device manufacturer [source: Meta Quest 2 safety instructions].
2. Photosensitivity: the manufacturer states about 1 in 4,000 people may have severe dizziness, seizures, twitching or blackouts triggered by light flashes or patterns, even with no seizure history, more often in children and young people [source: Meta Quest 2 safety instructions]. The Epilepsy Society states about 3% of people with epilepsy have photosensitive epilepsy, most often starting between 7 and 19; VR images usually flash too fast to trigger seizures, but the large field of view may still trigger one; flashing game content and long sessions without breaks raise risk; diagnosis uses EEG with photic stimulation [source: Epilepsy Society 2025].
3. Cybersickness: symptoms include eye strain, dizziness, nausea, disorientation, impaired balance, headache, drowsiness; stop immediately; symptoms can last hours; no driving, machinery or balance-demanding activity until fully recovered [source: Meta Quest 2 safety instructions]. FDA lists cybersickness, dizziness, fatigue, head and neck strain and possible effects on vision [source: FDA AR/VR page]. A 2026 systematic review appraised nine cybersickness instruments (e.g. SSQ, MSSQ, FMS, CSQ-VR, VRNQ), found most validated in healthy young adults with limited validation in neurological groups, and advised that scores be interpreted with caution when deciding progression [source: Fernández-Cañas et al. 2026]. It reports one cited stroke study in which more than 40% of survivors had mild to moderate symptoms, and that moving scenes or first-person views may worsen symptoms after stroke [source: Fernández-Cañas et al. 2026].
4. Falls and collisions: clear play space, level floor, no stairs, windows or hazards nearby, a spotter if moving, seated use unless content requires standing; boundary systems only warn and cannot prevent falls [source: Meta Quest 2 safety instructions].
5. Headset hygiene: do not share with anyone who has a contagious eye, skin or scalp condition; clean headset and controllers between users with non-alcohol, non-abrasive antibacterial wipes, lenses with a dry microfibre cloth; replace worn facial interfaces; stop if skin reactions occur [source: Meta Quest 2 safety instructions]. Clinic infection-control procedures follow local policy [uncertain: not verified].
6. Adverse events in trials: in the stroke review, adverse events were monitored in many studies and were rare and mild (pain, headaches, feeling faint or dizzy), with no serious events reported [source: Cochrane plain-language summary; Cochrane news 2025]; none were reported in the Parkinson's trials [source: Cochrane Parkinson's review 2016].
Example language (illustrative): "Before you start with the headset, it helps the team to know about things like seizures, fainting, migraines, travel sickness or panic in enclosed spaces. Is it okay if I let your physio know what you've told me?"
Watch for: unreported seizure history; persistent symptoms after sessions; near-falls at home; shared home devices without cleaning; a client driving soon after a session while still dizzy.

Part B: the psychotherapist's interventions. These are general collaborative-care and psychological practices applied to this setting [synthesis throughout unless a source is given].

B1. Role clarification and collaboration with the rehabilitation team

Purpose: to agree who does what, so psychological work supports rehabilitation and you never step into training decisions. Use at the start and whenever roles blur.
Steps:
1. With consent, identify the treating physiotherapist, OT, neuropsychologist or rehab physician and the system in use.
2. Agree what you will share (mood, anxiety, engagement barriers, safety-relevant history) and what they will share (goals, tolerance, adverse events).
3. Agree a route for urgent concerns (seizure-like event, fall, severe symptoms, suicidal risk).
4. Align therapy goals with rehab goals (e.g. confidence to use the arm at meals).
5. Review the arrangement at team reviews or discharge.
Example language (illustrative): "I'm working with [client] on mood and motivation. I won't advise on the training itself; could we agree how to flag anything that affects their sessions?"
Watch for: the client relaying conflicting messages between professionals; you being asked to judge whether a game is appropriate (redirect). Working: shared goals, timely two-way updates.

B2. Psychoeducation and expectation setting

Purpose: to help the client and family understand what VR and exergames are, what they can and cannot do, and why practice volume matters. Use before or early in rehab, or when hopes are unrealistic.
Steps:
1. Ask what the client already believes about the technology.
2. Give a plain, attributed summary: an engaging way to get more practice; modest benefits, mainly for the arm and activity, best as an add-on to usual therapy [source: Cochrane news 2025].
3. Distinguish screen-based games from headsets, and consumer from medical systems [source: FDA AR/VR page; Cochrane 2025].
4. Explain that progress is gradual and scores can fluctuate with fatigue and mood.
5. Refer specific questions ("Is this the right game for me?") to the team.
Example language (illustrative): "Think of the games as a way of getting many more practice repetitions in without it feeling like a chore. They usually help most alongside your normal therapy, not instead of it."
Watch for: magical expectations, or dismissal ("it's for kids"); discouragement when gains are small. Working: the client describes the purpose in their own words and keeps realistic goals.

