Greek Occupational Therapists’ Perspectives on the Clinical Application of Fully Immersive Virtual Reality in Post-Stroke Upper Limb Rehabilitation: An Exploratory Qualitative Study

Abstract

Stroke is a leading cause of long-term disability worldwide, and new technologies such as Fully Immersive Virtual Reality (FIVR) are being explored to promote functional recovery as well as optimize rehabilitation outcomes. The aim of the present study was to explore Greek OTs’ perspectives on the use of FIVR in rehabilitation of the upper limb after stroke. Two focus groups took place with six experienced OTs, who were recruited from diverse clinical settings across Greece. The interviews were facilitated using a semi-structured guide and inductively coded using thematic analysis following Braun and Clarke’s six-stage process. Six theme-rich findings were elicited. Therapists identified FIVR’s potential to enable patient involvement, motivation, and recovery of function through the use of immersion and feedback-based practice. They reported significant barriers, however, in terms of technical challenges, safety issues, and costly equipment. OTs also highlighted the fact that occupation-based, culturally sensitive task design is central to ensuring ecological validity and transfer to naturalistic settings. There is a high potential for FIVR in stroke rehabilitation, but it requires user-centered design, cultural adaptation, adequate training, and systemic support towards long-term implementation.

1. Introduction

Stroke recovery is a dynamic, multi-stage phenomenon, and it requires timely, specific, and multidisciplinary intervention, typically involving Physical Therapy (PT), Occupational Therapy (OT), and Speech and Language Therapy (SLT) to address motor, functional, and communication deficits [1]. Stroke rehabilitation, an essential process for this recovery, is traditionally divided into three stages (acute, subacute, and chronic) with varying goals towards maximizing functional improvement and independence [2]. Early mobilization and the provision of Activities of Daily Living (ADL) in the acute phase prevent complications and promote neurological recovery [3]. The subacute phase focuses on intensive, task-oriented rehabilitation that is grounded in motor learning principles (such as repetition, feedback, and progressively increasing challenge) that form the foundation of OT practice [4]. In the chronic phase, rehabilitation emphasizes long-term functional care and reintegration into the community, with augmented utilization of new technologies to ensure engagement and facilitate further neuroplasticity adaptations [5].

While the efficacy of conventional rehabilitation is proven, most stroke survivors still exhibit motor impairment, i.e., upper limb function, due to reduced intensity of treatment, participation, and concurrent performance feedback [6]. This has generated growing interest in new approaches that facilitate neuroplasticity and compliance of patients. Virtual reality (VR) has been a promising complement to traditional therapy delivering interactive, immersive contexts that mimic functional activities in engaging, secure environments [7]. The majority of the literature has employed non-immersive VR systems (i.e., video games on a screen or console-based systems such as Nintendo Wii or Xbox Kinect) while Fully Immersive VR (FIVR) remains to be evaluated for its utility in clinical practice [8].

FIVR, as characterized by Head Mounted Displays (HMDs), 360° interactive environments, motion tracking, and real-time sensory feedback, creates an immersive presence illusion that can enable participation and motor learning. A growing body of literature suggests that the inclusion of FIVR in rehabilitation interventions leads to additional improvement in dexterity of the upper limb, gait function, and dynamic balance above usual treatment, particularly among subacute and chronic stroke survivors [9]. Moreover, FIVR has been shown to lead to long-term improvements in upper limb function and performance of ADL through enhanced neuroplasticity and patient motivation [10]. FIVR’s adaptability also enables telerehabilitation, expanding access to care and allowing personalized, goal-directed therapy [7].

Nevertheless, clinical use of FIVR is hampered by significant barriers. The vast majority of FIVR systems are developed from a technological or gaming perspective with little input from clinicians, and OTs in particular, who are at the front line of functional upper limb rehabilitation [11]. This disconnection risks limiting the clinical utility and potential of the systems. Personalized VR environments co-designed with occupation-based activities, dressing, cooking, or grooming, for example, can facilitate enhanced therapeutic congruence with ADL objectives and integration into everyday OT practice [12]. Additionally, although feasibility trials indicate that FIVR is generally tolerable by stroke survivors with minimal cybersickness side effects, safety, usability, and practical applicability into real clinical workflows are seldom reported [9].

There remains a significant knowledge gap regarding how frontline clinicians, that is, OTs, perceive and work with FIVR. In a recent study [13], authors indicated that 23.5% of neuromotor rehabilitation usability research included healthcare professionals, showing limited clinician-oriented evidence. Therapists, though, point to the necessity of community-based, functionally relevant activities facilitating individualized goal setting and client-centered practice [14].

