Спортивные представления в виртуальных мирах: систематический обзор спортивной имитации у неврологических паралимпийских спортсменов и неатлетических групп населения.

Introduction

Neurological populations encompass individuals with disorders of the central and/or peripheral nervous system that produce enduring impairments and consequent activity and participation limitations. Epidemiologically this umbrella includes stroke, traumatic brain injury (TBI) and spinal cord injury (SCI), cerebral palsy (CP), multiple sclerosis (MS), Parkinson’s disease (PD), hereditary or acquired ataxias and peripheral neuropathies, among others [ 1 , 2 ]. Within this broader clinical landscape, it is useful to delineate the subset engaged in organized sport. In a performance context Paralympic populations are athletes with an eligible impairment as defined by the International Paralympic Committee (IPC) (impaired muscle power, impaired passive range of movement, limb deficiency, leg-length difference, short stature, hypertonia, ataxia, athetosis, visual impairment, or intellectual impairment) who are classified to ensure that sport outcomes are determined by training, skill, and tactics rather than by the degree of impairment [ 3 , 4 ].

Conceptual precision is critical: operational definitions delimit study inclusion and, by extension, determine the evidentiary base that can legitimately inform clinical and performance decision-making for athletes with disabilities. Global Burden of Disease (GBD) data indicate neurological disorders as a leading cause of ill health worldwide [ 1 , 2 ]. Stroke remains the largest causes to neurological disability-adjusted life years [ 5 ], and PD and MS are rising [ 6 , 7 ]. For para-athletes, motor, sensory, visual, autonomic, fatigue, and dual-task deficits constrain balance, agility, power, endurance, reaction speed, visuomotor anticipation, and decision-making, limiting sport performance and return-to-sport potential [ 8 – 13 ].

Virtual reality (VR) is a promising approach because it can instantiate sport-like affordances with controllable difficulty and augmented feedback while preserving safety, repeatability, and data richness. In rehabilitation, VR range from immersive systems (head-mounted displays or CAVE-like rooms creating strong presence) and non-immersive systems (screen or console-based “exergames”) [ 14 – 17 ]. High-level evidence is cautiously positive, with Cochrane syntheses and umbrella reviews indicating small-to-moderate improvements in upper-limb function and activity after stroke when VR augments usual care, while effects on gait speed remain uncertain. Broader stroke umbrella reviews and meta-analyses, together with scoping reviews in other neurological conditions, converge on feasibility, safety, and engagement benefits, but clinical effect sizes are variable [ 18 – 22 ]. Growing proof of concept studies suggest that sport-simulation VR (e.g., canoe paddling, boxing, wheelchair skills, team ball-sports) can improve sport-linked outcomes such as trunk control, upper-limb function, wheelchair maneuverability, and exercise intensity [ 23 – 25 ].

Ecological dynamics frames skilled performance as emergent from the continuous regulation of performer-task-environment constraints. VR affords precise manipulation of these constraints (ball speed/spin, opponent behavior, optical flow, wheelchair dynamics), enabling representative learning design with titrated variability [ 26 ]. The Challenge Point Framework holds that learning peaks when nominal and functional task difficulty match the learner’s skill and the task’s complexity. VR enables that match through tight parameter control and automated feedback, updated set by set [ 27 ]. The Optimizing Performance Through Intrinsic Motivation and Attention for Learning (OPTIMAL) theory emphasizes motivational and attentional mechanisms, enhanced expectancies, and autonomy support that facilitate learning. VR and exergames can embed autonomy, quick successes, and an external focus by design [ 28 ]. Transfer from virtual to real performance depends on presence and fidelity [ 29 – 33 ]. Immersive systems strengthen place-illusion and feasibility. When paired with high functional fidelity in information-movement couplings (e.g., time-to-contact, spin, haptic timing), they promote transfer-appropriate processing and skill generalization. Low fidelity or cybersickness can undermine learning and adherence [ 29 – 33 ]. These theories justify focusing on sport-simulation VR rather than generic tasks. They also support targeting outcomes proximal to return-to-sport capacity, sport-specific tests, agility, anticipatory control, reaction time, and physiological responses. Recent syntheses confirm feasibility, including telerehabilitation and home programs [ 17 , 34 ]. They also document heterogeneity, small samples, and inconsistent endpoints. Most exergaming reviews still do not isolate sport-simulation tasks or return-to-sport outcomes [ 17 , 34 ]. Unlike prior work focused on generic neurorehabilitation VR [ 35 ], enjoyment/intensity metrics in exergames [ 36 , 37 ], or able-bodied sports performance [ 38 ], our review delimits to virtual environments that explicitly simulate recognized sports within sports-rehabilitation medicine.

Therefore, the objective of this systematic review is to evaluate, within neurological Paralympic populations undergoing sports rehabilitation, the effectiveness of sport-simulation VR (delivered in either immersive or non-immersive formats) in enhancing sport-specific performance and validated return-to-sport indicators, compared with eligible alternative interventions (including conventional rehabilitation, other active treatments, sham or low-dose VR, and usual care).

Materials and methods

PICO evaluation

We applied the PICO model (Population, Intervention, Comparison, Outcome) to create our search terms [ 39 ]. We defined the population as children, adolescents, and adults with neurological conditions relevant to sports rehabilitation, including SCI, stroke, TBI, CP, MS, PD, hereditary or acquired ataxias and peripheral neuropathies. Both athletes (including Paralympic athletes) and non-athlete patients were eligible, provided the intervention was delivered in a sports rehabilitation context. The intervention comprised VR programs that simulated a recognized sport or a clearly sport-like skill (for example, tennis, boxing, soccer/football, table tennis, archery, goalball, kayaking, or sitting volleyball). Interventions could be immersive or non-immersive. The virtual tasks had to embody sport-specific perceptual-motor demands (e.g., ball-bat or glove interactions, striking, kicking, paddling, wheelchair sport maneuvers) and be deployed with the explicit intent to restore, enhance, or assess sport-relevant capacities. Eligible comparators included conventional rehabilitation or exercise programs, alternative active interventions (e.g., non-sport simulation VR, functional electrical stimulation, strength or balance training), sham or minimal-dose VR, and wait-list or usual-care controls. When controlled comparators were unavailable, single-group pre–post designs were retained and treated as within-subject comparisons to baseline. The primary outcomes were sport-relevant functional measures, which we operationalized as either direct sport-specific performance (e.g., task accuracy, speed, consistency, or biomechanical efficiency in the simulated or real sport) or validated functional surrogates tightly linked to return-to-sport capability (e.g., balance and gait metrics, agility tests, upper- or lower-limb power or endurance, reaction time, and kinematic quality of movement). Secondary outcomes included physiological and autonomic responses (heart rate (HR), heart rate variability (HRV), and oxygen uptake when available), participation and return-to-sport indicators, patient-reported outcomes (symptoms, confidence, and quality of life), adherence and usability/acceptability, and safety or adverse events.

