STRENGTHS AND LIMITATIONS OF THIS STUDY
This review will be among the first to focus exclusively on virtual reality-based telerehabilitation (VR-TR) for Parkinson’s disease, distinguishing remote VR delivery from clinic-based VR and other TR modalities.
The protocol follows Preferred Reporting Items for Systematic review and Meta-Analysis Protocols and the Cochrane Handbook; it is PROSPERO-registered, uses dual independent screening/extraction, Cochrane Risk of Bias Tool V.2.0/Risk Of Bias In Non-randomised Studies Of Interventions (ROBINS-I) for risk of bias and Grading of Recommendations Assessment, Development and Evaluation with ‘Summary of Findings’ tables.
Clinically important outcomes (balance, gait, global motor function) and safety (adverse events) are prespecified as primary/secondary endpoints to maximise clinical relevance.
Anticipated heterogeneity across VR modality, delivery format and intervention parameters may limit pooling but will enable identification of the most effective and feasible VR-TR approaches for Parkinson’s rehabilitation.
English-language restriction and variability in outcome instruments may introduce language and measurement bias, and the inclusion of quasi-experimental studies may increase overall risk of bias.
Introduction
Parkinson’s disease (PD) is a neurological disorder resulting from the degeneration of dopaminergic neurons in the basal ganglia, with profound consequences for motor, cognitive and emotional functioning. 1 It is the second most common neurodegenerative disorder, 2 with an average age of onset between 60 and 65 years; however, 4–10% of cases occur in the early onset or juvenile onset population. 3 The incidence of PD increases with age, and its prevalence is expected to rise as the ageing population grows. 4 Globally, disability and mortality due to PD are increasing more rapidly than for any other neurological disease, 1 with the number of individuals affected more than doubling between 1990 and 2016. 5
The cardinal motor symptoms of PD are tremor, rigidity, akinesia (or bradykinesia) and postural instability, 6 often accompanied by increased fall risk, reduced muscle performance and gait changes. 7 These impairments significantly limit functional independence, contributing to inactivity, social isolation and reduced quality of life (QoL). 8 Physiotherapy is a key component of PD management alongside drug and device-based therapies. 9 The European Physiotherapy Guideline for PD recommends early referral to physiotherapy following diagnosis to receive individualised exercise prescriptions, 10 with the aim of optimising movement quality, functional independence and general fitness while preventing secondary complications. 11
Systematic reviews and meta-analyses indicate that various exercise modalities including conventional physiotherapy, resistance training, treadmill training, aquatic therapy, dance and balance/gait training can improve motor severity, QoL, freezing of gait, mobility and balance in people with PD. 12 Conventional physiotherapy remains the most common approach, focusing on exercises for strength, balance, gait and range of motion. 10 However, PD is a chronic, progressive condition requiring long-term, regular physiotherapy. Ongoing supervised therapy is frequently hindered by transportation barriers, lack of assistance, travel costs and motor limitations, often leading to discontinuation. 13 These challenges reduce therapy adherence and compromise outcomes.