To address this gap, this study aims to explore Greek OTs’ perspectives on the clinical application of FIVR in post-stroke upper limb rehabilitation, focusing on perceived benefits, implementation challenges, and opportunities for occupation-based integration.

2. Materials and Methods

Because of the complexities of tailoring new technologies in practice, a focus group methodology was chosen to facilitate face-to-face, in-depth discussion that stimulates shared experiences, common sense, and differing opinions [15]. Focus groups are well-suited for OT research, as they align with the profession’s client-centered philosophy and enable exploration of contextual, social, and practical factors, including decision-making processes, that influence therapeutic interventions [16]. To ensure transparency, completeness, and trustworthiness in the reporting of this qualitative study, the COnsolidated criteria for REporting Qualitative research (COREQ) checklist will be used throughout the research process [17]. COREQ is a 32-item checklist developed to help researchers report qualitative studies clearly and comprehensively. More specifically, in Domain 1, reflexivity was addressed by providing documentation of the coordinator’s background, training, and potential biases, as well as the strategies used to minimize their influence during data collection. In Domain 2, COREQ guided the transparent reporting of sampling procedures, eligibility criteria, recruitment, framework, and development of the semi-structured interview guide. Finally, in Domain 3, COREQ supported the clear documentation of coding procedures, theme development, data saturation, and analytical decisions made by the research team. The integration of COREQ throughout the study ensured rigor, consistency, and clarity in the presentation of methods and findings.

The primary researcher, who served as the focus group moderator, is a trained OT with clinical experience in neurorehabilitation within the Greek healthcare system but no prior experience conducting focus groups. To ensure methodological competence and procedural clarity, the moderator received guidance from supervisor experienced in qualitative research and followed established protocols for focus group facilitation. To minimize bias, the moderator employed bracketing and adhere to a semi-structured guide, despite having prior knowledge of VR applications in rehabilitation. Participants were informed of the study’s purpose and the researcher’s background through informed consent documents, ensuring transparency about the study’s objectives and the moderator’s role.

Synchronous video-based focus groups were conducted via Zoom (Zoom Video Communications, Version 5.18.3, San Jose, CA, USA; https://zoom.us), selected to enhance conversational flow, accommodate geographically dispersed participants across Greece, and align with best practices in virtual rehabilitation research [18]. To mitigate potential technical challenges, pre-session technical checks and support were provided, and moderator used structured facilitation strategies like turn-taking, open-ended questioning, summarizing responses, and explicit encouragement of quieter participants to ensure equitable participation.

Focus groups comprising 6–9 Occupational Therapists (OTs) were chosen. This group size is based on recommendations for smaller groups (6–9 participants) to support balanced participation, manageability, and in-depth discussion, particularly for nuanced topics such as FIVR adoption in clinical workflows [19]. Each focus group lasted approximately 90 min and was facilitated using a semi-structured guide designed to elicit insights on perceived benefits, implementation challenges, and decision-making processes related to occupation-based FIVR applications. Data collection continued until thematic saturation was confirmed.

2.1. Study Participants and Recruitment

Participants were registered OTs with recent or current clinical practice experience in neurological rehabilitation with adult stroke survivors. The recruitment criteria included a minimum of two years of neuromotor rehabilitation experience and exposure to technological interventions as measured by prior use, training in, or self-reported interest in FIVR systems for rehab. PTs were excluded to maintain an OT perspective because OTs uniquely value occupation-based, functional upper limb rehabilitation, different from the mobility-focused intervention that PTs are typically tasked with. This focus in this manner ensures that results are congruent with the purpose of the study to explore FIVR’s role within occupation-based practice. As emphasized by [20,21], clinician input is important in early evaluation of new technologies to establish clinical suitability, therapeutic alignment, and feasibility of implementation before testing at the patient level. OTs are ideally placed to provide future-oriented advice on goal setting, task adjustment, safety, and skill transfer to real-life everyday ADL that have not been fully verbally described by patients during initial technology assessment [14].

2.2. Recruitment

A purposive sampling strategy was employed to ensure that participants had relevant expertise. Invitations will be distributed through social media platforms (Facebook, LinkedIn) and email communications directed at professionals working in public hospitals and private rehabilitation centers across Greece. Participation was voluntary and uncompensated. Ethical approval for this study was obtained from the Bioethics Committee of the Democritus University of Thrace (Approval No. 13/19 July 2024).