B3. Supporting informed consent and shared decision-making

Purpose: to help the client make an informed, values-based choice about whether to use VR or exergames, including immersive headsets. Use when VR is offered or the client is unsure.
Steps:
1. Check the client has had the team's explanation of the system, its likely benefits, risks (cybersickness, falls, seizures, skin reactions) and alternatives [source: Meta Quest 2 safety instructions; FDA AR/VR page].
2. Explore preferences, values and worries (technology anxiety, embarrassment, fear of falling, privacy).
3. Check understanding with teach-back; screen for cognitive or communication barriers after stroke and suggest the team use accessible information.
4. If capacity is in doubt, flag to the team, who assess under local law.
5. Make clear that declining or stopping is the client's right and that the team can offer alternatives.
Example language (illustrative): "What would make this worth trying for you, and what would make you want to say no? Let's write down your questions for the physio."
Watch for: agreement given to please staff; aphasia masking misunderstanding; family pressure. Working: the client can state the choice, the reasons and how to stop.

B4. Psychological contribution to pre-use screening

Purpose: to pass on psychological and history information relevant to safety, since the manufacturer advises people with psychiatric disorders or seizure history to consult a doctor first [source: Meta Quest 2 safety instructions]. Use before first headset use or when history changes.
Steps:
1. Ask about seizures, blackouts, photosensitivity, migraine and motion sickness; panic, claustrophobia, PTSD and trauma reminders; dissociation and derealisation; psychosis or unusual perceptual experiences; current substance use [synthesis; susceptibility items drawn from Meta Quest 2 safety instructions and Fernández-Cañas et al. 2026].
2. With consent, share relevant findings with the team; you do not decide eligibility.
3. For trauma-related concerns, think through likely triggers in the virtual content with the client (e.g. vehicles, heights, hospital scenes) and pass these on.
4. Note medicines the client mentions only to suggest that the team or prescriber review them; never comment on changing them.
Example language (illustrative): "Some people find headsets disorienting or find that certain scenes bring back memories. Is there anything about wearing something over your eyes or particular places that worries you?"
Watch for: undisclosed seizures or blackouts (urgent flag); strong anticipatory panic; perceptual disturbances. Working: the team has the information it needs before use.

B5. Motivation, engagement and adherence conversations

Purpose: to support the client's own reasons for practising, especially with home exergames where practice volume depends on them. Use when practice drops, or proactively.
Steps:
1. Explore the client's view of the practice without judgment; ask about barriers (fatigue, pain, mood, boredom, setup problems, shame, family space).
2. Use a motivational-interviewing style: elicit their reasons and goals, reflect ambivalence, support autonomy.
3. Problem-solve psychological and practical barriers (routines, reminders, a support person) within the plan the team set; never change the amount or type of practice yourself.
4. Pass physical barriers (pain, symptoms, technical failures) to the team.
5. Reinforce effort and small gains, not only scores.
Example language (illustrative): "Part of you wants to keep going and part of you is fed up with the games. What's the fed-up part telling you? What would help you get back to the plan your physio set?"
Watch for: low mood or apathy presenting as "laziness"; pain or symptoms behind avoidance; overdoing it beyond the plan to "catch up" (flag to team). Working: practice matches the agreed plan and the client links it to their goals.

B6. Processing reactions to performance feedback and the avatar

Purpose: to help the client cope with what games make visible: scores, comparisons, and virtual limbs that show what the real limb cannot do. Use when the client reports frustration, shame, grief or unusual reactions to the virtual body.
Steps:
1. Invite the client to describe a recent session and the moment of strongest feeling.
2. Validate grief and frustration about the impairment; distinguish game score from personal worth.
3. Address perfectionism and self-criticism with standard cognitive or compassion-focused methods.
4. Explore and normalise reactions to seeing a virtual version of the limb [source for the mechanism: MobiHealthNews 2017]; refer distressing or persistent body-perception reactions to the team.
5. Ask the client and team whether score displays can be framed around personal progress (team decision).
Example language (illustrative): "When the score drops, what does your mind tell you about yourself? If a friend had that score after a stroke, what would you say to them?"
Watch for: catastrophic interpretations ("I'll never recover"); emerging depression; avoidance of sessions after poor scores. Working: the client tolerates setbacks and keeps engaging.

