Creating a Joyful Therapeutic Experience with CogniviveVR



Strokes affect nearly 800,000 people per year in the United States alone. While most people survive a stroke, they are often left with life-changing neuromotor disabilities. Two classic examples of this are hemiparesis (weakness on one side of the body) and hemipelagia (paralysis of one side of the body).

These two conditions create obvious daily challenges for patients and severely affect their quality of life.

Fortunately, both conditions can be improved with regular therapeutic exercise. As patients practice these exercises, their brains re-establish proper control over their affected limbs, eventually allowing many patients to live independent lives.

Unfortunately, rehab exercises are often dull, demotivating, and extremely challenging. As a result, many patients don’t exercise enough, and their recovery slows or stops.


CogniviveVR was a virtual reality experience designed to help solve the problem of compliance with ideas borrowed from the gaming world. As Cognivive’s Chief Creative Officer, I was responsible for the entire product’s design and user experience.

Throughout the experience, our patient-players would regularly perform rehabilitation exercises disguised as game actions. By re-contextualizing the various exercise motions we removed the first two barriers to compliance: that the exercises were dull and unmotivating. CogniviveVR also featured a proprietary “Therapeutic Adaptive Difficulty System” which could learn about the patient’s cognitive abilities, and adjust the experience to fit. This system allowed CogniviveVR to always challenge the patient in an appropriate, therapeutically effective way, removing the third barrier to compliance. The entire CogniviveVR experience would be delivered to patients’ homes as a simple system of a VR headset, hand controllers, and a companion tablet. By making it an at-home therapeutic tool, we hoped to lower two more barriers to compliance: the cost and availability of quality therapists.

The finished demo of CogniviveVR featured 3 therapeutic activities designed by myself and our software engineer Joey Salisbury. After donning their headset, patients could switch amongst the 3 activities, or explore Crystal Cove Resort, the experience’s narrative setting which I designed. Patients also had the ability to visit Ronnie, the resort’s personal trainer, for a routine assessment of their physical abilities. The entire experience was also predicated by an interactive “Welcome to VR” sequence that allowed patients to become comfortable with VR before starting to use it regularly.

Design Principles

As the creative lead for CogniviveVR, I developed a list of “Design Do’s and Don’t’s” to guide our design process.

At the core of the list were two key design principles for any therapeutic activity in CogniviveVR: “Hide The Exercise” and “You Can’t Lose At Therapy”

“Hide the Exercise” meant that we should never ask the player to specifically do a therapeutic exercise. Since nearly all of the therapeutic exercises we covered in CogniviveVR involved the patient moving their hands in particular ways, that also meant we couldn’t ask the player to move their hand somewhere simply for the sake of it. We always needed to give the player a higher order task, such as hitting a ball or rotating a laser cannon with a joystick.

“You Can’t Lose At Therapy” reminded us to design game activities where the player’s success was as independent of their rehabilitation goals as possible. For example, an activity might challenge the player to remember ingredients for a recipe. This would have been appropriate since that kind of cognitive challenge was not a part of the player’s rehabilitation goals. Failing to complete the recipe challenge would not mean players failed their rehabilitation goals.

The idea behind these principles was simple: we wanted players to feel empowered beyond their disabilities. This would keep them motivated and excited to continue engaging with CogniviveVR’s activities much longer than if we tied their rehabilitation progress to any notion of “game progress”.

Activity Highlight: Rally Zone

The first activity patients could “play” (and the first activity we designed) was called Rally Zone. It was presented to patients as an arcade game in the resort’s lounge. In Rally Zone, players needed to hit a virtual ball with a racket and use it to break several neon-colored blocks in the distance, similar to a first-person Breakout. The goal of the game was to break all of the blocks in each level as fast as possible. The challenge of the game came from the fact that the player held the racket in their “affected” hand (i.e. the hand/arm the patient was working to improve through therapy). Thus, in order to hit the ball, the patient would have to move their injured arm with precision, which is a major goal of stroke rehab.

Where Rally Zone became truly compelling and an effective therapy tool was in the physics of the ball.

First, we adjusted the trajectory of the ball so it would always return to a place our Therapeutic Adaptive Difficulty System determined would be therapeutically beneficial. For example, if the system estimated that the player could only reach 4 inches past their shoulder, we might adjust the trajectory of the Rally Zone ball so it would pass the player roughly 4 inches away from their shoulder. By encouraging the player to reach toward the edge of their limited range of motion, we encouraged them to expand that range.

Second, we adjusted the trajectory of the ball off the racket so that it would always hit at least one block before returning to them. We then told the player that the ball could break more blocks before returning to them if they either hit the ball harder or hit it multiple times without missing. This “controlled trajectory” mechanic removed any risk of demotivating moments: if the player hit the ball they made progress towards their goal. It also encouraged two behaviors that were therapeutically beneficial for more advanced players: moving with speed, and moving with consistency.

Finally, we changed the physics of the ball so players only needed to touch it with their racket to put it into play, instead of striking it. This helped our most disabled players feel powerful without risking injury by wildly swinging their arm.

In concert, all of these mechanics made for an exciting, compelling experience that had patients performing arm extension exercises for 5-10 minutes at a time without complaint. In fact, most of the patients we interviewed claimed that it was the most fun they’ve had doing rehab exercises. At least one patient even found the experience “empowering”, claiming that it was the most she had felt able to use her affected arm in years.

Feature Highlight: First-Time User Experience

Through interviews with therapists and patients, we determined that the ideal at-home first time user experience would involve the user removing the headset from its box, powering it on, and donning it while in a seated position. This would allow users to begin using the device without the need for a home visit from a therapist. However, since the majority of its users were VR novices, it was important for CogniviveVR to have an onboarding experience that explained how CVR (and VR in general) works, in VR.

Here is a recording of a user going through the CogniviveVR first time user experience. The version shown here was created specifically for a trial Cognivive was organizing with one of our major healthcare partners. The production version would have skipped the brief segment thanking them for their participation. I created this entire flow, from the script, to sequencing the animations, to the design of the different environments and characters. Most of the assets were temporary for the trial.

We went through several iterations of this introductory experience, and decided to create something that explained important safety details outside of the narrative of the game, then transitioned the user into the game experience for the remainder of the tutorial. Removing the safety details from the game narrative made them seem more important, and helped keep explanations clear and precise. The out-of-narrative portion of the tutorial also taught users the gaze cursor control, which was to be our only non-diagetic control. Once the user transitioned into the narrative portion of the experience, they were introduced to several characters, who would explain how certain aspects of the game worked (e.g. basic world building and how to get around). The majority of this initial flow was designed to be as on-rails as possible, with several key interaction points to keep the user engaged.