2.3. Data Collection

A semi-structured discussion guide was developed to support consistent data collection based on the literature and pilot-tested with two clinicians to ensure clarity and relevance. The guide will be informed by the literature on technology integration in rehabilitation and aligned with key domains relevant to OT practice, including user experience, therapeutic alignment, patient engagement, accessibility, and skill transfer.

The final guide includes open-ended questions organized around the following topics:

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Experiences and challenges with VR use in clinical practice;

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Alignment of VR interventions with OT goals;

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Patient engagement and motivation during VR-based therapy;

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Accessibility and customization of VR systems for diverse patients;

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Characteristics of effective and functionally meaningful VR tasks;

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Feedback mechanisms and suggestions for improving VR integration.

2.4. Data Analysis

Thematic analysis was conducted following the six-phase framework proposed by [22], ensuring a systematic and transparent approach to data interpretation. To enhance methodological rigor, coding was cross-verified manually by two independent researchers. Final themes were defined and named to clearly capture the core patterns and experiences expressed by OTs regarding the clinical application of FIVR in post-stroke upper limb rehabilitation.

All sessions were conducted in a private, secure Zoom environment. Participants were informed about the study’s purpose, their rights, and confidentiality procedures prior to commencement. With participants’ oral consent, each session was audio-recorded and later transcribed verbatim. Personal identifiers were removed from transcripts, and anonymized codes will be assigned to ensure data confidentiality and protect participant privacy.

3. Results

3.1. Participants

Six Greek OTs with clinical experience in neurorehabilitation, and specifically in upper limb rehabilitation following stroke, participated in the study (see

Table 1. Participants demographics.

Participants	Gender	Age (in Years)	Level of Education	Work Experience (in Years)	Employer
OT1	Male	39	MSc	15	Private Rehabilitation & Recovery Center
OT2	Female	31	MSc	8	University
OT3	Female	33	MSc	10	University
OT4	Female	49	MSc	27	Public Hospital
OT5	Male	41	BSc	14	Private Rehabilitation & Recovery Center
OT6	Female	31	MSc	8	Private Rehabilitation & Recovery Center

). All participants met the inclusion criteria, namely working currently or having worked in adult rehabilitation services in Greece, in which they were involved in FIVR interventions. Despite the small sample size, this was targeted and purposeful, as a limited number of OTs in Greece have practical experience with FIVR in clinical practice, due to low adoption of new technologies, limited training programs, and constrained resources in rehabilitation centers. Efforts were made to recruit additional participants by sending invitations to public and private rehabilitation centers across the country; however, no other suitable clinical therapists were identified. Despite the small number, the participants were information-rich, representing a wide range of clinical settings—including public hospitals, private rehabilitation centers, and academic institutions—which enhanced the breadth and transferability of the findings within the context of the Greek healthcare system. Furthermore, data collection continued until thematic saturation was achieved, ensuring that the study captured the key perspectives on the application of FIVR in post-stroke rehabilitation. The therapists’ ages ranged from 31 to 49 years, their experience in adult stroke rehabilitation ranged from 8 to 27 years, and their involvement with FIVR systems spanned 1–6 years. Five participants held a master’s degree (MSc), providing a strong foundation in evidence-based practice and advanced rehabilitation procedures, while the remaining participant held a bachelor’s degree (BSc).

Clinicians reported their practical experience with immersive headsets such as Oculus Rift, Meta Quest 2 and HTC VIVE, along with motion-tracking controllers and hand/finger-tracking devices, non-immersive tools such as the Wii BalanceBoard and Wii controllers, and upper limb rehabilitation systems such as Armeo and HandTutor. They also described the software and therapeutic scenarios commonly used in the clinic, such as functional approach tasks and game-based activities that promote engagement and improvement of motor skills. These FIVR solutions were used in both subacute and chronic rehabilitation, allowing therapists to tailor interventions to patients’ functional abilities and engagement.

The homogeneity of professional experience (all Greek OTs) facilitated thematic consistency in occupation-centered care within the Greek healthcare framework, but the diversity of workplace settings, levels of experience, and technological familiarity added richness to the level of discussion. The focus groups were built with the same six OTs to allow for richer insights, with prompts for each session (e.g., perceived benefits in the first, challenges and barriers in the second) in order to minimize redundancy while maximizing data richness [23]. Despite the small sample, together their opinions exhibited a synergy of clinical experience, practical problem-solving, and open-minded attitudes towards innovation that positioned them well to offer useful contribution to the evaluation of FIVR as a rehabilitation procedure for post-stroke upper limbs in the Greek context.