Inclusion criteria

We considered only peer-reviewed original research that evaluated VR, either immersive (e.g., head-mounted displays or CAVE systems) or non-immersive (e.g., console-based exergames or projection screens), when the virtual environments explicitly simulated a recognized sport or sport-like skill such as tennis, boxing, soccer/football, table tennis, archery, goalball, kayaking, or sitting volleyball. Interventions had to be framed within sports rehabilitation medicine, aiming to restore, enhance, or assess sport-relevant functions rather than generic motor practice. Eligible populations were those specified in PICO, including both athletes (Paralympic and non-Paralympic) and non-athlete patients. Randomized controlled trials (RCT), non-RCTs, crossover trials, prospective or retrospective cohorts, and single-group pre–post designs were all eligible provided they reported quantitative outcomes interpretable for sports rehabilitation, such as sport-specific performance tests, balance and gait metrics, agility, strength or endurance, reaction time, kinematics, cardiorespiratory or autonomic indices (e.g., HR) or HRV, participation or return to sport indicators, adherence, and safety. No restrictions were set on setting (clinic, laboratory, home, or community), delivery mode (in-person or telerehabilitation), intervention dose or duration, or comparator type; co-interventions were permitted when the VR sport component represented a substantive part of the program and outcome attribution remained reasonable. No a priori limits were applied to publication year and only studies published in English were considered eligible, provided the full text contained sufficient methodological detail to support data extraction and appraisal.

Exclusion criteria

We excluded all non-original formats, non-English articles, and non–peer-reviewed sources; narrative, scoping, or systematic reviews, meta-analyses, editorials, letters, commentaries, protocols, conference abstracts or proceedings, and theses did not meet eligibility. Single-patient case reports were also excluded. Engineering demonstrations or validation studies conducted exclusively in healthy participants without a neurological diagnosis were excluded, nor did virtual environments that failed to simulate a sport or sport-like action (e.g., generic reaching tasks, abstract balance platforms, or cognitive VR unrelated to sport). Studies relying solely on augmented or mixed reality without a bona fide VR component or using only 2D video and other non-interactive screens without embodied interaction, were not eligible. Wheelchair driving or mobility simulators were retained only when they were explicitly positioned as training for wheelchair sport technique or performance; simulations aimed solely at transportation or activities of daily living were excluded as outside the scope of sports rehabilitation medicine.

Search strategy

We designed a comprehensive, concept-driven search to identify VR interventions that explicitly simulate recognized sports within sports-rehabilitation settings for neurological and Paralympic populations. No a priori date limits were applied and searches were run from database inception through 2 July 2025. We omitted time restrictions deliberately to avoid availability and survivorship bias in an emerging field, to capture formative original studies alongside contemporary systems, and to enable sensitivity analyses across successive VR hardware/software generations. Controlled vocabulary (e.g., MeSH) and free-text terms were combined and adapted to each database’s syntax, covering VR modality (immersive/non-immersive), specific sports, rehabilitation context, neurological diagnoses relevant to para-sport, and sport-relevant outcomes. To operationalize these constructs consistently across sources, we used three complementary strings: String 1: “virtual reality” AND (exergaming OR “active video games” OR “head-mounted display” OR “head mounted display”) AND (tennis OR “table tennis” OR boxing OR soccer OR football OR archery OR “sitting volleyball” OR goalball OR “wheelchair basketball” OR “wheelchair rugby” OR “wheelchair tennis” OR swimming OR rowing OR canoeing OR kayaking OR basketball OR rugby OR fencing OR badminton OR handball OR hockey) AND (rehabilitation OR “sports rehabilitation” OR “sports medicine” OR “exercise therapy”) AND (“spinal cord injury” OR stroke OR “traumatic brain injury” OR “cerebral palsy” OR “multiple sclerosis” OR “Parkinson disease” OR “Parkinson’s disease” OR ataxia OR “peripheral neuropathy”); String 2: “virtual reality” AND (Paralympic OR Paralympics OR “para athlete” OR “wheelchair sport” OR “wheelchair basketball” OR “wheelchair rugby” OR “wheelchair tennis” OR “sitting volleyball” OR goalball OR “blind soccer” OR “five a side football” OR “para swimming” OR paracanoe OR “para archery”) AND (rehabilitation OR “sports rehabilitation” OR “sports medicine” OR “exercise therapy”) AND (“spinal cord injury” OR “cerebral palsy” OR stroke OR “traumatic brain injury”); String 3: “virtual reality” AND (tennis OR “table tennis” OR boxing OR soccer OR football OR archery OR “sitting volleyball” OR goalball OR “wheelchair basketball” OR “wheelchair rugby” OR “wheelchair tennis” OR rowing OR canoeing OR kayaking OR swimming) AND (balance OR “postural balance” OR gait OR “walking speed” OR agility OR “reaction time” OR kinematics OR biomechanics OR “muscle strength” OR endurance OR “aerobic capacity” OR “oxygen consumption” OR “heart rate” OR “heart rate variability” OR “return to sport” OR adherence OR usability OR safety) AND (“spinal cord injury” OR stroke OR “traumatic brain injury” OR “cerebral palsy” OR “multiple sclerosis” OR “Parkinson disease” OR “Parkinson’s disease” OR ataxia OR “peripheral neuropathy”) AND (rehabilitation OR “sports rehabilitation” OR “exercise therapy”). Searches were executed in PubMed, Web of Science, the Cochrane Library, Embase, EBSCOhost, and Scopus, a portfolio selected to balance depth in biomedicine and rehabilitation (PubMed, Embase), rigorous coverage of trials and systematic evidence (Cochrane), and multidisciplinary breadth with citation tracking to surface cross-domain sport-technology studies (Web of Science, Scopus), while EBSCOhost provided access to specialist health-sciences indexes. Database-specific controlled term were tuned per platform. By employing these databases, we aimed to strengthen the rigor and validity of our search strategy while minimizing the likelihood of missing relevant studies and capturing a broad range of high-quality evidence.

