# Developing a Serious Video Game to Engage the Upper Limb Post-Stroke Rehabilitation
###### Contents  
* 1 Introduction
* 2 Stroke represents a highly prevalent and life-threatening neurovascular emergency that remains one of the leading causes of mortality worldwide. According to 2019 data, it was identified as the fifth leading cause of death globally, with implications for long-term disability [1]. The burden of stroke commonly results in physical and cognitive impairments that affect patients' quality of life and show the need for effective rehabilitation [2]. Approximately 101 million individuals worldwide have experienced a stroke [3], nearly doubling over the last three decades. Numerous studies underscore the prevalence of post-stroke cognitive impairment (PSCI), affecting 25% to 80% of stroke survivors [4]. It is estimated that approximately 50-80% of stroke survivors exhibit some degree of upper limb impairment in the early phase following a stroke [5]. When a stroke occurs, the sudden interruption of blood flow to the brain, caused by either a blood clot blocking a brain vessel (ischemic stroke) or the rupture or leakage of a blood vessel in the brain(hemorrhagic stroke), leads to the immediate death of brain cells. Prompt intervention is crucial. The impact of a stroke depends on the affected area of the brain, influencing speech, comprehension, emotions, sensations, motor functions, and vital functions such as heart rate, swallowing, and breathing. The consequences of a stroke may manifest as weakness, paralysis (hemiplegia), coordination difficulties (apraxia), changes in muscle tone (hypertonia or hypotension), subluxation, contracture, swelling (edema), and pain [6]. Stroke affects not only motor functions but also cognitive functions, which can impact various domains, such as memory, focus, attention, control, and executive functions. These cognitive impairments influence rehabilitation outcomes and the way different techniques and technologies are applied [7]. Stroke rehabilitation is broadly characterized as any aspect associated with stroke treatment, with the overarching objective of mitigating disability and fostering engagement in everyday activities. Its objectives encompass the prevention of deterioration, improving patient functionality, and achieving the utmost level of independence--physically, psychologically, socially, and financially--within the enduring limitations imposed by the stroke [1]. In stroke rehabilitation, various innovative approaches are being explored to improve patient outcomes, including traditional therapies, technology-assisted solutions, and gamification, which introduces interactive, rewarding activities to enhance engagement and motivation during recovery. Gamification can be characterized as a method of augmenting a particular activity through the incorporation of motivational elements. [PERSON] and [PERSON] [8] define gamification as the creation of a psychological experience that has the same positive impact as games. The term serious game is often closely associated with gamification and refers to a game designed with education or rehabilitation as its primary objective. Such games integrate elements of entertainment, attentional engagement, and problem solving to challenge functionality and performance. For the creation of these games, virtual reality (VR) can be implemented as a form of human-computer interaction (HCI), wherein individuals engage with a three-dimensional (3D) interface within a simulated environment comprising digital objects. The games mentioned in the articles by [PERSON] et al. [9], [PERSON] et al. [10], [PERSON] et al. [11], and [PERSON] et al. [12] are some examples of the use of VR in game creation for upper limb stroke rehabilitation that employ various hardware devices, including Leap Motion [9; 10; 11; 13], smart gloves (equipped with embedded sensors) with headbands [10], or an instrumented fork and knife with a 3D printed pressure pad, which measure and communicate information [11]. Closely associated with serious games are two critical factors: feedback and management of difficulty.