3.2. Findings: Thematic Analysis

Two Zoom virtual focus groups were conducted, each lasting approximately 90 min. The number of groups was determined by the data saturation concept that was achieved when in the second session there emerged no new significantly new ideas or insights [24]. The thematic analysis was conducted according to the six stages of Braun and Clarke’s methodology, adapted to the context of this study for the analysis of qualitative data from the two focus groups. In the first stage (familiarization with the data), all transcribed interviews were read repeatedly and carefully, with the aim of gaining a comprehensive understanding of the content and initially identifying common patterns and ideas, recording initial observations. In the second stage (coding), manual, inductive line-by-line coding was applied, without predetermined themes, assigning each relevant excerpt one or more codes (words or phrases) that summarize the basic meaning, using color coding for visual organization. In the third stage (theme search), the codes were grouped into initial thematic units through interpretive analysis, focusing on substantive patterns that reflect the participants’ experiences in relation to the aim of the study. In the fourth stage (review of topics), the resulting themes were checked for internal consistency (common meaning of the excerpts within each theme) and external differentiation (avoidance of overlap) through a two-level review: first of the individual excerpts and then of the data as a whole, leading to a coherent thematic map without significant changes and confirming data saturation (absence of new themes). In the fifth stage (definition and naming of themes), each theme was interpreted in depth, defining its core, its connection to the purpose of the research, and its organization into sub-themes for greater clarity, with comprehensive names assigned. Finally, in the sixth stage (reporting findings), the results were compiled with excerpts from the interviews to document the themes, ensuring transparency and reliability. The process enhanced validity through repeated checks and anonymity (removal of personal details, use of codes). Finally, thematic analysis yielded six interconnected themes.

3.2.1. Technical and Functional Challenges: Barriers to Seamless Integration

Rolling out FIVR in clinic settings is highly technical and operationally demanding (see Table 2). Participants indicated that configurations that included HMDs, motion-tracking sensors, calibration software, and compatible equipment were cumbersome and time-intensive. Resolving connectivity or lag problems tended to involve extensive trial-and-error and digital competencies above and beyond typical clinical training. As one therapist (OT3) noted:

“Every session starts with 15–20 min of technical setup before we even begin therapy.”

All these demands reduce the active therapy time, particularly in public hospitals with no specialized IT support. Secondly, safety was a persistent concern. Patients with impaired balance, poor trunk control, or spatial neglect are more vulnerable to dizziness, disorientation, or falls when undergoing FIVR. Therapists emphasized that close supervision, physical support, and adaptations in the environment, such as the removal of obstacles or application of safety harnesses, were required. One of the participants (OT1) stated:

“Safety is a major concern—patients with poor trunk control may feel dizzy or fall during FIVR sessions.”

Although cybersickness was reported infrequently and generally mild, screening carefully and incrementally is recommended to minimize side effects, especially during early recovery. Overall, implementing FIVR is technologically difficult and labor-intensive with safety concerns also limiting its use further. Simplified setups, staff training, and stringent safety protocols are all required for expanded clinical use.

Table 2. Technical and Functional Challenges Reported by OTs.

Category of Challenge	Key Issues Reported	Clinical Impact	Representative Quotes
Installation & Setup Complexity	Lengthy preparation, environment arrangement, difficulty assisting patients	Reduces active therapy time, delays sessions, limits spontaneous use	“Every session starts with 15–20 min of setup before we even begin therapy.” (OT3) “Sometimes we don’t have enough time for FIVR because setting it up takes so long.” (OT1)
Motion Tracking & Calibration Errors	Hand/controller tracking loss, misalignment, frequent recalibration	Breaks session flow, frustrates patients, reduces trust in FIVR	“Sometimes the hands disappear, and we have to stop everything to fix it.” (OT4) “Patients get annoyed when the system doesn’t respond to their movements.” (OT4)
Software Instability & Connectivity Issues	Crashes, freezing, delayed loading, weak Wi-Fi, Bluetooth disconnections	Session interruptions, system unpredictability, increased workload	“The program crashed three or four times in one session—it’s not sustainable.” (OT1) “We often lose connection mid-task, and patients get confused.” (OT5)
Device Comfort & Safety Risks	Heavy headsets, visual fatigue, dizziness, fall risk	Shorter sessions, increased therapist assistance, limited use with severe patients	“Safety is a major concern—patients with poor trunk control may fall.” (OT1) “Some patients get dizzy or can’t wear the headset for long.” (OT3)
Lack of IT Support & Training	Therapists handle troubleshooting, limited technical training, no institutional guidelines	Increased cognitive load, system underutilization, reluctance to use VR regularly	“If something didn’t work, we had to figure it out ourselves.” (OT4) “I wish we had more guidance on how to use the system effectively.” (OT2)

Table 2. Technical and Functional Challenges Reported by OTs.