Telerehabilitation (TR), the remote delivery of rehabilitation services via communication technology, offers a potential solution to improve access and continuity of care. 13 14 First described in 1998, 15 TR gained traction around 2016 and expanded significantly during the COVID-19 pandemic. 16 It can be delivered via messaging, telephone, videoconferencing, web or mobile applications, integrated systems or virtual reality (VR) platforms. 17 18 People with PD may be particularly suited to TR due to mobility limitations and the potential benefits of continuous rehabilitation. 19 TR has been shown to be feasible, safe 20 and effective in managing PD symptoms. 21 , 30
With modern VR devices becoming increasingly portable and user-friendly, there is growing potential for their home-based application through TR. 31 32 Early trials, reported as early as 2005, used simultaneous VR displays for patients and therapists with remote supervision via videoconferencing. 33 VR-based TR (VR-TR) delivers gamified, task-specific exercises that enhance motor function, balance and overall functional abilities, 34 , 36 with adaptive difficulty and real-time feedback to sustain engagement. 34 37 Remote monitoring enables therapists to track performance and ensure safety either synchronously or asynchronously. 35 38 Beyond clinical gains, this approach can reduce travel costs, decrease the frequency of in-person sessions and enable therapists to manage multiple patients simultaneously. 38 39 It also supports continuity of care during service disruptions such as the COVID-19 pandemic. 40 Despite these advantages, barriers such as limited technical skills, system complexity, uncertainty about efficacy and constrained home space continue to hinder widespread adoption. 14 41
Numerous studies have explored the use of VR to improve motor symptoms in PD 1124 31 34 42 , 47 ; however, these studies generally reported the overall effects of VR on clinical outcomes without distinguishing whether the interventions were delivered in person or through TR. Evidence remains limited regarding how VR can be effectively delivered remotely through TR. Existing systematic reviews have examined the role of VR-TR in neurological rehabilitation, with some combining data across stroke, multiple sclerosis and PD, 48 and others focusing exclusively on stroke. 49 These reviews collectively suggest that VR-TR can enhance balance and functional outcomes, yet their conclusions are constrained by heterogeneous populations and interventions. The present review therefore aims to evaluate the effectiveness and safety of VR-TR in improving motor function, balance and gait in individuals with PD and to explore how variations in the type of VR (immersive or non-immersive), supervision format (synchronous or asynchronous) and treatment parameters (duration, intensity and frequency) influence outcomes and feasibility.
Objectives
This review aims to evaluate the effectiveness and safety of VR-TR in improving motor function, balance and gait among individuals with PD. It also seeks to examine how variations in intervention design, supervision format and treatment parameters influence outcomes, thereby identifying which forms of VR-TR are most effective and feasible for this population.
Methods and analysis
This protocol was registered in the PROSPERO with registration number CRD420251009423 and adheres to the guidelines of the Preferred Reporting Items for Systematic review and Meta-Analysis Protocols (PRISMA-P) 50 ( online supplemental appendix 1 ). The systematic review will be carried out according to the recommendations of the Cochrane Handbook for Systematic Reviews of Interventions. 51
Eligibility criteria
Types of studies
Randomised controlled trials and quasi-experimental studies reported in English will be eligible. Grey literature (theses, conference proceedings) will also be searched; where sufficient data are available, these records may be included and explored in sensitivity analyses. The language restriction will be recorded as a limitation.
Types of participants
Studies including individuals with idiopathic PD diagnosed by a clinician will be eligible. No restrictions will be imposed based on age, gender, prescribed medications, disease severity, duration since diagnosis, cognition status or any other treatment being received. We will rely on statements from study authors for confirmation of the medical diagnosis.
Types of intervention
The treatment group includes VR-TR, using immersive or non-immersive VR technology with remote supervision, delivered synchronously (real-time interaction via video conferencing) or non-synchronously (delayed interaction via performance monitoring).
Types of comparators
Randomised controlled trials and quasi-experimental studies comparing VR-TR with any of the following comparator groups will be included:
Conventional physiotherapy : Physiotherapist-supervised, active exercise programmes designed to enhance gait, balance, transfers and/or general physical capacity.
Usual care : Routine clinical management, which may include disease education, medication adherence support, advice on physical activity and nutrition, speech and sleep management and broader lifestyle counselling aimed at overall well-being. It includes understanding the disease, adhering to medication, maintaining physical activity, ensuring proper nutrition, managing speech and sleep and making informed lifestyle choices to promote general well-being.
Other active treatments : Alternative interventions distinct from VR-TR, such as clinic-based VR exercise, commercially available exergaming or keyboard/motion-sensor exercise platforms, provided they are delivered in a physiotherapy or rehabilitation context.
