Background: Extended Reality (XR) holds significant potential for advancing rehabilitation practices. However, its ability to enhance the Therapeutic Alliance (TA)—a fundamental element of effective therapy—remains underexplored. This study investigates how co-design with healthcare professionals can inform the creation of an XR system that incorporates key themes of the therapeutic alliance, including communication, collaboration, and connectedness, to improve rehabilitation outcomes.
Methodology: Co-design workshops were conducted with qualified and student occupational therapists and physiotherapists to design and evaluate an XR rehabilitation system. Participants were required to have clinical experience working with brain-injured patients, ensuring their insights were grounded in practical expertise. A pre-existing prototype was used, enabling the real therapist to exist in the virtual environment alongside the patient. This prototype served as the foundation for discussions and roleplaying therapy scenarios, allowing participants to explore its features, offer real-time feedback, and engage in collaborative ideation to refine the system. AI tools supported participant ideation during the workshops, enabling the rapid generation of concepts and possible system features. Discussions centred on identifying features that could enhance connectedness, strengthen the therapist-patient partnership, and foster safety and confidence within the virtual and real-world environment.
Results: Key design insights emerged, emphasising the need for a patient-centred system that can adapt to individual needs. Participants highlighted the value of utilising passthrough technology for safety and enhancing communication through features such as gestural feedback and guidance in the virtual environment. The prototype's ability to support rapport and empathy by allowing the real therapist to interact directly with the patient in the virtual space was highlighted as a significant advantage. Features such as real-time feedback, agreement on tasks and goals, and personalised activities were identified as crucial for building trust. Themes of communication, collaboration, and safety were consistently recognized as critical to reducing perceived disconnect between therapists and patients and fostering active engagement.
Conclusion: This research underscores the value of co-design in developing XR tools for rehabilitation, prioritising the therapeutic alliance. By embedding adaptability, collaboration, and safety into XR design, this study contributes to the advancement of immersive rehabilitation technologies tailored to real-world clinical practices.

• https://journals.sagepub.com/doi/full/10...