Data extraction

Two reviewers (RSC, AC) independently executed the searches and screening to enhance reproducibility and reduce selection error. The strategy was refined iteratively by piloting alternative combinations of keywords, Boolean operators, and controlled vocabulary (e.g., MeSH), with the explicit aim of balancing sensitivity for sport-simulation VR and specificity for sports-rehabilitation contexts. Study selection followed the Preferred Reporting Items for Systematic Reviews and Meta-Analyses ( PRISMA) framework, as depicted in Fig. 1 [ 40 ]. Titles/abstracts and then full texts were screened in duplicate using piloted, standardized forms; disagreements were resolved through discussion, with unresolved cases adjudicated by a third reviewer (AQ). Inter-rater agreement was quantified using Cohen’s κ at both stages and interpreted using conventional thresholds (substantial ≥ 0.61, almost perfect ≥ 0.81) [ 41 ]. Inter-rater agreement was substantial at both stages and higher for full-text screening (Cohen’s κ = 0.70 for titles/abstracts and κ = 0.78 for full texts). For each VR intervention, we also coded VR modality and hardware using a prespecified three-level fidelity taxonomy. This taxonomy distinguished immersive head-mounted display or projection systems, non-immersive but sport-specific screen-based simulators, and console-based exergames with more simplified sport representations. Risk of bias in RCTs was appraised with the Cochrane RoB 2 tool (five domains) [ 42 ], and non-randomized studies of interventions were assessed with ROBINS-I [ 43 ], in accordance with the Cochrane Handbook. A priori data items included bibliographic details; design and setting; sample size; diagnosis and chronicity; participant age/sex; VR modality (immersive vs. non-immersive), hardware/system, and degree of sport representativeness; simulated sport discipline; training dose (sessions, minutes, intensity/progression); comparators and co-interventions; outcome taxonomy (sport-specific performance and validated return-to-sport surrogates; physiological/autonomic indices; adherence, usability/acceptability; safety/adverse events); follow-up timing; and funding/conflict statements. Data extraction was conducted independently by two reviewers (RSC, AC) with cross-checks to mitigate missing-results, language, and time-lag biases; discrepancies were reconciled by consensus or third-party adjudication (AQ). Extraction and management were implemented in Microsoft Excel using locked templates with validation rules, dropdowns, and audit trails to standardize entries and limit transcription error; built-in filters facilitated discrepancy resolution and evidence synthesis. The review protocol was prospectively registered on PROSPERO (CRD420251178910), providing a public record of methods and outcomes and reinforcing transparency, accountability, and resistance to selective reporting [ 44 ]. Fig. 1 PRISMA 2020 flow diagram of evaluated studies

Narrative synthesis framework (SWiM)