Types of outcome measures
We selected outcomes based on a consensus set of outcomes for PD developed by the International Consortium for Health Outcomes Measurement. 52
Primary outcomes
Balance will be assessed using instrumented force-platform measures (eg, center-of-pressure sway) and standardised clinical tests, including the Berg Balance Scale, 53 54 Activities-specific Balance Confidence Scale, 55 56 Functional Reach Test 57 and Timed Up-and-Go. 58 In PD, postural instability is one of the major contributors to falls, which occur in about 42% of patients after 8 years and 72% after 16 years of disease progression. Balance deficits not only increase fall risk but also reduce independence, mobility and QoL. Therefore, improving balance is a clinically meaningful goal and a key determinant of safety and participation in daily life. 59
Gait will be evaluated using direct measures such as walking speed, cadence and step length, along with clinical tools including the Freezing of Gait Questionnaire 60 and other validated assessments. In PD, gait impairment evolves throughout the disease course, characterised by reduced step length, asymmetry, shuffling and freezing episodes. These abnormalities not only increase fall risk but also limit independence and participation. 61
Global motor impairment will be assessed using the Movement Disorder Society–Unified Parkinson’s Disease Rating Scale Part III (MDS-UPDRS III). 62 This clinician-rated motor examination quantifies tremor, rigidity, bradykinesia, postural instability and gait disturbance. The MDS-UPDRS III has demonstrated excellent reliability and validity and is the standard instrument for evaluating motor symptom severity and treatment response in PD. 63
Secondary outcomes
QoL will be evaluated using validated instruments such as the Parkinson’s Disease Questionnaire (PDQ-39 or PDQ-8). 64 In PD, reduced mobility, postural instability and impaired daily functioning directly diminish patients’ physical independence and psychosocial well-being, thereby affecting their QoL. 65 VR-TR may improve QoL by enhancing functional mobility, engagement and self-efficacy through repetitive, task-oriented and motivating home-based practice.
The most frequently reported adverse events associated with the use of VR include discomfort or pain, motor fluctuations, falls, fatigue, near falls, hypotension, dizziness and headache. 66 Evaluating adverse events in this review will help determine the overall safety, feasibility and clinical acceptability of VR-TR for individuals with PD. Monitoring safety outcomes is essential in Parkinson’s rehabilitation, as patients often experience postural instability, dyskinesia and motor fluctuations that increase the risk of falls or other complications during therapy.
The outcomes and specific measurement tools mentioned are not criteria for study inclusion.
Exclusion criteria
Non VR-TR.
Studies reporting only non-motor symptoms as outcome measures.
Observational studies—cross-sectional, cohort, qualitative, case reports, reviews and the meta-analysis.
Non-English language publications.
Incomplete or preliminary studies.
Search methods for identification of studies
Electronic searches
Electronic search will be conducted in PubMed (National Library of Medicine), Scopus (Elsevier), CENTRAL (Cochrane Library) and PEDro (Physiotherapy Evidence Database), covering each database from its inception to June 2026 and restricting retrieval to English-language publications. For every platform, we will merge controlled vocabulary using MeSH with relevant keywords, adapting the syntax to the database’s indexing conventions; the full search strings are provided in online supplemental appendix 2 . To minimise publication bias, the search will be supplemented by screening grey literature including dissertations and theses along with two trial registries. We will also hand-check the reference lists of pertinent studies, systematic reviews and clinical guidelines, and contact recognised experts in the field to uncover any ongoing trials.
Data collection and analysis
Selection of studies
Two review authors acting independently (IWN and VV) will evaluate the titles and abstracts of all documents obtained through the systematic search to ascertain studies that may align with the inclusion criteria or necessitate additional scrutiny. Subsequently, full-text articles corresponding to potentially suitable studies will be acquired and evaluated autonomously by the aforementioned authors in accordance with the predetermined inclusion and exclusion criteria. Each study that is omitted will be accompanied by a minimum of one clearly stated rationale for its exclusion. All screening and selection processes will be facilitated using Rayyan software 67 to streamline workflow. Any disagreements during title/abstract screening or full-text assessment will be resolved through discussion between IWN and VV. If consensus cannot be reached, a third review author (MNK) will arbitrate to ensure impartiality. The entire selection process will be documented in detail to enable the completion of a PRISMA flow diagram ( figure 1 ), ensuring transparency and reproducibility.
Data extraction and management
Two review authors will independently extract data from each included study using a structured and piloted form. Any discrepancies will be resolved by consensus, and if unresolved, a third reviewer will make the final decision.
