Stroke Rehabilitation Using Extended Reality.

Stroke is a leading cause of long-term disability worldwide. Many individuals living with chronic stroke experience persistent impairments in motor function, balance, gait, activities of daily living (ADL), and health-related quality of life. Effective rehabilitation requires intensive, task-specific, and repetitive practice; however, maintaining motivation and adherence to conventional rehabilitation programs can be challenging.

Extended Reality (XR) technologies have emerged as promising tools in rehabilitation. XR-based training can provide structured, repetitive, and individualized exercises while incorporating interactive holographic elements into the rehabilitation process. The exercises can be adapted to each participant's abilities and rehabilitation goals, and the level of difficulty can be adjusted according to individual performance and progression.

The Stroke Rehabilitation with Innovative Extended Reality (STRIVE) program was developed to provide a structured XR-based rehabilitation intervention for individuals with chronic stroke. The intervention utilizes the RehAtt XR system and includes exercises targeting upper extremity function, lower extremity function, balance, gait performance, and functional activities.

The primary aim of this study is to investigate whether XR-based rehabilitation, based on established virtual reality rehabilitation principles, can influence motor function, balance, gait performance, activities of daily living, and health-related quality of life in individuals living with chronic stroke. A secondary aim is to explore participants' experiences of using and training with XR technology and to evaluate the feasibility of implementing the intervention in routine clinical practice.

The study uses a Single-Case Experimental Design (SCED) in which each participant serves as their own control. During the baseline phase, repeated assessments will be conducted without XR training to establish the stability of outcome measures and capture natural variation in performance. The baseline phase will last between 1 and 3 weeks and include a minimum of 5 and a maximum of 9 assessment points. Following baseline, participants will receive XR-based rehabilitation for 5 weeks. Outcome measures will continue to be collected three times per week throughout the intervention phase, with assessments performed prior to each XR training session to explore potential changes in physical function, activity performance, participation, and quality of life. The findings will provide important information regarding the feasibility and potential benefits of XR-based stroke rehabilitation and will inform the design of future larger-scale studies.

• RehAtt XR System (Device): Participants will receive XR-based rehabilitation using the RehAtt XR system. The intervention consists of individualized exercises targeting upper extremity function, lower extremity function, balance, gait, and functional activities. Training will be delivered three times per week for five weeks following a baseline phase with repeated assessments. Exercise difficulty will be adjusted according to each participant's abilities, performance, and rehabilitation goals.

Primary outcomes

• Fugl-Meyer Assessment Lower Extremity (FMA-LE) [Baseline(5,7,9 assessments over 1.5-3 weeks before the intervention,randomly assigned to each participant). 3 times per week during the 5-week intervention(assessments conducted before XR training). At 3 and 6 months after completion of the intervention.]: Assessment of lower extremity motor function following stroke. Scores range from 0 to 34, with higher scores indicating better motor function.
• Action Research Arm Test (ARAT) [Baseline(5,7,9 assessments over 1.5-3 weeks before the intervention,randomly assigned to each participant). 3 times per week during the 5-week intervention(assessments conducted before XR training). At 3 and 6 months after completion of the intervention.]: Assessment of upper extremity activity capacity and manual dexterity. Higher scores indicate better upper limb function.
• Timed Up and Go Test (TUG) [Baseline(5,7,9 assessments over 1.5-3 weeks before the intervention,randomly assigned to each participant). 3 times per week during the 5-week intervention(assessments conducted before XR training). At 3 and 6 months after completion of the intervention.]: Assessment of functional mobility. Time required to stand up from a chair, walk 3 meters, turn, return, and sit down. Shorter times indicate better mobility.
• 10-Meter Walk Test (10MWT) [Baseline(5,7,9 assessments over 1.5-3 weeks before the intervention,randomly assigned to each participant). 3 times per week during the 5-week intervention(assessments conducted before XR training). At 3 and 6 months after completion of the intervention.]: Assessment of walking speed over a 10-meter distance. Higher walking speed indicates better gait performance.

Secondary outcomes

• Barthel Index [Assessed at four time points: the initial baseline assessment, immediately post-intervention, and at 3 and 6 months following completion of the intervention.]: Assessment of independence in activities of daily living. Higher scores indicate greater independence.
• RAND-36 [Assessed at four time points: the initial baseline assessment, immediately post-intervention, and at 3 and 6 months following completion of the intervention.]: Assessment of health-related quality of life across multiple domains. Higher scores indicate better perceived health status.

Other outcomes

• Participants' Experiences of XR-Based Rehabilitation [End of intervention, 3-month follow-up, and 6-month follow-up.]: Semi-structured individual interviews will be conducted to explore participants' experiences of XR-based rehabilitation and changes over time. The interview guide will explore experiences of XR-based rehabilitation, including perceived benefits, challenges, motivation, fatigue, and the impact of the intervention on everyday life.

Sex: All, ages: 18 Years to any

Inclusion Criteria:

* Adults (≥ 18 years) with a verified stroke diagnosis at least six months ago

  * Sufficient cognitive ability MMES (mini mental state examination) ≥ 23
  * Continued need for rehabilitation
  * Ability to walk at least 10 meters, with or without aids
  * Be able to read, understand and express themselves in the Swedish language.

Exclusion Criteria:

* • Serious vision problems that would affect the use of XR equipment

  * Other progressive or serious illness such as multiple sclerosis, Parkinson's disease, dementia or cancer
  * People with epilepsy or pacemakers