Given the clinical and methodological heterogeneity across neurological diagnoses, athlete status, VR modalities, simulated sports, comparators, and outcome constructs, we undertook a structured narrative synthesis in accordance with the SWiM guideline and Cochrane recommendations for syntheses without meta-analysis, alongside PRISMA 2020 reporting. Consistent with SWiM, we prespecified: (i) how studies would be grouped; (ii) the effect measures to be extracted or transformed; (iii) procedures for combining results when statistical pooling was inappropriate; (iv) how heterogeneity and risk of bias would shape conclusions; and (v) how certainty in the body of evidence would be judged [ 45 ]. Studies were grouped by (a) neurological condition (e.g., stroke, SCI, TBI, CP, MS, PD, ataxias, neuropathies) and athlete status (para-athlete vs. non-athlete patients); (b) VR modality and task representativeness (immersive vs. non-immersive; degree of sport-specific perceptual-motor coupling and equipment interfaces such as wheelchair, paddle, and racquet); and (c) sport simulated (ball-striking sports, wheelchair court sports, paddling/rowing, and archery/target). Within each grouping, outcomes were organized by domain and time point: direct sport-specific performance in the virtual or real task; validated functional surrogates (balance, gait/agility, reaction time, kinematics, power/endurance); physiological/autonomic markers (HR, HRV, Volume of Oxygen (VO₂); participation/return-to-sport; adherence/usability; safety; and immediate post-intervention versus follow-up. For continuous outcomes on comparable scales, we extracted post-intervention means and standard deviations (or change scores) and, where appropriate, transformed them to standardized mean differences or percent change to aid comparability. For heterogeneous constructs, we used a direction-of-effect rubric with a priori improvement rules (e.g., lower reaction time; higher task accuracy/consistency; faster gait/agility tests; increased VO₂ peak; favorable parasympathetic HRV indices; reduced adverse events). Heterogeneity was examined qualitatively across immersion level, degree of representativeness/presence, delivery mode (in-person vs. telerehabilitation), dose (session length, frequency, total exposure), setting (clinic/home/community), time since injury, and comparator type. Sensitivity analyses excluded studies with high overall RoB, insufficient detail on the VR intervention or sport representativeness, substantial co-interventions that impeded attribution, or missing variance data. Potential small-study and publication biases were explored narratively by contrasting findings across sample size, funding source, and risk-of-bias strata. Table 1 provides an overview of the methodology employed for this systematic review. Table 1 Detailed summary of the systematic review methodology Section Methodology Details Search Strategy Databases and search strings • Databases: PubMed/MEDLINE, Web of Science, Cochrane Library, Embase, EBSCOhost (specialist health-sciences indexes), Scopus. • Concept-driven approach targeting sport-simulation VR in sports-rehabilitation for neurological/Paralympic populations. • Controlled vocabulary (e.g., MeSH) combined with free-text; database-specific syntax adapted per platform. • String 1 : “virtual reality” AND (exergaming OR “active video games” OR “head-mounted display” OR “head mounted display”) AND (tennis OR “table tennis” OR boxing OR soccer OR football OR archery OR “sitting volleyball” OR goalball OR “wheelchair basketball” OR “wheelchair rugby” OR “wheelchair tennis” OR swimming OR rowing OR canoeing OR kayaking OR basketball OR rugby OR fencing OR badminton OR handball OR hockey) AND (rehabilitation OR “sports rehabilitation” OR “sports medicine” OR “exercise therapy”) AND (“spinal cord injury” OR stroke OR “traumatic brain injury” OR “cerebral palsy” OR “multiple sclerosis” OR “Parkinson disease” OR “Parkinson’s disease” OR ataxia OR “peripheral neuropathy”). • String 2 : “virtual reality” AND (Paralympic OR Paralympics OR “para athlete” OR “wheelchair sport” OR “wheelchair basketball” OR “wheelchair rugby” OR “wheelchair tennis” OR “sitting volleyball” OR goalball OR “blind soccer” OR “five a side football” OR “para swimming” OR paracanoe OR “para archery”) AND (rehabilitation OR “sports rehabilitation” OR “sports medicine” OR “exercise therapy”) AND (“spinal cord injury” OR “cerebral palsy” OR stroke OR “traumatic brain injury”). • String 3 : “virtual reality” AND (tennis OR “table tennis” OR boxing OR soccer OR football OR archery OR “sitting volleyball” OR goalball OR “wheelchair basketball” OR “wheelchair rugby” OR “wheelchair tennis” OR rowing OR canoeing OR kayaking OR swimming) AND (balance OR “postural balance” OR gait OR “walking speed” OR agility OR “reaction time” OR kinematics OR biomechanics OR “muscle strength” OR endurance OR “aerobic capacity” OR “oxygen consumption” OR “heart rate” OR “heart rate variability” OR “return to sport” OR adherence OR usability OR safety) AND (“spinal cord injury” OR stroke OR “traumatic brain injury” OR “cerebral palsy” OR “multiple sclerosis” OR “Parkinson disease” OR “Parkinson’s disease” OR ataxia OR “peripheral neuropathy”) AND (rehabilitation OR “sports rehabilitation” OR “exercise therapy”). Search Period Time range and execution • Coverage: database inception to 2 July 2025; no a priori date limits. • Rationale: minimize availability/survivorship bias; capture formative and contemporary sport-VR systems. Study Selection Screening, agreement, PRISMA 2020 • Dual independent screening (titles/abstracts → full text) using piloted forms. • Disagreements resolved by discussion; persistent conflicts adjudicated by a third reviewer. • Cohen’s κ (95% CI) computed for both levels; interpretation: substantial ≥ 0.61, almost perfect ≥ 0.81. • PRISMA 2020 flow diagram documents identification, screening, eligibility, inclusion. Inclusion Criteria Population, intervention, outcomes, design • Population: children, adolescents, adults with neurological conditions (SCI, stroke, TBI, CP, MS, PD, hereditary/acquired ataxias, peripheral neuropathies); athletes (including Paralympic/para-athletes) and non-athlete patients. • Intervention: VR explicitly simulating a recognized sport or clearly sport-like skill (e.g., tennis, boxing, soccer/football, table tennis, archery, goalball, kayaking/canoeing, sitting volleyball); immersive (HMD/CAVE) or non-immersive (console/projection). • Tasks: sport-specific perceptual–motor couplings (striking, kicking, paddling, ball–bat/glove interactions, wheelchair sport maneuvers) intended to restore, enhance, or assess sport-relevant capacities. • Designs: RCTs, non-randomized controlled studies, crossover trials, prospective/retrospective cohorts, single-group pre–post, with quantitative outcomes interpretable for sports-rehabilitation. • Outcomes: direct sport-specific performance and/or validated return-to-sport surrogates; physiological/autonomic indices; participation/return-to-sport; adherence; usability; safety. Exclusion Criteria Non-eligible scope and quality filters • Non-original formats and non–peer-reviewed sources (reviews, meta-analyses, editorials, letters, commentaries, protocols, conference abstracts/proceedings, theses). • Single-patient case reports. • Engineering demos/validation exclusively in healthy participants without neurological diagnosis. • Virtual tasks not simulating a sport/sport-like action (generic reaching, abstract balance platforms, cognitive VR unrelated to sport). • Augmented/mixed reality without bona fide VR, or non-interactive 2D video only. • Wheelchair driving/mobility simulators retained only if explicitly training wheelchair sport technique/performance; transportation/ADL simulators excluded. • Language: English full text required. PICO Evaluation Framing of the question • Population: neurological and Paralympic-relevant conditions across the lifespan; para-athletes and non-athlete patients in sports-rehabilitation contexts. • Intervention: immersive or non-immersive sport-simulation VR explicitly simulating recognized sports or sport-like skills. • Comparison: conventional rehabilitation/exercise, alternative active interventions, sham/minimal-dose VR, usual care; when unavailable, within-subject pre–post versus baseline. • Outcomes: primary—sport-specific performance, validated return-to-sport surrogates; secondary, physiological/autonomic, participation/return-to-sport, patient-reported, adherence/usability, safety/adverse events. Setting, Delivery & Dose Pragmatic scope • Any setting (clinic, laboratory, home, community). • Delivery: in-person or telerehabilitation. • No restrictions on session length, frequency, total exposure, or program duration; co-interventions allowed when VR-sport is substantive and attribution remains reasonable. Data Extraction Items and procedure • Two reviewers independently extracted data with cross-checks; discrepancies resolved by consensus or third-party adjudication. • A priori items: bibliographics; design/setting; sample size; diagnosis/chronicity; age/sex; VR modality and fidelity level (immersive, semi-immersive, non-immersive), hardware/system; degree of sport representativeness; sport discipline; training dose (sessions, minutes, intensity/progression); comparators/co-interventions; outcome taxonomy; follow-up timing; funding/conflicts; adverse events. • Extraction managed in Microsoft Excel with locked templates, validation rules, dropdowns, audit trails. Risk of Bias & Tools RoB instruments and integration • Randomized trials: Cochrane RoB 2 (five domains). • Non-randomized studies: ROBINS-I. • Appraisal conducted per the Cochrane Handbook; RoB informs synthesis weighting and confidence. Registration & Reporting Transparency and standards • Protocol prospectively registered on PROSPERO (CRD420251178910). • Reporting aligns with PRISMA 2020 and SWiM guidance for narrative synthesis without meta-analysis. Synthesis Approach (SWiM) Grouping, metrics, heterogeneity, sensitivity • Structured narrative synthesis (SWiM) when pooling is inappropriate. • Pre-specified grouping: (a) neurological condition and athlete status; (b) VR modality and representativeness (immersive vs. non-immersive; equipment interfaces, wheelchair, paddle, racquet); (c) sport simulated (ball-striking; wheelchair court sports; paddling/rowing; archery/target). • Continuous outcomes summarized as means/SDs or change scores; transformed to standardized mean differences or percent change when appropriate. • Heterogeneous constructs summarized via effect-direction rubric (↓reaction time; ↑accuracy/consistency; faster gait/agility; ↑VO₂peak; favorable parasympathetic HRV; fewer adverse events). • Heterogeneity explored across immersion level, representativeness/presence, delivery mode, dose, setting, time since injury, comparator type. • Sensitivity analyses: exclude studies with high overall RoB, insufficient intervention detail or representativeness, substantial co-interventions impeding attribution, or missing variance data. • Small-study/publication biases explored narratively (by sample size, funding, RoB strata). Legends PRISMA Preferred Reporting Items for Systematic Reviews and Meta-Analyses, PROSPERO International Prospective Register of Systematic Reviews, RCT randomized controlled trial, RoB 2 Cochrane Risk of Bias 2, ROBINS-I Risk Of Bias In Non-randomized Studies—of Interventions, SCI spinal cord injury, TBI traumatic brain injury, CP cerebral palsy, MS multiple sclerosis, PD Parkinson’s disease, HR heart rate, HRV heart rate variability, VO₂ oxygen uptake, VR virtual reality, HMD head-mounted display, CAVE Cave Automatic Virtual Environment, ADL activities of daily living, SMD standardized mean difference