The following information will be extracted:
Study characteristics (year of publication, country, design, setting, sample size, follow-up duration).
Participant characteristics (mean age, gender distribution, disease stage).
Intervention characteristics (type of rehabilitation (eg, VR-TR), supervision mode, session dose and frequency, total number of sessions, adherence rates, cointerventions).
Comparator characteristics (description of the control condition, eg, usual care, conventional physiotherapy, non-VR exercise).
Outcome measures (instruments used, timing of assessments and follow-up points).
Results of interest (for dichotomous data, event counts and relative risks; for continuous data, group means and SD).
Extracted data will be summarised in a ‘Characteristics of Included Studies’ table, with reasons for study exclusions documented separately.
Assessment of risk of bias
Two authors (IWN and VV) will independently appraise each randomised trial using the Cochrane Risk of Bias Tool V.2.0. 51 This tool covers five domains: randomisation process; deviations from intended interventions; missing outcome data; measurement of the outcome; and selection of the reported result, each guided by a set of signalling questions. For every domain, studies will be judged as having ‘low risk’, ‘some concerns’ or ‘high risk’ of bias. 51 Disagreements will be settled by discussion, with a third author (MNK) consulted if needed. We will present a graphical summary of these assessments.
For non-randomised studies, the same pair of reviewers will apply the Risk Of Bias In Non-randomised Studies Of Interventions (ROBINS-I) tool, which examines seven domains organised across the study timeline:
Preintervention: confounding; selection of participants.
At intervention: classification of interventions.
Postintervention: deviations from intended interventions; missing data; measurement of outcomes; selection of the reported result. Each domain will be rated as ‘low’, ‘moderate’, ‘serious’, ‘critical’ or ‘no information’ based on signalling questions. 51 Any conflicts will be resolved by consensus or, if necessary, by a third reviewer. A composite risk-of-bias chart will accompany the final report.
Addressing missing data
The primary analysis will include all available data from the included studies, with extraction performed independently by two reviewers (IWN and VV) to ensure accuracy. Where outcome data are incomplete or missing, study authors will be contacted by email. 51 If no response is received after two follow-up attempts, analyses will be conducted using the available data without imputation. The potential impact of missing data on the overall findings will be explored in sensitivity analyses. 68 All analyses will be performed using RevMan V.5.4.
Estimation of the treatment effect
For dichotomous outcomes, the treatment effect will be reported using relative risk with a 95% CI. 69 For continuous outcomes, we will calculate the mean difference (MD) with its 95% CI when studies report the same outcome using identical measurement scales, ensuring direct comparability. 69 If studies measure the same outcome using different scales (eg, different quality-of-life instruments), we will use the standardised MD with its 95% CI to account for scale variability. 68
Assessment of heterogeneity
Clinical and methodological heterogeneity among studies will be explored using data extraction tables and by reviewing study characteristics. Statistical heterogeneity will be assessed through visual inspection of forest plots and quantified using the χ² test and the I² statistic. Based on the Cochrane Handbook for Systematic Reviews of Interventions, 70 I² values will be interpreted as follows: 0–30% may indicate low or negligible heterogeneity, 30–60% moderate heterogeneity, 60–90% substantial heterogeneity and 90–100% considerable heterogeneity.
Assessment of reporting biases
We will explore possible small-study effects by plotting study size against effect size in a funnel plot and examining the overall pattern. Any uneven spread of points will be interpreted with reference to the explanations offered in the Cochrane Handbook for Systematic Reviews of Interventions . 69 If our meta-analysis contains more than ten trials, we will also apply the formal tests for funnel-plot skewness recommended in the same chapter.
Data synthesis
Results will be reported according to the Cochrane Handbook. The study selection process will be presented in a PRISMA flow diagram, with reasons for exclusion summarised in a table. 71 Characteristics of included studies will be tabulated. Where appropriate, results will be pooled using a random-effects model in RevMan, with effect sizes and 95% CIs displayed in forest plots. If a meta-analysis is not feasible due to substantial heterogeneity, a narrative synthesis will be provided.
