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Engagement with upper limb rehabilitation post-stroke can improve rehabilitation outcomes. Virtual Reality can be used to make rehabilitation more engaging. In this paper, we propose a multiple case study to determine: (1) whether game design principles (identified in an earlier study as being likely to engage) actually do engage, in practice, a sample of stroke survivors with a Desktop Virtual Reality-based Serious Game designed for upper limb rehabilitation; and (2) what game design factors support the existence of these principles in the game. In this study, we considered 15 principles: <italic>awareness</italic>, <italic>feedback</italic>, <italic>interactivity</italic>, <italic>flow</italic>, <italic>challenge</italic>, <italic>attention</italic>, <italic>interest</italic>, <italic>involvement</italic>, <italic>psychological absorption</italic>, <italic>motivation</italic>, <italic>effort</italic>, <italic>clear instructions</italic>, <italic>usability</italic>, <italic>purpose</italic>, and a <italic>first-person view</italic>. Four stroke survivors used, for a period of 12 weeks, a Virtual Reality-based upper limb rehabilitation system called the Neuromender Rehabilitation System. The stroke survivors were then asked how well each of the 15 principles was supported by the Neuromender Rehabilitation System and how much they felt each principle supported their engagement with the system. All the 15 tested principles had good or reasonable support from the participants as being engaging. Use of feedback was emphasised as an important design factor for supporting the design principles, but there was otherwise little agreement in important design factors among the participants. This indicates that more personalised experiences may be necessary for optimised engagement. The insight gained can be used to inform the design of a larger scale statistical study into what engages stroke survivors with Desktop Virtual Reality-based upper limb rehabilitation.

Improving Engagement of Stroke Survivors Using Desktop Virtual Reality-Based Serious Games for Upper Limb Rehabilitation: A Multiple Case Study