Results

We conducted a comprehensive search across six databases, PubMed, Web of Science, Cochrane Library, Embase, EBSCOhost, and Scopus, yielding 2,950 records (PubMed 21; Web of Science 106; Cochrane Library 71; Embase 46; EBSCOhost 9; Scopus 2,697). Before screening, we removed 650 duplicates and 40 non-English records, leaving 2,260 records for title/abstract screening. At the title screening stage, 1,800 records were excluded for prespecified reasons: out of scope (not VR sport/sport-like or not in a sports-rehabilitation setting; n = 1,250), non-original publications (Reviews & Case Reports n = 400; Congress & Guidelines n = 10; total n = 410), non-neurological populations (healthy/orthopedic/athlete-only; n = 52), AR-only or 2D non-interactive with no VR ( n = 28), non-human/in-vitro ( n = 20), and engineering-only without human data ( n = 40). The remaining 460 records advanced to abstract screening, where a further 320 were excluded because they were non-sport/sport-like on closer inspection (generic VR, abstract balance platforms, or non-sport cognitive VR; n = 205) or reported outcomes not relevant to sport (no functional/physiological measures useful for sport; n = 115). We sought 140 full texts; despite reasonable retrieval attempts (database checks and author contact), 9 could not be obtained, leaving 131 reports for eligibility assessment. Of these, 92 were excluded with recorded reasons: no explicit sport or sport-like simulation (e.g., generic reaching/balance tasks; n = 26); wheelchair mobility/driving for transport only (not wheelchair-sport technique/performance; n = 11); non-neurological or mixed populations without stratified neuro data ( n = 13); no quantitative sport-relevant outcomes (functional, physiological, or participation; n = 18); and VR interventions without sport or sport-like simulation (immersive or non-immersive; n = 24). Thirty-nine studies met al.l inclusion criteria and were included in the review (Fig. 1 ) [ 46 – 84 ].

The 39 included studies primarily reflect the broader neurological rehabilitation population rather than exclusively Paralympic or elite sport cohorts, and any implications for Paralympic athletes should therefore be interpreted as extrapolations from this mixed clinical context [ 46 – 84 ]. Most samples comprised adults with SCI, stroke, MS, or CP [ 46 – 49 , 51 – 57 , 63 – 66 , 71 – 75 ], with smaller cohorts including PD, ataxia, or mixed ABI [ 60 , 62 , 78 , 82 – 84 ]. Typical interventions simulated boxing or racket sports, balance-board tasks such as skiing or soccer heading, cycling or arm-crank plus functional electrical stimulation, and paddling or rowing, delivered in either immersive or non-immersive formats [ 47 – 49 , 51 – 53 , 56 – 58 , 60 , 61 , 64 – 67 , 71 , 74 , 80 , 81 ]. Study protocols usually integrated sport-simulation VR into multidisciplinary rehabilitation or home exercise programs for short cycles ranging from a few supervised laboratory sessions to 24-week home-based protocols [ 46 – 49 , 52 – 56 , 69 , 71 , 75 , 83 , 84 ]. Most interventions used non-immersive console or screen-based exergames with moderate sport fidelity (34/39 studies; 87.2%) [ 47 – 63 , 66 , 68 – 81 , 83 , 84 ], whereas a smaller subset employed fully immersive head-mounted display platforms (4/39; 10.3%) [ 46 , 64 , 65 , 82 ] and a single semi-immersive projection-based system (1/39; 2.6%) [ 67 ]. Among the thirty-nine included studies, 3/39 (7.7%) were acute single-session physiology or feasibility experiments with immediate pre-post assessment only [ 78 – 80 ], whereas the remaining 36/39 (92.3%) delivered multi-session programs over approximately two to twenty-four weeks [ 46 – 63 , 67 – 77 , 82 – 84 ]. Only 7/39 studies (17.9%) collected any outcome data beyond the immediate post-intervention time point [ 51 , 58 – 60 , 75 , 83 , 84 ]. Final follow-up was scheduled at approximately four weeks in four studies [ 58 , 75 , 83 , 84 ], at six weeks in one study [ 51 ], at eight weeks (two months) in one study [ 60 ], and at six months in one study [ 59 ], yielding a median timing of the last follow-up of four weeks (range four to twenty-four weeks). Follow-up assessments were therefore clustered in the early post-training period, and the durability of sport-relevant gains beyond these short time frames remains largely unknown.

