Effects of multi-sensory virtual reality training on gait adaptability and somatomotor network remodeling in patients with stroke: a randomized controlled trial

OBJECTIVE: To investigate the effects of multisensory-integrated virtual reality (VR) training on gait adaptability and its regulatory mechanisms on the somatomotor network (SMN) in patients with stroke. METHODS: In this randomized controlled trial, 68 patients with stroke were allocated to a VR group (multisensory-integrated VR training) or a control group (conventional rehabilitation). Both groups received 30-minute sessions, 5 days/week for 4 weeks. The primary outcome was gait adaptability assessed by the Dynamic Gait Index (DGI). Secondary outcomes included the Timed Up and Go Test (TUGT), Berg Balance Scale (BBS), and Fugl-Meyer Assessment for Lower Extremity (FMA-LE). Functional near-infrared spectroscopy (fNIRS) measured resting-state functional connectivity within the SMN and task-evoked activation during stepping and obstacle crossing. RESULTS: The VR group showed significantly greater improvements than the control group in DGI total score (P = 0.010), TUGT (P = 0.005), and BBS (P < 0.001 ). fNIRS analysis revealed that the VR group exhibited significantly greater increases in task-evoked activation in the right posterior parietal cortex (PPC) and supplementary motor area (SMA) during stepping (P = 0.029 and P = 0.032, respectively), and in the right SMA during unaffected-limb obstacle crossing (P = 0.048). Resting-state functional connectivity analysis showed significantly enhanced connections within the SMN, including left SMA-right PPC and right PPC-left dorsolateral prefrontal cortex (DLPFC) (both P < 0.05). Correlation analyses revealed that increased right SMA activation during obstacle crossing was positively correlated with TUGT improvement (r = 0.590, P = 0.001), while enhanced right PPC-left DLPFC connectivity was positively correlated with DGI improvement (r = 0.403, P = 0.041). CONCLUSION: Multisensory-integrated VR training was associated with improvements in gait adaptability and balance in patients with stroke. The underlying mechanisms may involve enhanced activation in the SMA and PPC, along with changes in functional connectivity within the SMN and between the SMN and cognitive control networks. However, given that the significant improvements in DGI, TUGT, and BBS were not sustained under the most conservative assumptions about missing data, these findings should be considered preliminary and warrant confirmation in studies with lower attrition rates. TRIAL REGISTRATION: Chinese Clinical Trial Registry, ChiCTR2500111919 (retrospectively registered). Registered 7 November 2025. Available from https//www.chictr.org.cn (registration number ChiCTR2500111919). Protocol The full trial protocol is available from the corresponding author upon reasonable request.