B7. Monitoring and passing on adverse effects and warning signs

Purpose: to notice and report to the team effects the client mentions in therapy. Use at every session during VR rehab.
Steps:
1. Briefly ask how sessions went and about after-effects (dizziness, nausea, headache, eye strain, drowsiness, balance problems, skin irritation, neck or joint pain) [source: Meta Quest 2 safety instructions; FDA AR/VR page].
2. Treat as urgent and advise immediate medical contact for any seizure, blackout, twitching or loss of awareness [source: Meta Quest 2 safety instructions; Epilepsy Society 2025].
3. Report falls or near-falls, persistent symptoms, pacemaker or implant concerns to the team.
4. Notice psychological after-effects: derealisation, panic, intrusive memories, or perceptual changes after sessions; pass on and address in therapy.
5. Remind clients of the manufacturer advice not to drive or do balance-demanding activities until symptoms resolve [source: Meta Quest 2 safety instructions].
Example language (illustrative): "Any dizziness, headaches or odd feelings after your last session? I'd like to let your physio know about the dizziness you described, if that's okay."
Watch for: minimising symptoms to keep access to the programme. Working: the team receives timely, specific reports.

B8. Cognitive rehabilitation liaison and transfer to daily life

Purpose: where VR or games include cognitive tasks (attention, memory, executive function), to link them with neuropsychological care and real-life strategies. Evidence on cognition after stroke is insufficient [source: Cochrane plain-language summary].
Steps:
1. Confirm who leads cognitive rehabilitation (neuropsychologist, OT).
2. Adapt your therapy to the client's cognitive profile (shorter segments, written summaries, repetition).
3. Help the client identify real-life situations where trained skills matter and plan small transfer experiments.
4. Feed back observations on daily functioning to the cognitive-rehab lead.
Example language (illustrative): "The memory games are one part. Let's think about where you'd most like your memory to work better this week, and what strategy you could try there."
Watch for: game improvement without daily-life change; cognitive fatigue; anosognosia (limited awareness) affecting consent and safety. Working: improvements reported in real-life tasks.

B9. Children and young people

Purpose: to support safe, developmentally suitable use when young clients use VR or exergames in rehabilitation.
Steps:
1. Check the age labelling of the specific system; one consumer headset is labelled not for under-13s, with adult monitoring for teenagers and limits on prolonged use [source: Meta Quest 2 safety instructions]. Newer products and accounts may have different age rules [uncertain: not verified].
2. Note higher photosensitive risk in this age group [source: Epilepsy Society 2025; Meta Quest 2 safety instructions].
3. Involve parents in supervision, play-space safety and online-safety settings; agree screen-time boundaries with the family, linking home gaming to the rehab team's plan.
4. Watch for gaming becoming a source of conflict or of escape from distress.
Example language (illustrative, to a parent): "Let's check with the therapy team how the game fits the plan, and agree how you'll supervise and when it stops."
Watch for: unsupervised use, online contact with strangers, sleep disruption. Working: supervised, plan-linked use.

B10. Data privacy and digital safety

Purpose: FDA lists cybersecurity and privacy among AR/VR risks [source: FDA AR/VR page]; help clients make informed choices about data.
Steps:
1. Ask what accounts, apps and cameras the client uses, and whether home systems record movement or video.
2. Encourage the client to ask the team or provider what data is collected, stored and shared, and how to opt out.
3. For consumer devices, discuss account privacy settings and shared household devices.
4. Keep your own records of rehab data within your usual confidentiality rules.
Example language (illustrative): "Do you know what the system records about you, and who can see it? It's fine to ask your therapist or the company."
Watch for: clients avoiding use from privacy fears (explore and refer for answers); unclear data flows. Working: the client knows where data goes.

B11. Risk, crisis and safety planning

Purpose: rehabilitation after stroke or brain injury can coincide with depression, anxiety and suicidal thinking; VR training does not replace mental-health risk management.
Steps:
1. Screen mood and risk with your usual validated methods and standard risk-assessment practice.
2. Build a collaborative safety plan (warning signs, coping steps, contacts, crisis services, means safety such as safe storage), and share relevant parts with the team with consent.
3. Agree how the team should contact you or crisis services if a client discloses risk in a rehab session.
4. Escalate urgent medical events (seizures, falls with injury) through medical routes.
Example language (illustrative): "Recovery can feel very slow. Have there been times you've felt it's not worth carrying on? Let's plan what to do if those thoughts get stronger."
Watch for: hopelessness after poor progress or discharge. Working: a current, shared plan.

