Abstract
BACKGROUND: Physical inactivity remains a global health concern, with only one in 5 adults meeting combined aerobic and muscle-strengthening guidelines. Exercise interventions delivered through immersive virtual reality (IVR) offer a novel mode of delivery. Little is known about the clinical effectiveness or feasibility of exercise via IVR across population groups. A detailed understanding of clinical effectiveness and feasibility is required for clinicians to decide whether to include IVR in exercise practice. OBJECTIVE: The objective of this systematic review was to assess the clinical effectiveness of IVR interventions using aerobic or anaerobic exercise. METHODS: A systematic review incorporating meta-analyses was conducted. Searches were conducted across PubMed, Embase, Web of Science, and CINAHL from inception until January 6, 2026. Randomized controlled trials including participants with an acute health condition, chronic disease, history of reconstructive or restorative surgery, and older adults implementing IVR exercise and reporting clinical effectiveness outcomes were included. Random effects meta-analyses were conducted for between-group comparisons for clinical effectiveness outcomes, grouped according to comparator group activity (exercising/nonexercising). Risk of Bias was assessed using the Cochrane Risk of Bias 2 tool and the certainty of evidence with Grading of Recommendations, Assessment, Development, and Evaluation. RESULTS: Twenty-six trials with 846 total participants were included in this review, with 23 progressing to meta-analyses. Pooled analyses revealed a general trend for IVR, but no statistical differences with comparator intervention (exercising or nonexercising) for mobility and functional balance (exercising: standardized mean difference [SMD] -0.345, 95% CI -1.095 to 0.406; P=.29; nonexercising SMD -0.322, 95% CI -0.931 to 0.288; P=.22), functional leg strength (exercising: SMD -0.161, 95% CI -0.573 to 0.250; P=.33; nonexercising: SMD -0.351, 95% CI -1.750 to 1.049; P=.48), quality of life (exercising: SMD 0.036, 95% CI -0.444 to 0.516; P=.84; nonexercising: SMD -0.053, 95% CI -0.839 to 0.728; P=.80) or other outcome domains. Eighty percent of outcomes assessed were rated as "some concerns" (n=16) or at "high" (n=21) risk of overall bias. Grading of Recommendations, Assessment, Development, and Evaluation certainty grading was deemed to be "low" or "very low" for all outcomes. CONCLUSIONS: This systematic review incorporating meta-analyses provides initial evidence for the clinical effectiveness of IVR exercise interventions. This review differs from previous literature by systematically collecting and appraising evidence exclusively from IVR aerobic/anaerobic exercise interventions from across a variety of populations and settings, and including a broad range of clinical effectiveness outcomes. Initial evidence may suggest that IVR exercise does not seem to statistically differ from comparators for clinical effectiveness outcomes. However, high heterogeneity, substantial risk of bias among trials, and "low" to "very low" certainty in evidence reduce overall confidence in the findings. While these results indicate that IVR may be a viable option for the delivery of exercise, a more robust methodology in future trials is needed to properly verify findings and improve certainty. This will help to determine the real-world applicability of IVR exercise interventions for the improvement of health-related measures.