Feasibility, acceptability, and preliminary efficacy of AdaptRehab VR, an immersive virtual reality system for upper limb stroke rehabilitation: A mixed-methods study in Ethiopia

: Stroke is a leading cause of long-term disability, with a disproportionate burden in low- and middle-income countries (LMICs), where upper limb impairment emerges as one of its most prevalent and debilitating consequences. Upper limb impairment significantly limits independence and community participation, and this makes rehabilitation a critical priority. While conventional therapy is essential, its effectiveness is often limited by challenges in patient engagement and adherence. To address these barriers, immersive virtual reality (imVR) offers a promising modality for enhancing upper limb rehabilitation. This study examined the feasibility, acceptability, safety, and upper extremity outcomes of the AdaptRehab VR system in Ethiopia with the aim of informing future randomized controlled trials. A mixed-methods design was used, including quantitative assessments of upper extremity function, usability, user experience, and cybersickness, alongside qualitative interviews and focus group discussion (FGD). The study was conducted at Jimma University Teaching Hospital, Ethiopia, and enrolled 20 adults aged ≥18 years with subacute or chronic stroke. Eighteen participants completed nine AdaptRehab VR sessions over three weeks. Physiotherapists collected baseline and post-intervention data. In addition, 18 participants (interview) and 6 physiotherapists (FGD) provided qualitative feedback. The study followed CONSORT guidelines for pilot and feasibility studies. Feasibility was excellent, with 93% adherence. System Usability Scale scores indicated good usability (mean 76.2 ± 12.1). User Experience Questionnaire ratings were positive across attractiveness (1.92 ± 0.84), pragmatic quality (1.78 ± 0.79), and hedonic quality (1.84 ± 0.81). Cybersickness was minimal, with mild transient symptoms (sweating: n = 6; fatigue and headache: n = 3). Significant improvements were observed in the Action Research Arm Test (33.0 ± 13.2 to 48.6 ± 13.1, p