B12. Integrating psychotherapy before, during and after rehabilitation; ending

Purpose: to time psychological work so it supports practice and the transition out of rehab.
Steps:
1. Before: address fears, expectations and consent (B2–B4).
2. During: keep sessions short if fatigue is high; schedule away from tiring rehab sessions if possible; work on motivation and reactions (B5–B7).
3. At discharge: process the ending of intensive rehab, adjustment to residual impairment, and plans for staying active as advised by the team.
4. After: help the client keep meaningful activity, return to the team for any new symptoms or questions about continuing home gaming.
Example language (illustrative): "The rehab programme is ending, but your recovery story isn't. What do you want to keep doing, and who will you ask if you're unsure what's safe?"
Watch for: a sense of abandonment at discharge; unsupervised continuation with unsuitable consumer games. Working: a clear post-rehab plan agreed with the team.

B13. Pointer rows

VR exposure therapy for anxiety, phobias or PTSD: see 092 VR exposure therapy.
Other rehabilitation methods with their own entries are described there; this entry covers VR and exergame use only.

5. Handling problems

The sources say little about psychological difficulties in VR rehabilitation; guidance below is [synthesis] unless a source is given. In every case, decisions about the training itself go to the rehabilitation team.

Stuck or plateaued progress: validate frustration; review what the client values beyond scores; check for depression, fatigue or pain; encourage the client to raise the plateau with the team, who decide on changes. Avoid suggesting other games or more practice yourself.
Resistance or dismissal ("it's a children's toy", technology anxiety): explore meaning (loss of status, fear of looking foolish, unfamiliarity); offer psychoeducation (B2); suggest the client ask the team for a supervised trial or a non-immersive option; respect a decision to decline.
Overwhelm in the headset (panic, claustrophobia, sensory overload): the person should stop and remove the headset; the manufacturer advises stopping on discomfort [source: Meta Quest 2 safety instructions]. In therapy, process the experience, teach brief grounding and breathing skills, and pass details to the team, who decide on seated use, non-immersive alternatives or stopping. Do not run graded exposure to the headset yourself unless that is an agreed, separate psychological treatment (see 092).
Cybersickness that persists: report to the team; reinforce manufacturer advice to wait until symptoms fully clear and to avoid driving and balance-demanding activities until recovered [source: Meta Quest 2 safety instructions]. If anticipatory nausea or anxiety develops, address it psychologically while the team reviews the system.
Seizure, blackout or twitching: urgent medical review; no further use until medically cleared [source: Meta Quest 2 safety instructions; Epilepsy Society 2025].
Falls or near-falls at home: report to the team; support the client and family to review the play space against the published safety advice [source: Meta Quest 2 safety instructions]; address fear of falling, which can reduce activity.
Non-adherence to home practice: use B5; identify mood, cognitive, practical and family barriers; pass technical and physical barriers to the team; avoid blame.
Overuse ("more must be better"): explore drivers (fear of permanent disability, perfectionism); explain that the plan is set by the team for safety; report overuse with pain or strain [source on strain symptoms: Meta Quest 2 safety instructions].
Ruptures with the rehab team ("they push me too hard", "the physio doesn't listen"): listen, avoid taking sides, help the client prepare what to say, and with consent facilitate a joint conversation. Repair ruptures in your own relationship if the client feels you are "just another professional pushing exercise".
Trauma-related reactions to virtual scenes (e.g. traffic, hospitals, heights): stabilise, pass on specific triggers, and plan with the team for content changes. If a trauma disorder is present, consider trauma-focused psychotherapy separately.
Derealisation or depersonalisation after sessions: assess, normalise transient after-effects, teach grounding, report to the team, and monitor for persisting dissociation or psychotic symptoms requiring medical review.
Cognitive and communication barriers (aphasia, neglect, memory impairment): coordinate with the speech and language therapist and neuropsychologist for accessible materials; check consent and understanding repeatedly.
Commercial device bought on marketing claims: explore hopes; share attributed evidence (A2); encourage the client to ask the team whether and how it fits, and to follow manufacturer warnings.
Privacy worries or data incidents: help the client ask the provider about data; involve your service's information-governance lead if records are affected.
Grief and identity loss at discharge: work on adjustment and meaning; plan continued activity agreed with the team (B12).

Sources

Cited works:

Laver KE, Lange B, George S, Deutsch JE, Saposnik G, Crotty M. (2017). Virtual reality for stroke rehabilitation. Cochrane Database of Systematic Reviews, CD008349.pub4.
Laver KE, et al. (2025). Virtual reality for stroke rehabilitation (update). Cochrane Database of Systematic Reviews [full author list and version number: uncertain].
Dockx K, et al. (2016). Virtual reality for rehabilitation in Parkinson's disease. Cochrane Database of Systematic Reviews, CD010760.pub2 [full author list: uncertain].
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