Effect of Virtual Reality-Based Music Therapy on Cognitive and Motor Skills in Subacute Stroke Patients

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.

Executive function was assessed using the Wisconsin Card Sorting Test (WCST), which evaluates cognitive flexibility and problem-solving. Participants were required to match cards based on undisclosed rules and adapt as the rules changed. The outcome measure is the number of correct categories completed. The maximum number of categories is 6. Higher scores reflect better executive functioning.

Motor function of the upper limb will be assessed using the Fugl-Meyer Assessment of Upper Extremity (FMA-UE), a validated and widely used scale in stroke rehabilitation. The FMA-UE evaluates reflex activity, volitional movement within and out of synergy, grasp, coordination, and speed. Scores range from 0 to 66, with higher scores indicating better motor function.

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.

Brunnstrom Staging is used to evaluate motor recovery stages in stroke patients, assessing movement patterns and motor control progression. This measure will assess motor function improvements following immersive virtual reality-based music therapy. Assessments will be conducted at baseline and 6 weeks post-intervention.

Spatial neglect will be screened using the Star Cancellation Test (SCT), a validated subtest of the Behavioral Inattention Test (BIT). Participants are asked to cancel 54 small stars among distractor stimuli on a printed page. The total score is based on the number of correctly cancelled small stars. Scores range from 0 to 54, with scores of 43 or below indicating the presence of spatial neglect. Lower scores indicate more severe neglect. The test will be administered to all participants at baseline. Participants who score ≤43 will be considered to have spatial neglect, and for these individuals the test will be repeated at 6 weeks to evaluate change. Participants who do not meet the cutoff at baseline will not be retested.

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.