Most virtual reality rehabilitation of balance and mobility studies about persons post-stoke report body function structure and activity level outcomes of the International Classification of Function. Only a few investigators have reported participation outcomes. Patient-centered approach to incorporating video games into the plan of care would require the use of participation outcomes. The purpose of this double-blind randomized controlled pilot study was to explore the use of the participation outcomes, both to customize the therapy for the participants and to measure patient-relevant outcomes. Methods: Persons in chronic phase post-stroke with residual balance and mobility deficits were randomized to a standard of care (SOC) or Video game-based balance group. An assessor blinded to group assignment measured the activity level measures of the Dynamic Gait Index and gait speed as well as the balance confidence (Activity Balance Confidence Scale: ABC) and participation using the Canadian Occupational Performance Measure (COPM). Therapy was provided for 12 one-hour sessions (3 times a week for 4 weeks). The sessions consisted of a warm-up, sitting balance, standing balance, and choice activities. The video game-based balance group used the Wii sports, Wii Fit, and Wii Active games. Data were analyzed using a 2 (group) × 3 (time) RM Anova with an alpha level set at.05 and adjusted for the time comparison. Emphasis of the analysis was on the within group comparison. Because it was a pilot study, the outcome variables were assessed for clinical meaningfulness with the MDC or MCID within groups. Results Participants in both groups improved their DGI score, the video-based group at follow up and the SOC group at both post and follow-up. Both groups improved their gait speed and retained it at follow-up. The SOC significantly increased the ABC at post but did not retain it at follow up. Both groups improved the beyond the MDC of 10 points on the ABC at follow-up. Both groups improved on COPM performance at post and follow up, both exceeded the MDC of 1.7 points. Only the SOC group had statistically significant clinically meaningful improvements for satisfaction on the COPM both at post and follow up. There were no between group differences for the variables. Conclusion Both groups improved in balance performance and self-efficacy as well as mobility and COPM performance Standard of care, which allowed for greater customization to their participation goals resulted in improvements on COPM satisfaction with participation goals, while the video game based group did not.