Enhancing Extended Reality Technology for Neuromusculoskeletal Rehabilitation: Recommendations for the Development of Clinically Relevant Serious Games

<b>Background</b>: Although traditional rehabilitation methods are effective in promoting recovery for patients with disabilities, some approaches can involve repetitive tasks, making it challenging to maintain high patient engagement and adherence. This can impact the amount of therapy patients receive, which can sometimes limit their overall recovery potential, particularly given constraints in healthcare resources. Extended reality (XR) technologies, which include virtual reality (VR) and augmented reality (AR), offer promising benefits to personalize care and enhance rehabilitation and engagement by increasing motivation and engagement through interactive and immersive environments. Despite these promising advantages, their successful integration in clinical practice has remained limited, partly due to lack of early involvement of clinicians and end-users in the development process. <b>Objective</b>: We aim to provide recommendations for XR rehabilitation technology development, including researchers and industry professionals, to foster more personalized, adoptable and effective tools for patients with neuromusculoskeletal disorders in a clinical setting. <b>Methods</b>: Principles from motor control and game theory are used to describe key features and recommendations for XR rehabilitation technology development to optimize rehabilitation applications in a clinical setting. These recommendations stem from established motor learning and game design principles, a state-of-the-art narrative review of emerging XR rehabilitation literature (2015-2025) and insights from the Ensemble! Program, a living lab where clinicians, researchers, and patients collaborate to explore emerging technologies, including but not limited to serious games using XR technologies. <b>Results</b>: Key design recommendations include strategies for supporting patient motivation, adjusting game difficulty, providing feedback and handling data collection. <b>Conclusions</b>: Integrating motor control and game theory principles into XR rehabilitation technology can help optimize its therapeutic effectiveness and clinical applicability for patients with neuromusculoskeletal conditions. By addressing clinician and patient needs early in the development process, these technologies can be better tailored to meet therapeutic goals and facilitate broader adoption in clinical practice.