Category of Challenge	Key Issues Reported	Clinical Impact	Representative Quotes
Installation & Setup Complexity	Lengthy preparation, environment arrangement, difficulty assisting patients	Reduces active therapy time, delays sessions, limits spontaneous use	“Every session starts with 15–20 min of setup before we even begin therapy.” (OT3) “Sometimes we don’t have enough time for FIVR because setting it up takes so long.” (OT1)
Motion Tracking & Calibration Errors	Hand/controller tracking loss, misalignment, frequent recalibration	Breaks session flow, frustrates patients, reduces trust in FIVR	“Sometimes the hands disappear, and we have to stop everything to fix it.” (OT4) “Patients get annoyed when the system doesn’t respond to their movements.” (OT4)
Software Instability & Connectivity Issues	Crashes, freezing, delayed loading, weak Wi-Fi, Bluetooth disconnections	Session interruptions, system unpredictability, increased workload	“The program crashed three or four times in one session—it’s not sustainable.” (OT1) “We often lose connection mid-task, and patients get confused.” (OT5)
Device Comfort & Safety Risks	Heavy headsets, visual fatigue, dizziness, fall risk	Shorter sessions, increased therapist assistance, limited use with severe patients	“Safety is a major concern—patients with poor trunk control may fall.” (OT1) “Some patients get dizzy or can’t wear the headset for long.” (OT3)
Lack of IT Support & Training	Therapists handle troubleshooting, limited technical training, no institutional guidelines	Increased cognitive load, system underutilization, reluctance to use VR regularly	“If something didn’t work, we had to figure it out ourselves.” (OT4) “I wish we had more guidance on how to use the system effectively.” (OT2)

3.2.2. Task-Oriented Design: The Need for Occupation-Based Relevance

Therapists consistently indicated that FIVR interventions must be embedded in meaningful, functionally relevant tasks to align with OTs fundamental philosophy. All participants agreed that commercially available FIVR games focus more on entertainment than therapeutic purpose, with activities such as catching falling objects, popping balloons, cartoon-style ball games, fruit picking activities, or simple “point and click” exercises in brightly colored fantasy environments, described as “childish” and ecologically invalid. These types of tasks do not address the multi-level motor-cognitive demands of ADLs and also do not resemble real-life activities and were often considered irrelevant or unattractive to adult patients. On the other hand, participants expressed strong interest in simulations of real-life ADL activities, such as cooking, opening cans, or collecting items from a shelf. As one therapist (OT4) described it:

“If the patient is practicing slicing bread in VR, that’s something they can actually use at home—it gives them a sense of real progress.”

This emphasis on task-specificity reflects principles of motor learning and neuroplasticity, which require repetitive, goal-directed practice in contextually meaningful environments [5]. The therapists viewed FIVR not just as a tool of movement repetition, but as a means of practice of integrated, goal-oriented action to bridge the gap from isolated exercises to daily function. Criticism of non-functional, game-like tasks points towards a fundamental mismatch between many existing VR systems, which are commonly built upon gaming or engineering foundations, and the occupation-enabling goals of rehabilitation. As one participant condensed:

“I prefer VR tasks that simulate real-life activities like cooking or dressing.”

3.2.3. Customization and Cultural Relevance: Toward Personalized and Contextually Appropriate Interventions

Most therapists shared a common problem, which concerned the lack of personalization and cultural adaptation in the available FIVR applications. Motivation and participation were considered to depend largely on individual factors such as age, gender, personal interests, and sociocultural background. Participants argued that a one-size-fits-all approach is likely to alienate patients, especially older people or those with little exposure to technology. One respondent (OT5) stated:

“When a 70-year-old woman sees a kitchen with appliances she’s never used, it breaks the immersion and makes the task feel irrelevant.”

Therapists also mentioned that difficulty level, visual complexity, and feedback needed to be individualized to suit the cognitive and physical abilities of the patient. For example, patients with aphasia, visual field deficits, or poor confidence would require simplified instructions, larger icons, and slower pacing, in effect all of the features that standard FIVR designs lack. Another participant (OT2) commented:

“We need content that reflects Greek culture and language to make it relevant.”

3.2.4. Skill Transfer to the Real World: Bridging the Virtual-Physical Divide

Participants stated with much emphasis that FIVR helped with motor training yet seemed somewhat insecure about the actual transfer of skills that clients gained in the virtual worlds to the outdoors functional activities. FIVR involves high-intensity, repetitive practice; immediate feedback is given, and all are in consonance with major motor learning principles. Therapists had doubts as to whether performance in a very organized, controlled, ad hoc environment could generalize to common real-world tasks, very pertinent claims being made such as that by one of the participants (OT5):

“It’s unclear if skills learned in VR transfer to real-world tasks.”