Quality of included studies - Risk of bias

To appraise methodological rigor, we undertook a structured risk-of-bias evaluation with design-appropriate, widely used instruments (e.g., RoB 2 for randomized trials [ 42 ] and ROBINS-I for non-randomized studies [ 43 ]) for all included studies [ 46 – 84 ]. Applying these tools in a standardized manner enabled us to identify potential weaknesses and inconsistencies, supporting a transparent, credible interpretation of results within the broader evidence base.

Cochrane risk-of-bias tool for randomized trials (RoB 2)

Across the eighteen randomized trials [ 46 – 63 ], overall judgments concentrated in some concerns category (15/18), with two trials at high risk and only one at low risk (Fig. 2 ). The balance of uncertainty stems less from manifest flaws than from under-specification of key safeguards against bias. For the randomization process (Domain 1), most trials provided insufficient detail on sequence generation and allocation concealment, sustaining some concerns in the majority. Where methods were explicitly described, computer-generated sequences, opaque allocation, and baseline comparability, judgments were low risk (e.g., Sajan et al. [ 50 ], Nilsagard et al. [ 53 ], Saposnik et al. [ 58 ], Adie et al. [ 59 ]). By contrast, trials that omitted concealment procedures or relied on quasi-random approaches retained avoidable selection bias. Fig. 2 Risk of Bias (RoB) of included RCT studies [ 46 – 63 ]

Deviations from intended interventions (domain 2) were a recurrent pressure point. In VR/device-based rehabilitation, blinding of participants and therapists is rarely feasible; however, many reports also lacked operational fidelity metrics (e.g., telemetry-confirmed exposure, adherence thresholds, or pre-specified rules for managing co-interventions). This combination anchored some concerns in 13/18 studies. A minority documented dose targets, supervision, and protocol deviations with sufficient granularity to approach low risk. Outcome-related domains performed better. Measurement of outcomes (domain 3) was low risk in two-thirds of trials (12/18) when assessor blinding was used for sport-specific tests or validated functional surrogates (accuracy, reaction time, agility), and when device metrics were calibrated and reliability was addressed. Where bespoke measures were collected without blinding, some concerns persisted. Missing outcome data (Domain 4) was generally well handled (low risk 11/18), with a single outlier at high risk due to substantial attrition without mitigation. Finally, selection of the reported result (domain 5) remained the most consistent weakness: 16/18 trials were rated some concerns because multiplicity (numerous endpoints, time windows, or sub-analyses) was not anchored to a registered, locked analysis plan; only Saposnik et al. [ 58 ] and Adie et al. [ 59 ] provided sufficient pre-specification to merit low risk. Two trials accumulated enough problems across domains to be judged high risk overall (e.g., Tarakci et al. [ 49 ]; Ersoy et al. [ 61 ]). Taken together, this distribution of RoB 2 ratings, with most trials at some concerns and two at high risk, led us to downgrade the randomized evidence for risk of bias so that most outcome-level inferences contribute at best low certainty to the overall conclusions.

Across designs, the recurring liabilities are under-specified randomization/concealment, heterogeneous exposure without fidelity documentation, and analysis multiplicity without preregistration. Strengths include clear intervention classification and generally sound handling of missing data. In a SWiM-structured narrative, signals that are (a) generated under low-risk measurement conditions and transparent exposure and (b) converge in direction across studies (e.g., improved task accuracy, agility, or reaction time under calibrated difficulty) should be emphasized, while isolated findings arising from studies with serious confounding or selective reporting are prudently down-weighted. Accordingly, trials that satisfy these safeguards (e.g., Saposnik et al. [ 58 ]) will be accorded proportionally greater evidential weight in our synthesis. By contrast, studies with cumulative high-risk judgments (e.g., Tarakci et al. [ 49 ]; Ersoy et al. [ 61 ]) will be treated strictly as hypothesis-generating: their results will be down-weighted, interpreted as exploratory signals rather than confirmatory evidence, and used primarily to inform sensitivity analyses and the design of future, methodologically rigorous trials.

The risk of bias in non-randomized studies - of interventions (ROBINS-I)

The twenty-one non-randomized studies [ 64 – 84 ] were predominantly rated as serious risk overall (16/21), with the remainder as moderate risk (5/21) (Fig. 3 ). The principal threat was confounding (domain 1) serious in 16/21, reflecting non-random allocation, baseline imbalances (injury chronicity, impairment class, training history), and concomitant therapies that were unmeasured or uncontrolled. Illustrative examples include Aprile et al. [ 67 ], Tarakci et al. [ 74 ], and Kassee et al. [ 75 ]. Selection of participants (domain 2) was typically moderate and serious in a substantial minority (8/21), owing to convenience sampling from single centers and inclusion criteria that favored higher-functioning participants, opening the door to selection on post-baseline variables. Fig. 3 Cochrane Risk of Bias in Non-randomized Studies of Interventions (ROBINS-I) [ 64 – 84 ]

By contrast, classification of interventions (domain 3) was consistently clear (low risk), with precise delineation of immersive vs. non-immersive VR and sport-simulation content, and deviations from intended interventions (domain 4) were usually moderate rather than serious, constrained by therapist-supervised protocols but weakened by incomplete exposure logging. Missing data (domain 5) was commonly low risk (18/21) with transparent accounting. Measurement of outcomes (domain 6) was mixed: low in 7/21 where blinded assessors and validated tests were used; moderate in most, where bespoke sport tasks or device signals lacked validation or masking; and serious in isolated cases (e.g., Seo et al. [ 78 ]; Herz et al. [ 83 ]) due to vulnerability of signals to motion/superficial noise or unblinded procedures. Selection of the reported result (domain 7) was uniformly moderate, reflecting absent preregistration and analytic multiplicity.

Given the predominance of serious confounding and moderate selective-reporting risks, non-randomized evidence offers very low to low certainty for causal inference while remaining informative for feasibility, safety, and implementation. This profile, combined with the RoB 2 ratings for the randomized trials, supports an overall certainty of very low to low for most sport-simulation VR outcomes in neurological rehabilitation. To strengthen inference, future cohorts should: (i) prospectively register protocols with an explicitly prioritized primary outcome aligned to return-to-sport; (ii) measure and balance key prognostics using propensity scores or inverse-probability weighting and consider quasi-experimental designs (stepped-wedge, interrupted time-series); (iii) blind assessors and employ validated sport-linked tests with documented reliability; (iv) implement comprehensive exposure/fidelity logs captured directly by the VR system; and (v) report in accordance with ROBINS-I, with transparent handling of multiplicity. Consistent with rigorous methodology, studies adjudicated at serious/critical ROBINS-I risk will be treated as hypothesis-generating only, down-weighted in the synthesis, interpreted as exploratory signals rather than confirmatory evidence, and used primarily to inform sensitivity analyses and the design of future, better-controlled investigations.

