A Review of Virtual Reality Technology
in Exercise Training for Older Adults
Louise P P Chan, Ying Cheng, Jamie Y H Ng, Zongji Zheng and Gladys L Y Cheing*
Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hong Kong
Submission: December 17, 2021; Published: February 04, 2022
*Corresponding author: Gladys LY Cheing, Department of Rehabilitation Sciences, The Hong Kong Polytechnic University, Hung Hom, Kowloon, Hong Kong
How to cite this article: Chan LPP, Cheng Y, Ng JYH, Zheng Z and Cheing GLY. A Review of Virtual Reality Technology in Exercise Training for Older
Adults. J Endocrinol Thyroid Res. 2022; 6(4): 555694. DOI:10.19080/JETR.2022.06.555694
Regular physical activity has profoundly positive impact on an individual’s physical and mental wellbeing. Older adults are recommended to engage in moderate-intensity physical activity for at least 30 minutes per day, and for three or more days per week. However, older adults may encounter various barriers which may lead to poor exercise compliance. In recent years, virtual reality (VR) technology has become increasingly popular in healthcare settings, with the aim to improve physical function, cognitive abilities, and mood in older people with chronic diseases. VR-based exercise may improve self-motivation in performing exercise, increase social interaction, and reinforces older adults’ compliance to exercise training. The aim of this review is to evaluate the effectiveness of VR exercise and the potential advantages of incorporating VR-based rehabilitation for the aging population.
The global elderly population of over 80-year-old has been estimated an increase from 126.5 million to 446.6 million between 2015 to 2050, more than doubling in this period . Aging is the accumulation of changes over time in physical, psychological, behavioural, and social processes. It is a degeneration process that results in deterioration in body functions, which leads to an increase in risk of developing more than one chronic disease and thus an increased mortality rates . Fall is one of the major health risks in older adults, which negatively impact their quality of life and it imposes a huge economic burden on the health-care system . Maintaining muscle strength, gait stability, and balance control are vital for improving health and reducing risk of falls in older people especially for those with chronic diseases.
Regular exercises can improve general health status in older adults. It can not only improve their immune system and bone density but also have better control over their blood pressure and reduces the risk of developing cardiovascular disease [4-6]. Regular exercise can also build up muscle strength, improves flexibility, postural control, coordination, and balance, thus reduce risk of falling . These benefits are particularly true for people with chronic diseases. For people with diabetes, common complications include peripheral neuropathy in the lower extremities, decline in balance performance and deterioration of the vestibular system, in which these factors increase their risk of falls . Studies have shown that regular physical activity produces modest increments in physical fitness of diabetic subjects and reduces the risk of overall mortality twofold. Hence, physical activity should be an essential part of diabetes management to maintain optimal blood glucose, lipid, and blood pressure levels [8-10]. In terms of exercise protocols, studies have shown that a combination of aerobic and resistance training is more effective for blood glucose management as compared to either type of exercise alone .
Regular exercise is of paramount importance to older adults , however, many of them encounter difficulties in maintaining regular physical activity, especially when the benefit of exercise is not visible within a short period of time. The common barriers for older adults to adhere to regular exercises include low self-efficacy, lack of motivation, depressed mood, lack of interest, fear of falling, unsafe environment, personal health, physical ability, low expectations, socioeconomic status, inconvenient location, and inability to choose the correct type of exercise [11-14]. There are various strategies that can be adopted to improve exercise compliance in different client groups. Lee et al. suggested several strategies to increase self-efficacy, which includes performance accomplishments, vicarious learning, verbal encouragement,physiological and affective status; in which these can initiate and maintain a positive physical activity behaviour .
Nowadays, virtual reality (VR) games are not only confined
to the younger generations. There is a developing interest in
older adults to attend VR-based rehabilitation program, which
could potentially improve their exercise adherence . The use
of VR games with stereo televisions may enhance interaction
and networking with their peers and increase enjoyment and
satisfaction. Such technology could serve to promote healthrelevant
activities whilst encouraging social engagement and
interaction, which thereby induce a positive attitude and behaviour
change . Another study showed that stroke survivors with
limitation in activities of daily living can improve upper limb
function by videogame-based training using VR technology .