Participants clarified that performing structured follow-up assessments, goal-setting frameworks, and strategies that deliberately link virtual and physical practice could be very helpful. Some of the suggested methods were graded practice in real-world settings following FIVR sessions, training in dual tasks (e.g., reaching for something while conversing), and introducing environmental variability (e.g., simulating a kitchen with many materials) to increase ecological validity. These findings are a clear indication of the need to integrate FIVR into comprehensive, client-centered rehabilitation programs rather than using it alone. The success of FIVR training that can be converted into valuable functional benefits depends on purposeful design, guided progress, and integration of practice into the real world.

3.2.5. Financial and Organizational Limitations: Structural Barriers to Adoption

Cost was identified as a primary barrier to the widespread adoption of FIVR. These systems, including high-resolution HMDs, motion-tracking sensors, and specialized software, are prohibitively expensive for most public rehabilitation centers in Greece. As one therapist (OT4) commented:

“We’re still using basic splints and resistance bands, and now you expect us to afford money for a headset?”

In addition to initial equipment expenses, ongoing outlays such as software updates, maintenance, and staff training further limit feasibility. The absence of reimbursement mechanisms or institutional funding streams exacerbates the issue. Respondents also identified a lack of institutional support and policy guidance. Without established protocols, training programs, or clinical guidelines, adoption is too dependent on individual clinician initiative. Although slightly better access was indicated by private clinics, this was confined to a few early adopters. Restricted availability of Greek-specific FIVR applications intensifies these barriers since commercial software often fails to meet local clinical or cultural needs.

3.2.6. Feedback and Motivation: Enhancing Engagement Through Interactive Reinforcement

Participants consistently highlighted the motivational advantages of FIVR. VR’s interactive, immersive character was perceived as a powerful means of boosting patient engagement, particularly in individuals who become bored with repetitive therapy. Real-time visual and auditory feedback devices, including scoring frames and progress indicators, enable immediate reinforcement, allowing patients to visualize their gradual progress. All participants (OT1–OT6) agreed that:

“Patients love seeing their progress in real-time—it motivates them.

Gamified elements engage intrinsic reward systems, supporting long-term participation, especially in chronic phases of recovery where motivation often wanes. Nonetheless, the significance of balancing fun with therapeutic intensity was emphasized. Motivational factors should facilitate exact movement patterns and functional goals. FIVR was viewed as an addition to conventional intervention, complementing clinical teaching, interpretation, and contextualization of performance, confirming that clinical know-how is central to technology-served therapy.

Overall, the themes involve a dual narrative: an optimistic one about FIVR’s potential to optimize engagement, motivation, and functional gains, and a second guarded about its integratable capabilities, ecological validity, and applicability within current healthcare systems (see

Table 3. Occupational Therapists’ Perspectives: Challenges and Advantages of FIVR.

Theme	Barriers	Benefits
Technical and Functional Features	Complex setup (HMDs, sensors, calibration, environment preparation) Frequent technical interruptions (software crashes, motion-tracking inaccuracies, connectivity issues). Limited IT support in public hospitals Safety concerns for patients with impaired balance, dizziness, spatial neglect, or low trunk control.	Enables immersive, controlled and customized practice Provides precise motion tracking and feedback Allows therapists to objectively monitor repetition rate, movement amplitude, and task accuracy.
Task-Oriented Design	Commercial applications often “childish” or inappropriate for adults (e.g., balloon popping, arcade throwing games). Limited simulation of real ADLs. Tasks lack multi-step, goal-directed components required for functional rehabilitation.	Supports realistic, occupation-based practice (e.g., slicing bread, preparing coffee). Enhances goal-directed, purposeful action aligned with OT philosophy. Facilitates graded task difficulty to match ADL progress.
Customization and Cultural Relevance	Limited ability to tailor tasks to patient needs (cognitive level, motor ability, visual impairments). Interfaces lack Greek language options and culturally familiar environments. Activities not matched to age, lifestyle, or prior roles (e.g., unfamiliar kitchen designs).	High potential for personalized intervention based on patient interests, strengths, and goals. Allows therapists to modify task pacing, visual complexity, and feedback modalities. Supports development of culturally grounded VR environments to increase relevance and engagement.
Skill Transfer to the Real World	Uncertainty about whether performance gains in FIVR generalize to daily activities. These environments may not reflect the variability of real home/community settings. Limited integration of dual-tasking or real-world distractions.	Enables high-intensity, repetitive training consistent with motor learning principles. Can be combined with real-world tasks to support transfer (e.g., practicing reaching in FIVR, then immediately applying it during dressing or kitchen tasks). Allows safe early practice before patients attempt tasks in complex environments.
Financial and Organizational Limitations	High cost of HMDs, tracking sensors, software licenses, and upgrades. Lack of reimbursement or institutional funding streams. Limited training opportunities for clinicians and absence of standardized protocols. Infrastructure in Greek public hospitals often inadequate (space constraints, limited Wi-Fi, outdated computers).	Potentially cost-effective long-term if scaled across multiple patients and centers. Allows standardized therapy delivery and consistent documentation. May increase therapy dose and patient throughput when integrated into routine practice.
Feedback and Motivation	Risk of over-gamification distracting from therapeutic goals. Some feedback systems emphasize scoring over movement quality.	Strongly enhances motivation and engagement, especially in chronic patients. Real-time visual and auditory feedback increases self-efficacy and awareness of progress. Gamified accomplishments (scores, levels, achievements) improve adherence and long-term participation.

