Participants in the control arm will receive conventional physiotherapy and rehabilitation exercises five days per week for six weeks, with sessions lasting approximately 60 minutes. The program includes:

Strengthening exercises for upper and lower extremities

Resistance training

Aerobic exercises

Basic and assisted parallel bar walking

Skill courses on different surfaces

Balance exercises on stable and unstable surfaces

Static and dynamic balance training

Fine motor skill exercises

Weight transfer exercises aimed at improving postural stability

Exercises will be tailored to individual patient capabilities and performed in various positions including standing, sitting, four-point kneeling, supine, and prone. The difficulty level will be adjusted based on patient performance and functional status.

Participants in the experimental arm will receive conventional physiotherapy and rehabilitation exercises five days per week for six weeks, each session lasting approximately 60 minutes. In addition to this, they will undergo immersive virtual reality (VR)-based music therapy sessions twice a week for 30 minutes per session over the same six-week period.

The VR therapy is administered under the supervision of a licensed physiotherapist using the Oculus Quest 2 headset. The intervention includes three main components:

Rhythm Exercises: Participants will engage in rhythm training by following clapping patterns streamed from the Brooklyn Music Factory YouTube channel, progressing from levels 1 to 4. During these exercises, participants clap their hands on a table to maintain the rhythm, which aims to improve motor coordination and timing.

PianoVision Application: A virtual piano that utilizes hand-tracking technology to allow participants to play without physical controllers. The pian

VR-Based Music Therapy Protocol:

Participants undergo immersive VR sessions twice weekly for 6 weeks, each lasting 30 minutes, supervised by a physiotherapist. Each session includes three 10-minute activities with 2-minute breaks:

Rhythm Exercises: Participants follow tempo by clapping on a table while watching Brooklyn Music Factory YouTube videos played within the VR headset (levels 1-4), progressing weekly.

Ocean Rift: Exploration of calming underwater environments with marine life to enhance relaxation, attention, and cognition.

PianoVision: Virtual piano exercises using hand tracking with the unaffected hand; difficulty increases from levels 0 to 4.

Cognitive function was assessed using the Montreal Cognitive Assessment (MoCA), a standardized screening tool for global cognitive functioning. The assessment was conducted face-to-face by a trained evaluator. The MoCA consists of tasks evaluating memory, attention, executive functions, language, visuospatial skills, abstraction, calculation, and orientation. Scores range from 0 to 30. Higher scores indicate better cognitive performance. A score of 26 or higher is generally considered normal.

Visual memory was evaluated using the Benton Visual Retention Test (BVRT), Form F, a standardized neuropsychological test that assesses short-term visual memory, visual perception, and visuoconstructive skills. In this version, participants were shown 15 geometric designs, each for 10 seconds, and were instructed to reproduce each design from memory immediately after viewing. Each figure was scored based on established accuracy criteria. The outcome measure was the total number of correctly reproduced designs, with scores ranging from 0 to 15. Higher scores indicate better visual memory performance. Increased errors may reflect difficulties in memory, attention, or visual-spatial processing.

Working memory was measured using the Digit Span subtest from the Wechsler Adult Intelligence Scale. The test consists of forward and backward repetition of digit sequences. Participants were asked to repeat sequences in the same order (forward) and reverse order (backward). Each correct sequence was scored, and the total score was recorded. Scores typically range from 0 to 30. Higher scores reflect greater working memory capacity.

Balance performance will be assessed using the Berg Balance Scale (BBS), a validated tool to evaluate static and dynamic balance in individuals with stroke. The BBS consists of 14 tasks related to postural control and risk of falling. Each task is scored on a 5-point scale from 0 to 4, with a total score ranging from 0 to 56. Higher scores indicate better balance and lower risk of falls. Assessments will be conducted at baseline and 6 weeks post-intervention to evaluate changes in balance following immersive virtual reality-based music therapy.

VR-induced sickness will be assessed using the Virtual Reality Sickness Questionnaire (VRSQ), a validated tool designed specifically for evaluating motion sickness symptoms in immersive virtual environments. The VRSQ includes 9 items categorized under two components: oculomotor symptoms (general discomfort, fatigue, eye strain, and difficulty focusing) and disorientation symptoms (headache, fullness in head, blurred vision, dizziness with eyes closed, and vertigo). Each item is scored on a 4-point Likert scale from 0 (none) to 3 (severe). Component scores are normalized to percentages and averaged to obtain the total score. Total scores range from 0 to 100, with higher scores indicating more severe VR sickness. The questionnaire will be administered immediately after the first VR session to evaluate tolerability and detect early side effects of immersive VR-based music therapy.