However, this study has been excluded due to the enrolment of
participants under the age of 65, which did not fulfil the inclusion
criteria of the present review.
Exergaming is the term used for video game that can also
be used as a form of exercise. It utilizes a VR environment to
improve general physical fitness and for therapeutic purposes
such as cardiac rehabilitation and neurorehabilitation. This
could potentially bridge the gap between gaming and exercising,
encouraging participation in physical activity. It also provides a
real-time personalized virtual support from coaches and peers to
improve behavioural adherence . Depending on the targeted
body movements, the resulting energy expenditure of exergames
commonly varies from light to moderate .
VR holds great potential in enhancing treatment fidelity and
offers an exciting aid in accelerating and sustaining behavioural
change. As compared to VR, the immersive experience in
augmented reality (AR) might further engage participants in the
treatment process. In addition, the VR/AR environment provides
an enjoyable experience for participants through personalized
treatment program, which also encourages engagement in the
intervention and offers unparalleled opportunity to enhance
treatment enactment [18, 20]. On the other hand, the combination
of training with VR not only induces benefits that conventional
physical training has, but also provides immediate feedback that
can facilitate motor learning and maximize therapeutic benefits.
This can encourage patients to overcome their own limits in the
pursuit of better performance . Therefore, VR rehabilitation
programmes can be conducted in line with current best practice
for balance training in falls prevention [19,22].
The benefit of exercise is well-documented and has extensive
evidence to support the effectiveness of VR exercises in improving
physical, psychological, and social aspects of older adults .
Our mini review aims to summarize studies that evaluated the
effectiveness of VR exercise in specific aspects including balance,
mobility, cognitive function, mood and self-motivation, quality of
life and social life in older adults.
Randomized controlled trials that implemented virtual reality
interventions in older adults’ rehabilitation were retrieved from
seven electronic databases including healthcare related and
psychological databases: CINAHL, EMBASE, MEDLINE, PubMed,
Web of Science, Scopus and PsychINFO databases. Timeframe was
set from 2000 to 2020, and the following search strategies were
used: “Exercise” AND “Virtual reality” AND “Senior Adults” OR
“Elderly” OR “Older Adults”. An advanced search was conducted
by adding key terms such as “Chronic diseases” OR “Diabetes”.
Studies that targeted older adult population (individuals over the
age of 65 years old), published between 2000 and 2020 and in
English with full text available are included. Studies that did not
fulfill inclusion criterion and any duplicates from search were
A total of 14 studies (4 RCTs, 1 cross-sectional study, 1 pilot
study and 8 quantitative studies) were selected for the purpose
of this review. Three studies investigated the effects of exercise in
older adults [4,24,25]; four studies examined the effects of virtual
reality in the elderly cohort [7,20,26,27]; two studies explored
the benefits of VR in obese/overweight individuals [16,18]; three
studies illustrated the use of VR in other patient cohorts including
Parkinson’s, stroke, and haemodialysis patients [21,22,28]. Two
studies evaluated the effectiveness of virtual reality in diabetic
patients [9,10] (Figure 1).
Outcome measures have been categorized into five domains,
including reduced falls risk and improved balance, mobility
performance, enhanced cognitive function and social life. The
study design, sample size calculation, outcome measures, and
results are presented in Table 1.
Aging and diabetes complications are common risk factors
of falls. Falls can be caused by reduced muscle strength or
muscle atrophy, which results in declined functions in the lower
extremities. Jin et al.  proposed a multi-barycentric area model
(MBAM) to examine human balance capacity based on visual
stimulation under VR environment. This model describes body
balance condition by computing center of gravity using a triangle
area surrounded by upper, middle, and lower parts of the body. The
analysis of projection coordinates from the triangle can provide
objective measures of balance dysfunction and therefore a more
accurate data on an individual’s balance ability. This proposed
research has provided valuable results for future investigations in
adopting such classification in patients with balance dysfunction
and potentially applicable to an extensive cohort of patients such
as stroke and multiple sclerosis individuals. VR-based exercise
can be easily translated into appealing, easy applicable, and potentially cost-effective videogame-based training regimes or
intergenerational balance training targeting falls prevention in
older adults [4,10,19,22].
