Stroke is a major cause of long-term disability worldwide, particularly in low- and middle-income countries (LMICs). Upper limb impairments following stroke can substantially limit an individual's ability to perform daily activities and engage in community life. Traditional rehabilitation approaches often require high levels of patient engagement and adherence, which can be challenging. Immersive Virtual Reality (imVR) systems offer a promising alternative by enhancing motivation and engagement, thereby supporting upper limb recovery. This study aims to assess the feasibility of the AdaptRehab imVR system in the Ethiopian context, providing valuable insights to guide the design of a future randomized controlled trial.

Background: Stroke represents a significant global health burden, affecting fifteen million individuals annually and causing over 5.5 million deaths worldwide. Fifty to eighty percent of stroke survivors experience upper-limb impairment. These disabilities may limit an individual's ability to take care of themselves, participate fully in social and community-related work, or engage in leisure activities leading to profound consequences.

New technology could be a potential solution to increase the provision of rehabilitation services despite the shortage of healthcare professionals, especially in LMICs. Amongst the different technologies, one of the most promising one, for stroke rehabilitation is immersive Virtual Reality (imVR). imVR has been shown to be effective in rehabilitation by reducing pain, accelerating recovery times, providing realistic environments, decreasing dependence on rehabilitation personnel, enabling increased treatment intensity and frequency, facilitating creative treatment delivery, standardizing therapeutic activities, and improving overall recovery outcomes. Key features include real-time feedback; customizable and adaptive environments enhanced motivation, safe and controlled environments, and multisensory stimulation including visual, auditory, and haptic feedback. Additionally, imVR facilitates essential repetitive exercises, with numerous studies demonstrating its effectiveness in stroke rehabilitation. Furthermore, recent studies have demonstrated the feasibility of implementing advanced rehabilitation technologies in LMICs, suggesting potential for significant enhancement of rehabilitation services in regions facing professional shortages. However, the implementation of imVR in healthcare, particularly for rehabilitation in LMICs, faces multiple significant challenges. These include shortage of rehabilitation services and technologies, existing imVR applications, primarily designed for HICs, often fail to address LMIC-specific needs and local technical realities such as cultural sensitivity issues, proprietary restrictions, and frequent technological updates. These challenges are compounded by limited research on effectiveness in LMIC contexts, and significant cultural and language barriers, as most systems are designed in English. In addition, currently there are no commercially available imVR solutions incorporating local cultural factors. This study is important as there is limited prior research on the specific intervention technique used and to consider the sociocultural health beliefs of the target population. The lack of data on the intervention in the particular context makes this study a significant contribution to the field. The study will offer important insights to guide the design and execution of a larger-scale randomized controlled trial by evaluating the effectiveness, usability, user experience cybersickness and acceptability of the AdaptRehab imVR system. Therefore, this study is objective is to conduct the feasibility study of the potential use of the AdaptRehab VR system for upper limb rehabilitation among stroke patients in Jimma, Southwest Ethiopia.

Specific Aims. (1) assess the usability of the Adapt imVR system, (2) To evaluate the user experience of the AdaptRehab imVR system,(3) examine the occurrence and severity of cybersickness associated with the AdaptRehab imVR system and (4) explore the acceptability of the AdaptRehab imVR system among patients and therapists and (5) evaluate the effectiveness of the AdaptRehab imVR system using upper-extremity outcome measures, including the Fugl-Meyer Assessment for the Upper Extremity (FMA-UE) , Action Research Arm Test (ARAT), and Box and Block Test (BBT).

Methodology. A mixed methods design approach will be used. The data will be included both quantitative and qualitative data. The quantitative includes upper extremity outcome measures, usability, user experience and cybersickness while qualitative will be the acceptability of the system using interview and focus group discussion. The proposed study's overall reporting and methodology adhere to CONSORT 2010 Extension for Pilot and Feasibility Studies (Non-Randomized). The study will be carried out in the physiotherapy clinic center of the Jimma University Teaching Hospital in Jimma, southwest Ethiopia. After reviewing their medical records and determining their eligibility, adults (age greater than 18) who present to the study setting with subacute and chronic, and those who consent to be contacted for research will be recruited. The therapists will collect the baseline data and post intervention data from the participants such upper extremity outcome measures, usability, user experience and cybersickness. Qualitative data will also be collected from all physiotherapists and nurses providing therapy services at the JUTH physiotherapy clinic to get their reflection on the proposed AdaptRehab VR system suitability and acceptability for stroke patients' upper limb rehabilitation. The sample size for this feasibility study is justified based on the estimated patient flow in the study context and the need to obtain sufficient data on the feasibility and acceptability of the intervention. The study plans to recruit 20 stroke patients over 3 weeks, considering a 15% non-participation rate and a 15% exclusion rate. Additionally, based on their consent, we will include all physiotherapists and trained nurses providing therapy services at the JUTH physiotherapy clinic.

Inclusion Criteria:

• Adults aged 18 years and older.
• Diagnosed with ischemic or hemorrhagic stroke.
• Stroke onset within the previous six months and more.
• Presence of upper-limb impairment.
• In the subacute or chronic stage of stroke recovery.
• Medically stable at the time of participation.
• Able to understand and follow instructions.
• Adequate cognitive and visual abilities to interact with the AdaptRehab im VR system.

Exclusion Criteria:

• Diagnosed severe cognitive impairment.
• Diagnosed significant visual impairment that interferes with imVR interaction.
• Presence of a severe psychological or psychiatric disorder.
• Any medical condition that would prevent safe participation in proposed AdaptRehab imVR
• Not medically stable or unable to safely engage in AdaptRehab imVR (example age).

Data on participants' usability, user experience, and cybersickness (primary outcomes), as well as FMA, ARAT, and BBT scores (secondary outcomes), will be shared upon request when needed.

The IPD and supporting information will be made available after publication of the study or for purposes related to publication.

The data may be shared with other researchers upon reasonable request, provided that the proposed use supports the advancement of scientific knowledge and aligns with the best interests of the study participants.