SWiM-structured narrative synthesis

We grouped studies (see supplementary Table 1 ) by neurological population (SCI, stroke, CP, MS, and mixed/other) and, within each group, by VR modality (immersive vs. non-immersive) and sport-simulation class (ball-striking, wheelchair-court, paddling/rowing, archery/target, cycling). Within each population-modality grouping we also recorded the fidelity level of the VR system so that immersive high-fidelity platforms and non-immersive exergames could be contrasted qualitatively when interpreting the direction and magnitude of effects. Outcomes were organized hierarchically as (i) direct sport-specific performance (e.g., accuracy, speed) or validated surrogates tightly linked to return-to-sport (balance, gait/agility, reaction time, power/endurance, kinematics), (ii) physiological/autonomic markers (HR, VO₂, HRV), (iii) participation/return-to-sport, adherence/usability, and safety. When pooling was inappropriate, we applied a direction-of-effect rubric with a priori improvement rules (e.g., faster timed tests, higher task accuracy, favorable HRV, fewer adverse events). Certainty judgments in this narrative explicitly reflect the design-specific risk-of-bias appraisals (RoB 2 and ROBINS-I). Findings drawn mainly from trials with some concerns or high risk, or from non-randomized studies at serious risk of bias, are treated as low or very low certainty and interpreted as hypothesis generating, whereas more confident statements are reserved for outcomes supported by lower risk-of-bias strata and transparent dosing and fidelity reporting.

From exergame boxing to VR cycling: cardiometabolic load and performance in SCI

Across SCI cohorts, two themes recur: sport-simulation VR is feasible and acceptable, and it can deliver sport-linked functional gains or health-promoting aerobic doses over short exposures. In a home-based RCT of immersive VR soccer for ambulatory, motor-incomplete cervical SCI, the VR group outperformed a matched non-VR program over four weeks on lower limb functional performance (Chair Stand Test, d = 0.71), fall-risk mobility (Timed Up-and-Go, d = 0.42), overground gait speed (10-m Walk, d = 0.61), and a distinct VR kick-speed test (d = 0.31), with all between-group contrasts significant despite both groups improving from baseline (twelve 30-min sessions) [ 46 ]. Acute physiology studies suggest that sport exergames can achieve at least moderate cardiovascular stimulus, but intensity varies by title and setup. A laboratory crossover in wheelchair boxers using an immersive boxing application reported essentially identical average HR across conditions (129 bpm; 69% HRmax), placing sessions in the American College of Sports Medicine (ACSM) moderate domain. Small wrist loads elevated perceived exertion without materially altering HR-zone exposure; enjoyment was high in both conditions [ 47 ]. Complementary cross-sectional data in wheelchair-dependent adults showed that 45 min of mixed exergaming sustained 25 min above 50% VO₂peak and 7 min above 80% VO₂peak, with boxing yielding a small increase in high-intensity time versus a fruit-slicing game; time above threshold was not meaningfully influenced by lesion level or baseline cardiorespiratory fitness [ 64 ]. Head-to-head modality comparisons reinforce feasibility. During seated boxing, a 15-minute PlayStation Move session produced VO₂, metabolic equivalent of task (METs), HR, and perceived exertion that were statistically indistinguishable from conventional heavy-bag work, while participants preferred the exergame for enjoyment and home suitability [ 47 ]. In hybrid arm-crank plus FES-leg cycling, a non-immersive VR replication of an outdoor course matched real-world cycling for VO₂ (1.3 L·min⁻¹) and HR (125–128 bpm), yet indoors achieved substantially higher distance, speed, limb activity counts, and mechanical efficiency, with similar rating of perceived exertion (RPE) and minimal cybersickness [ 65 ].

Read together, these groupings yield a coherent pattern: short-term improvements in sport-relevant function with immersive sport-simulation VR and reliable delivery of moderate cardiometabolic load with boxing-style paradigms, supported by convergent physiological and performance metrics. The certainty underpinning these statements is low, with relatively higher confidence for short-term functional outcomes derived from randomized trials rated as having some concerns in RoB 2 and for laboratory-classified dose, and very low for longer-term transfer to on-field performance, which currently rests on small non-randomized samples at serious risk of bias [ 46 , 47 , 64 , 65 ].

Stroke Rehabilitation, reframed: Sport-Simulation VR as Task-Specific practice

Evidence in stroke spans metabolic characterization of sport-like exergames and task-specific practice embedded in a paddling archetype, with convergent signals on aerobic dosing and proximal postural control. In a proof-of-principle study of ambulant adults with chronic stroke, Wii Sports boxing and tennis elicited moderate aerobic intensity, approximately 4.1 and 3.7 METs, respectively, with session VO₂ rising to roughly 2–3 × resting levels; perceived exertion was consistently higher during boxing, although oxygen cost did not differ significantly between titles, and heart-rate responses remained within safe training zones [ 51 , 52 ]. These data situate widely available sport-exergames within a training range compatible with submaximal conditioning in stroke rehabilitation, while also indicating that title selection (striking vs. racket) modestly shifts the perceptual load without materially changing metabolic demand [ 51 , 52 ]. Task-representative training produced the clearest functional effects when virtual environments instantiated canoe-paddling, a trunk-centric, bilateral upper-limb task with continuous postural regulation. In a randomized inpatient trial in subacute stroke (randomized n = 31, analyzed n = 30), adding five weeks of game-based paddling to conventional therapy yielded greater improvements than usual care alone in seated Functional Reach (forward and lateral) and posturography under challenging sensory conditions, with statistically significant between-group advantages for closed eyes center of pressure path and sway velocity (Eyes Closed - Center of Pressure path length p = 0.044; Eyes Closed - Sway Velocity p = 0.028) [ 56 ]. Upper-limb performance mirrored this proximal emphasis: Manual Function Test (MFT) total and upper-limb subscores improved more in the VR arm (MFT total p = 0.025), whereas hand-specific dexterity did not differ between groups, consistent with the paddling task’s load on trunk control and shoulder–elbow coupling rather than fine prehension [ 56 , 57 ]. Adherence met pre-specified thresholds, therapist usability ratings were favorable, and no intervention-related adverse events were recorded, supporting ward-level feasibility for short cycles of sport-simulation practice [ 56 , 57 ].