In recent years, VR technology plays an important role in
exercise training of balance performance. Findings showed that
playing VR games can improve Berg Balance Scale (BBS) scores
and extend the stability limits of institutionalized and frail
older adults with history of falls [6,12,20,22]. Video games are
considered as a new nonmedical intervention for elderly, allowing
them to maintain good health conditions by engaging in regular
physical and cognitive exercises [20,26]. The use of VR games is
not only limited to the older adult population, but it is also evident
that fully immersive VR training systems can also bring positive
impact to cardiovascular and muscular parameters in young
healthy population . Many studies have examined the potential
benefits for VR amongst older population and has concluded the
implementation of VR in balance training to be effective for falls
Sensory inputs are essential for initiating any movements,
in which VR exercise provide an opportunity to integrate motor
and sensory system to interact with video-game based exercise.
The reaching component can be used to assess an individual’s
ability to move through the entire range of their body. Upperlimb
sensorimotor function can be assessed using visually guided
reaching, as it requires input from both sensory and motor system.
This can improve the full spectrum of physical functioning, from
finest finger motions to gross movements involving the whole
Mocanu et al  proposed a smart home platform to enhance
mobility in older adults, using two core components, namely
Physical Activity Training (PAT) and Vital Signs Monitoring (VSM).
This platform is designed to tackle the major barrier to physical
activity in older adults that is adherence to exercise program. The
purpose of PAT is to monitor individual’s movement during physical
activity. It computes the joint’s relative positioning error, which
will then provide immediate visual feedback and guidance for
correction. VSM offers an online platform for medical professionals
to monitor individual’s condition, medication, and treatment plan.
These two components together create a holistic approach for
patient care. This study has concluded positive feedback, where
users have reported system to be very personalized and have
commented that these features have increased their motivation
and enhanced their mobility . Similarly, in another study that
explored the effectiveness of Online-Gym concluded consistent
results, where specifically found improved hand-eye coordination
and delayed onset of memory decline in older adults.
Hsieh et al.  conducted a study to explore the cognitive
and physical effects of VR-based Tai Chi program on older adults
with cognitive impairment. Exercise regimes consist of tasks that
progressively gets more complex and covers essential activity
of daily living. Outcome measures used in this study assessed
both cognitive and physical components; including 6-min walk
test, 30-s sit-to-stand test, functional reach, 5m / sec gait speed,
abstract thinking, and judgment. The VR-based Tai Chi group
showed significant improvement in these assessed components,
demonstrating a positive effect on their level of fitness.
Virtual environment utilized in a video-game setting could
educate patients regarding lifestyle management, medication,
and nutrition in addition to physical activity. This addresses both
cognitive and physical elements of rehabilitation . Crossing
road, for example, it provides an opportunity for user to navigate
through virtual scenes to mimic everyday life under a controlled
environment. Extensive evidence has demonstrated that VRbased
exercise enhances cognitive function in older adults. Hsieh
et al  have also explored the effects of VR-based Tai Chi exercise
program on cognitive function of older adults. The VR-based Tai Chi exercise showed a protective effect for cognitive and physical
functions in older adults with cognitive impairment.
The more engaging the program, the greater extent of physical
and cognitive improvement elicited. The exercise program was
delivered twice weekly for 6 months. The duration of each training
session varied from 20 to 120 minutes; the frequency varied
from 1 to 4 times per week with the overall training program
lasted for 4 weeks to 1 year. Participants attended two sessions
of 45–60-minute training weekly, in which results have shown
significant improvements in balance but no change in lower
extremity endurance after three months of VR intervention. It is
important to take note that it took at least six months to obtain
significant protective effects for other assessed components, such
as cognitive function, cardiopulmonary endurance, and mobility
function. Therefore, the overall duration of exercise program is
recommended to last for at least 6 months to achieve all potential
cognitive and physical benefits .