Subgroup analysis and investigation of heterogeneity
Heterogeneity across studies is anticipated in terms of intervention characteristics, delivery methods, comparators and disease severity. Statistical heterogeneity will be assessed using the I² statistic and visual inspection of forest plots. If substantial heterogeneity is detected and sufficient data are available, subgroup analyses will be performed. 72 Planned subgroups include disease severity, intervention duration, type of VR (immersive vs non-immersive), delivery mode (synchronous vs asynchronous), type of device, study design (randomised vs non-randomised) and type of comparator. These analyses will help identify which intervention parameters most influence treatment outcomes and ensure that differences across studies are systematically explored. However, if subgroup analyses result in smaller sample sizes or inconsistent findings, subtotals will be presented instead of totals, and the certainty of evidence will be downgraded for imprecision in the Grading of Recommendations Assessment, Development and Evaluation (GRADE) assessment. All analyses will be performed using RevMan.
Sensitivity analysis
Sensitivity analyses will be undertaken, where possible, by excluding studies at high risk of bias and repeating the analyses to assess the robustness of the findings. 72
Summary of finding table
We will use the GRADE approach to assess the certainty of the evidence and the strength of recommendations. 73 The GRADEpro GDT software ( https://gdt.gradepro.org/app/ ) 74 will be used to generate concise ‘Summary of Findings’ tables for our key outcomes:
Primary outcomes: Balance, gait and global motor function.
Secondary outcomes: QoL and adverse events.
Each table will present comparisons for:
VR-TR versus therapist-supervised exercise.
VR-TR versus usual care (eg, education or medication advice).
VR-TR versus other interventions (eg, clinic-based VR or keyboard-driven programmes).
Two reviewers will independently rate the certainty of the evidence across the five GRADE domains, namely risk of bias, inconsistency, indirectness, imprecision and publication bias, and assign overall grades of high, moderate, low or very low. 73
Patient involvement
Patients will not be involved in this study.
Ethics and dissemination
This study does not involve human participants and uses data from published studies; therefore, ethics approval is not required. However, as per institutional requirements, ethical clearance was obtained from the Institutional Ethics Committee of Datta Meghe Institute of Higher Education and Research (DMIHER) (Ref. No.: DMIHER(DU)/IEC/2025/204). Findings will be published in peer-reviewed journals and presented at conferences.
Discussion
VR-TR is emerging as a promising approach for managing motor symptoms in PD, though challenges in its implementation and evidence base remain. Previous systematic reviews have demonstrated that VR can improve motor and balance outcomes in PD, 75 but these findings largely reflect clinic-based interventions. Evidence specific to its use in TR where therapy is delivered remotely with digital monitoring remains limited. 48 This systematic review and meta-analysis will synthesise the available evidence on VR-TR for motor outcomes (balance, gait and global motor function) in people with PD, assess safety and explore sources of heterogeneity across interventions and study designs.
This review also has certain limitations. Restriction to English-language publications may introduce language bias. In addition, the inclusion of quasi-experimental designs could increase methodological bias; therefore, pooled estimates should be interpreted with caution.
Considerable heterogeneity is expected across studies in VR modality (immersive vs non-immersive), delivery model (synchronous vs asynchronous), treatment dose, device type, comparators and outcome measures. The variations may restrict data pooling and necessitate subgroup and sensitivity analyses. However, these analyses will strengthen the review by identifying which specific VR-TR formats and parameters are most effective and feasible for Parkinson’s rehabilitation, ensuring that anticipated heterogeneity contributes to deeper understanding rather than being viewed as a limitation.
Supplementary material
Footnotes
Funding: The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Prepub: Prepublication history and additional supplemental material for this paper are available online. To view these files, please visit the journal online ( https://doi.org/10.1136/bmjopen-2025-109967 ).
Provenance and peer review: Not commissioned; externally peer reviewed.
Patient consent for publication: Not applicable.
Patient and public involvement: Patients and/or the public were not involved in the design, or conduct, or reporting, or dissemination plans of this research.
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