Background <p>While mirror neuron-based rehabilitation approaches demonstrate efficacy in post-stroke upper limb motor recovery. Crucially, whether sequential activation of sensory mirror neurons preceding motor mirror neurons enhances functional outcomes remains unsubstantiated. Furthermore, conventional protocols require auditory-controlled environments and sustained high-attentional engagement for optimal efficacy. This study proposes a novel integrated intervention incorporating somatosensory observation (SO) components into Graded Motor Imagery (GMI), augmented by virtual reality (VR) technology to enhance participant engagement and attentional allocation. This synergistic approach aims to potentiate sensorimotor cortical integration, thereby optimizing upper limb recovery trajectory and clinical outcomes in stroke patients.</p> Methods <p>Sixty patients were randomized into four experimental groups: the conventional GMI Group received standard graded motor imagery; the SO-GMI Group incorporated SO with GMI; the VR-GMI Group implemented GMI through virtual reality; and the VR-SO-GMI Group combined SO and GMI within a VR environment. All interventions followed a standardized 4-week protocol. Resting-state functional MRI (rs-fMRI) assessed neuroplastic changes at baseline and post-intervention. Upper limb functional recovery was evaluated using three validated metrics: Fugl-Meyer Assessment for Upper Extremity (FMA-UE), Action Research Arm Test (ARAT), and Modified Barthel Index (MBI), administered at treatment initiation, week 2 (mid-intervention), and week 4 (conclusion) to track therapeutic efficacy. The study flow diagram is Fig. 1.</p> Discussion <p>The purpose of this clinical trial is to observe the efficacy of increased SO in GMI on the recovery of upper limb motor function after cerebral stroke through a randomized controlled clinical trial, and to explore the clinical efficacy after implementing the above therapy using immersive VR technology, as well as to further investigate whether this research protocol can achieve the neurophysiological mechanism of “sensory-motor” linkage in the brain. This research method is widely applicable to patients with poor motor function and those with limitations in active movement. At the same time, VR technology allows for one-to-many training. At the same time, VR technology can conduct one-to-many training. This study aims to improve the efficacy of graded exercise therapy for upper limb rehabilitation in cerebral stroke and provide a new method that requires less physical effort, saves manpower, and has a wide range of applicability.</p> Trial registration <p>China Clinical Trial Registry ChiCTR2400084611. Registered on 21 May 2024.</p>