VR-based exercise and social media have been proposed to be
promising strategies in increasing users’ motivation and thus their
willingness to practice. Research have suggested social media
can help overcome boredom and spark the desire to continue
physical activity. Family members and friends can share their
experience and enjoyment on social media platform, specifically
aiming to encourage inclusion of elderly population. Regular
physical activity can also improve sleep quality by increasing
sleep duration, and thus wake up feeling more energetic and
refreshed . Interactive VR games and exercises has opened a
new horizon for community dwelling older adults to explore and
to foster positive health attitudes.
Research has found that elderly people walk at a slower speed
and tire more quickly owing to the loss of strength and mass in
lower extremities. Slow walking speed not only correlates with
adverse health outcomes, but it also increases the risk of traffic
accidents for older people walking in urban areas. Therefore,
VR exercises may incorporate appropriate functional training
targeting pedestrian safety to reduce risk of traffic accident.
Eggenberger et al  conducted a cross sectional assessment
on walking speed and has observed inadequate fitness level in
majority of community-dwelling older patients, putting them at
risk at crossroads. This study has suggested training measures
aiming to improve elderly population’s cognitive and physical
fitness, has positive impact on their walking speed, mobility, and
VR has been proven to be an effective strategy in therapeutic
programs. Combining exercise training with VR technology
enables playful, interactive work and accurate feedback,
facilitating patient’s interest and probable adherence to treatment
program . Simulating outdoor activities and travelling abroad in VR environment seem to be appealing to older adults who
have physical and/or financial limitation. VR cycling, for example,
spatial navigation while cycling is now feasible and that older
adults have reported similar enjoyment as to younger adults. This
technology can continuously motivate older adults to engage in
exercises by progressing into different VR scenario, based on their
performance and ability .
Maynard et al.  reported VR training therapy can minimize
depressive symptoms. VR training reinforces goal achievement
by providing real-time and objective feedback, in which the
discrepancies between current performance and targeted goals
can be visualized. The application is customized to facilitate
accountability and social support from coaches and peers for
self-monitoring . Some of them expressed their motivation
to maintain regular exercise is to stay fit for their favourite sport
or for keeping up with their grandchildren . The goal is to
maximize older adults’ level of independence in activities of daily
living, which therefore enhance their quality of life.
Group exercise seems to be a better alternative as compared
to doing it alone, since people may feel more supported and
motivated when exercising with peers. During VR exercise, older
adults can fully immerse into the virtual environment; this can
increase their level of motivation and arousal, which enhances
their performance as well as their adherence to exercise program.
Various studies have demonstrated VR exercise to be effective in
reducing the risk of falling, through the improvement of frailty
indicators, which can subsequently promote social participation.
Therefore, it appears to be interesting in evaluating whether
the customization of avatars’ characteristics, perhaps through
a reward mechanism, enhances older adults’ participation and
engagement in physical activity .
Dancing has a dual task character, which potentially stimulates
physical and cognitive functions simultaneously. The RCT
research proposal hypothesized that dancing has superior effect
on improving executive function (e.g., memory, flexible thinking)
as compared to physical exercise alone or through exergaming,
however there is no evidence available so far . Combining
exercise with socialization can make a difficult task easier; it has
been shown that older adults who perform physical activity with
peers or in groups tend to have better exercise compliance. They
enjoy having conversations whilst exercise and that they may
perceive time goes by quicker than usual.
Aging often leads to various health problems and that can
reduce social engagement and have an impact on individual’s
mental wellbeing. There are many barriers to physical activity in
older adults, which by far, lack of interest is the major factor. It is
therefore essential to find innovative methods to motivate older
adults to participate in exercise program. VR-based exercise may
potentially be a solution to this barrier, as it has been proven to
encourage older adults’ self-motivation. This review has evaluated
the effectiveness of VR-based exercise in improving balance,
mobility, cognitive function, mood and self-motivation, quality of
life and social life in older adults. VR exercise training may also
contribute to improvement in emotional and social well-being of
older adults. Exercise program usually last for 8 weeks or longer,
where the dropout rate is usually high owing to low compliance.
