Targeting Cognition and Behavior Post-Stroke: Combined Emotional Music Stimulation and Virtual Attention Training in a Quasi-Randomized Study

<b>Background</b>: Emotionally salient music may enhance attention-focused rehabilitation, yet concurrent music plus virtual-reality programs in chronic stroke are largely untested. We assessed whether personalized emotional music stimulation (EMS) layered onto a standardized virtual reality rehabilitation system (VRRS) augments cognitive, affective, physiological, and functional outcomes. <b>Methods</b>: In a quasi-randomized outpatient trial, 20 adults ≥ 6 months post-ischemic stroke were allocated by order of recruitment to VRRS alone (control, <i>n</i> = 10) or VRRS+EMS (experimental, <i>n</i> = 10). Both groups performed 45 min of active VRRS cognitive training (3×/week, 8 weeks), while the EMS group received approximately 60 min sessions including setup and feedback phases. Primary outcomes were cognition and global function; secondary outcomes were intrinsic motivation, depression, anxiety, and heart rate. Non-parametric tests with effect sizes and Δ-scores were used. <b>Results</b>: The experimental group improved across all domains: cognition (median +4.5 points), motivation (median +54 points), depression (median -3.5 points), anxiety (median -4.0 points), heart rate (median -6.35 beats per minute), and disability (median one-grade improvement), each with large effects. The control group showed smaller gains in cognition and motivation and a modest heart-rate reduction, without significant changes in mood or disability. At post-treatment, the music group outperformed controls on cognition, motivation, and disability. Change-score analyses favored the music group for every endpoint. Larger heart-rate reductions correlated with greater improvements in depression (ρ = 0.73, <i>p</i> < 0.001) and anxiety (ρ = 0.58, <i>p</i> = 0.007). <b>Conclusions</b>: Adding personalized emotional music to virtual-reality attention training produced coherent, clinically relevant gains in cognition, mood, motivation, autonomic regulation, and independence compared with virtual reality alone.