Background <p>Virtual reality has received significant attention in clinical rehabilitation. Therefore, we developed a bilateral upper limb interactive game-based VR system for post-stroke rehabilitation of the upper extremities, and assessed its usability and clinical efficacy.</p> Methods <p>We carried out a usability test for this system within representative user groups. Then, the clinical efficacy was assessed through a randomized controlled trial, in which 22 patients with stroke received 12 sessions (4 weeks) of conventional physical therapy or bilateral upper limb synchronous training based on VR system in the clinic. The Wolf Motor Function Test-Functional Assessment Scale (WMFT-FAS), Fugl-Meyer Assessment for the Upper Extremity (FMA-UE), range of motion (ROM) of shoulder flexion, shoulder abduction, and elbow flexion, as well as bilateral temporal difference were recorded.</p> Results <p>The requirements for stroke rehabilitation were established and incorporated into this VR system. The usability test revealed high ratings for interest, perceived competence, value, and effort, contrasted by low levels of perceived stress. The clinical trial demonstrated that VR-based bilateral training yielded superior efficacy compared to conventional physical therapy, as evidenced by greater improvements in WMFT-FAS (<i>P</i> = 0.007; ηp² = 0.310), FMA-UE (<i>P</i> = 0.040; ηp² = 0.195), shoulder flexion ROM (<i>P</i> = 0.025; ηp² = 0.228), shoulder abduction ROM (<i>P</i> = 0.007; ηp² = 0.314), elbow flexion ROM (<i>P</i> = 0.019; ηp² = 0.245), and bilateral temporal difference (<i>P</i> &lt; 0.001; ηp² = 0.475).</p> Conclusions <p>The system is proven safe and effective for enhancing the function of the paretic upper limb and bilateral coordination in stroke patients.</p>