With the implementation of VR technology, exercise program is
more enjoyable and older adults are more likely to adhere to it.
VR-based exercise program may also promote physical activities in
older adults with chronic diseases, where improvement in physical
and cognitive function can allow them to live more independently.
This review has highlighted encouraging findings from previous
VR-based exercise studies, but a limited number of randomized
controlled trials has been conducted on the therapeutic effects of
VR-based exercise in people with chronic diseases. More rigorously
designed methodology with standardized interventions, larger
sample size and multi-centred randomized controlled trials
are needed to provide stronger evidence to verify the potential
advantages of VR-based exercise .
Older adults are recommended to engage in moderateintensity
exercise, including muscle-strengthening activities of
all major muscle groups for at least 30 minutes, three days per
week [14,19,22,33]. Typical exercise training includes progressive
weight training programme, weight bearing calisthenics, stair
climbing and other strengthening exercises. Stretching exercise is
also recommended to be conducted twice a week. Note that the
above recommendations on physical activities should be adjusted
accordingly depending on the individual’s ability. Particular
attention should be paid to elderly with chronic diseases, such
as diabetes, hypertension, osteoarthritis, osteoporosis, and
cardiovascular diseases. Recently, Lee & Shin  found that
VR exercise program for older adults with diabetes elicited
significant improvement in muscle strength, gait, balance and falls
efficacy. Interactive video gaming and VR gaming provided new
platforms for the delivery of exercise programs . Colberg et
al.  reported people with diabetes who performed resistance
or aerobic exercise alone have improved their overall glycaemic
control. However, for subjects who undergone a combination
of aerobic and resistance training, they demonstrated a more
effective glycaemic control and a significantly lower HbA1c value
as compared to those who performed either type of exercise alone
While this mini review has established the physical, mental,
and social benefits of VR-based exercise on older adults, some
older adults find it difficult to adhere to physical activity, especially
when the benefit of exercise is not visible within a short period
of time. Exergames make use of VR to create an ecological and
controlled environment specifically designed to challenge users.
VR is interactive and immersive, which makes physical activity
more appealing and more enjoyable for users [21,26]. It provides real-time visual feedback to allow self-correction of motion, which studies have documented valuable therapeutic effects in
balance rehabilitation. It has been concluded that exergame has
the potential in increasing adherence to treatment and enhancing
exercise compliance in older adults [3,20,22].
Furthermore, the use of VR chart to record metrics and track
progress of training is helpful by providing quantitative results
for older adults, which may encourage them to work harder
and prevent drop-outs due to perceived lack of progress. The
implementation of novel technology may increase their level of
arousal and motivation and motivate them to maintain active
lifestyle. In addition, by avoiding the same exercise routine can
reduce boredom. User will receive positive visual reinforcement
when correct task achieved and this can often intensify the
connection between enjoyment and exercise. VR cycling, for
instance, may encourage participants to cycle with peers whilst
enjoying the stimulated scenarios displayed on the VR system.
Various interventions have been explored to improve exercise
adherence in older adults; it has been concluded that more
feedback and monitoring would promote exercise adherence .
VR-based exercise also makes good use of visual and auditory
feedback, and these can be useful strategies in encouraging older
adults to adhere to physical activity. Future studies can examine
whether VR-based exercise can improve exercise compliance for
older adults to consolidate this statement.
Virtual reality-based exercise is an interactive and innovative
technology to be implemented into exercise program for older
adults. Performing exercise with peers through competitive
VR games may increase their motivation and satisfaction and
therefore increase their exercise compliance. VR exercise can
improve balance and mobility that may subsequently reduce the
risk of falls. In addition, VR exercises also have a positive impact
on cognitive function, quality of life, mood and self-motivation and
social life. All the above highlighted positive impact of VR exercises
is especially beneficial for older adults with chronic illnesses.
Optimized physical health is vital for maintaining independence
and quality of life for older adult in this aging population.