).

4. Discussion

This study examined the views of Greek OTs on the clinical application of FIVR in upper limb rehabilitation after stroke. Through interactive focus groups involving therapists with clinical experience, the findings highlighted important aspects of the benefits and functional challenges associated with the application of FIVR in real rehabilitation settings. The results emphasize that, while FIVR is highly adaptable to the basic principles of motor learning and client-centered practice, its successful implementation in OT programs depends on resolving some of the most important issues related to usability, safety, therapeutic relevance, and support systems. The results suggest several essential considerations for effective use of FIVR in stroke rehabilitation. Similarly, another study with the same methodological approach [20], found that while therapists (OTs and PTs) rated treatment using neuro-activated images (NAT) for its ability to provide intensive upper limb rehabilitation and motivate patients, they emphasized that its successful implementation depends on appropriate training, technical support, and the presence of a therapist. They also noted the need for systemic and organizational changes to make such technologies feasible in actual rehabilitation.

Therapists emphasized that complex installation procedures, software stability issues, and technical maintenance requirements significantly disrupt clinical workflow and reduce the potential for daily use. These concerns are particularly common in public and private healthcare settings, where IT support is not always available. Beyond technical support, it is also important for OTs themselves to receive further training in the use of these systems and to be kept informed about new equipment. It is important to note here that most participants had experience with FIVR devices that require a camera to be installed around the user, rather than being integrated into the device. In recent years, standalone systems have been increasingly used, which include built-in cameras that capture patients’ hand movements. Taking this into account, it is possible that the participants’ opinions would have been different if they had used or been trained in these systems.

Patient safety during FIVR exposure is also a priority. Since most stroke survivors have impaired spatial orientation, trunk control, or balance, the immersive nature of VR has the potential to cause disorientation or increase the likelihood of falls. Therapists emphasized the need for environmental adaptations, close supervision, and gradual exposure protocols to prevent these risks. In addition, the emphasis of therapy on FIVR content for functional, occupational goals was repeatedly highlighted. Participants much more often simulated real-life activities, such as cooking, dressing, or reaching for objects in the home, than non-specific, playful activities, such as popping balloons or catching imaginary objects. This is not surprising, given the inherent philosophy of OT that emphasizes meaningful participation in ADL. The strong criticism of games that do not correspond to the interests of adults highlights the significant gap between commercially available FIVR programs, which are generally developed from a gaming or mechanical perspective, rather than rehabilitation professionals.

In addition, occupational therapists emphasized the importance of adaptation and cultural appropriateness in maintaining patient interest. The lack of applications in the Greek language and culturally familiar contexts was recognized as a significant disadvantage, especially for older individuals with limited digital literacy. This observation is consistent with growing calls for participatory design approaches, where patients and clinicians collaborate to design context-appropriate and personalized interventions [25]. Finally, the benefits of real-time feedback and progress tracking as motivators were widely recognized. Visual indicators of improvement and scoring systems and celebratory animations were described as powerful tools for reinforcing effort and promoting compliance, especially in the chronic phase of recovery, where traditional therapy can become monotonous. These characteristics are consistent with evidence showing that immersive virtual reality enhances patient engagement by making repetitive motor practice more enjoyable and less cognitively demanding [7].

Limitations and Future Research

Despite its contributions, this study has several limitations. The sample size was small (n = 6), which limits the generalizability of the findings. However, our participants were experienced OTs with prior exposure to rehabilitation technologies, which likely enhanced the depth and specificity of their contributions. This professional training and familiarity may have facilitated the rapid emergence of major themes, supporting the adequacy of our sample to capture core perspectives. Moreover, all participants were based in Greece, operating within a specific healthcare and cultural context, which may affect the transferability of findings to other countries with different funding models, technological infrastructure, or patient demographics.

Furthermore, the small number of participants reflects the limited number of Greek OTs who currently have practical experience with FIVR systems. The limited availability of FIVR in Greek rehabilitation centers, due to low technology adoption, limited training opportunities, and resource constraints, has significantly limited the number of eligible participants. Future research should broaden recruitment to multiple regions and healthcare settings, include clinicians with varying levels of familiarity with the technology, and consider multi-center or mixed-method approaches. Expanding the sample to include PTs, patients, stakeholders and software developers may also enrich the understanding of FIVR integration into stroke rehabilitation.

The qualitative, interpretative nature of the analysis also introduces subjectivity, as theme development relied on the researchers’ interpretation of the data. Additionally, the absence of direct observational data or patient perspectives means that the study captures clinician perceptions rather than actual patterns of FIVR use or patient outcomes.

Finally, while the moderator’s lack of prior experience with focus groups posed a potential limitation, the use of a structured guide, pilot testing, and supervisory support helped maintain consistency and quality in data collection. Furthermore, the interactive nature of focus groups—valued for generating shared insights and collective reflections—was preserved through active listening, follow-up probing, and efforts to ensure balanced participation. Future studies including a larger and more heterogeneous sample of therapists, with varying levels of training and technological experience, could provide additional conceptual depth.

5. Conclusions

To our knowledge, this study represents the first qualitative exploration of OTs’ perspectives on FIVR for post-stroke upper limb rehabilitation within the Greek healthcare context—and one of the first globally focusing exclusively on FIVR through an occupation-based lens. While [26] provided seminal insights into 9 Swiss therapists’ experiences with non-immersive, screen-based VR (YouGrabber system), identifying shared facilitators like patient motivation and barriers like technical setup, our work addresses critical gaps: FIVR-specific challenges and occupation-centered focus demanding culturally adapted ADL tasks. These distinctions position our findings as foundational for FIVR’s maturation, emphasizing culturally sensitive, ecologically valid design essential for real-world transfer in Southern European settings. Also, the findings highlight that while FIVR has much potential to maximize upper limb rehabilitation post-stroke by enhancing motivation, enabling intensive practice, and supporting occupation-based participation, its effectiveness is also dependent on careful design, cultural adaptation, and systemic support.

Beyond its immediate value to local practice, this study contributes to the broader theory of technology adoption in OT by emphasizing the general need for ecological validity, client-centered practice, and cross-cultural sensitivity. OTs’ emphasis on occupation-based relevance, safety, and cultural adaptation provides crucial guidance for interdisciplinary planning so that FIVR interventions are technically feasible but also clinically meaningful and aligned with patient-centered outcomes. By translating these findings into systems-level decision making, policy makers and rehabilitation clinicians are better able to determine investment priority, develop interprofessional training programs, and institute protocols that integrate innovation with safety and functional impact.

At the level of healthcare systems, the study delineates how budget constraints, few technological facilities, and lack of official policy direction affect FIVR adoption potential. In resource-constrained settings such as Greece, where spending on rehabilitation technology remains in the infancy stage [27], the incorporation of FIVR requires policy intervention, strategic funding models, and organizational structures that eliminate breaks in continuity of access. Although the findings are situated within the Greek rehabilitation context, they also have broader ramifications for countries with comparable systemic constraints, i.e., limited funding for rehabilitation technologies, limited clinician training programs, and underdeveloped policy frameworks for digital health. The majority of low-resource or middle-income health care systems face equivalent barriers to FIVR uptake, including cost, infrastructure, and cultural adaptation demands. The emphasis on occupation-based, culturally relevant task design and the requirement for systemic investment in training and organizational support are not unique to Greece but have relevance elsewhere in the world. Future research needs to generalize these findings by including patient reports, longitudinal measurement of skill transfer to practice, and cost-effectiveness analysis within a range of healthcare payment systems.

In conclusion, FIVR has potential for stroke rehabilitation in OT programs, but its effective implementation depends on a number of factors relating to patients, therapists themselves, application designers, and healthcare systems. Only through the coordinated efforts of all of the above can it be ensured that these technologies can be an effective tool for OTs to help stroke survivors regain their autonomy and improve their quality of life.