Viewed through the SWiM lens, the direction of effect is coherent across designs: sport-like exergaming in ambulant, chronic stroke reliably reaches moderate intensity without safety signals [ 51 , 52 ], and canoe-simulation add-ons in subacute inpatient care preferentially enhance postural stability and proximal upper-limb function beyond usual therapy over five weeks, with statistically robust changes on reach and sway metrics and meaningful gains on the MFT composite [ 56 , 57 ]. Although exposure was short and outcomes concentrated on proximal control rather than distal hand skill, the pattern aligns with the representativeness of the trained task: energy-cost profiles track the movement archetype (boxing > tennis for RPE at comparable VO₂), and functional benefits accrue where the virtual constraints (continuous bilateral paddling, optical flow, seated balance demands) are tightly coupled to the targeted capacities (trunk control, anticipatory postural adjustments, shoulder–elbow power) [ 51 , 52 , 56 , 57 ]. The overall certainty of evidence in stroke populations is low because the key trials are small, single-centre studies with RoB 2 some concerns due to incomplete reporting of randomization, lack of preregistered analysis plans, and limited follow-up, so the observed gains should be viewed as short-term, low-certainty signals rather than definitive proof of durable sport performance change [ 51 , 52 , 56 , 57 ].

Balance-Board vs. Striking games in CP: who gains what?

A recurrent theme across CP trials is task-outcome specificity: balance-board, weight-shift paradigms consistently enhance postural stability and short-distance mobility, whereas striking/hand-tracking content preferentially improves manual dexterity and prehension, with between-group advantages most apparent when intervention dose is higher and the virtual task closely aligns with the targeted functional construct. Across four controlled trials, sport-themed exergaming consistently demonstrates feasibility and short-term functional gains, with between-group superiority emerging for balance and mobility in selected protocols and for hand dexterity in others. In children with mild CP receiving standardized neurodevelopmental treatment (NDT), adding Wii Fit balance games for 12 weeks produced larger improvements than adding conventional balance exercises in forward/side reach, Sit to Stand, Timed Up and Go, 10-m walk, and 10-step climb (between-group partial ηp² up to 0.70) and yielded a higher Wee-FIM total. Transfers did not differ between groups [ 49 ]. These large between-group effects arise from a single-centre RCT judged at high overall risk of bias in RoB 2 because allocation concealment and assessor blinding were not reported and analyses were based on completers, so findings are best interpreted as hypothesis generating rather than definitive evidence of superiority [ 49 ]. In an assessor-blinded, three-week pilot RCT, Wii tennis/boxing added to intensive therapy produced within-group gains in Pediatric Balance Scale, Box-and-Block, walking speed, and endurance comparable to therapy alone, while the VR arm showed unique improvements in QUEST grasp and total. Between group change scores were not significant, indicating that the brief exposure likely preferentially trained grasp/prehension rather than postural stability [ 48 ]. From a SWiM perspective, effects cluster by outcome domain and task representativeness. Balance oriented, weight shift “board-sport” paradigms align with postural stability and mobility gains and tend to show between-group advantages when delivered at higher dose (e.g., 12 weeks) and embedded alongside NDT [ 49 ]. Striking and hand-tracking content (e.g., tennis, boxing, Leap Motion tasks) primarily trains manual dexterity, yielding selective gains, such as improved QUEST grasp scores and unilateral Minnesota Manual Dexterity Test (MMDT), without consistent advantages in gross mobility over short exposures [ 48 , 50 ]. Two additional trials emphasize home feasibility and mixed transfer: a powered RCT of home Wii Sports Resort™ (six weeks with 12-week maintenance) reported no group advantage on coordination or hand-function tests, a small, nonsignificant trend for grip strength, and higher caregiver-reported bimanual use at 12 weeks [ 52 ]. An eight-week comparison of video game based therapy (Wii + Leap Motion) versus NDT showed improvements in both groups across dexterity, strength, and activities of daily living (ADLs), with a larger unilateral MMDT gain in the gaming arm ( p = 0.014) but otherwise comparable outcomes, except better “eating” scores with NDT [ 53 ]. Adherence was high across clinic and home programs, and adverse events were not reported as serious in these cohorts, supporting deliverability of sport-themed VR within pediatric rehabilitation pathways [ 48 – 50 , 52 ].

Overall, the direction-of-effect pattern indicates that balance-board paradigms most reliably enhance static/dynamic balance and short-distance mobility, whereas striking/hand-tracking games preferentially influence prehension and task-based dexterity, with the magnitude of between-group differences contingent on dose and the closeness of the virtual task to the targeted functional construct [ 48 – 50 , 52 ]. The certainty underpinning these patterns is very low to low, reflecting small samples, short exposures, and RoB 2 ratings of some concerns or high risk across most CP trials, so clinicians should treat the observed task-specific gains as preliminary signals pending confirmation in larger, methodologically robust studies [ 48 – 50 , 52 , 53 ].

Risk profile of Sport-Simulation VR: signals on Safety, Adherence, and enjoyment

Across studies reporting safety, serious adverse events were rare, and adherence was generally high. In MS trials, supervised balance board programs documented no falls during sessions or travel; over the study periods, total falls were fewer in the exercise arms than in controls, and a long home program noted only mild/moderate knee or low-back pain in a minority, with one withdrawal attributed to musculoskeletal symptoms [ 53 – 55 ]. In SCI laboratory protocols and exergame sessions (boxing, cycling), no autonomic dysreflexia or injuries were recorded; cybersickness was minimal during indoor VR cycling, with low ocular symptom scores on the VRSQ and no nausea reports, and perceived exertion remained in a submaximal range despite moderate HR/VO₂ responses [ 47 , 65 ]. Pediatric CP programs, clinic-based and home-based, achieved high adherence (e.g., 96% of planned Wii sessions) and no serious adverse events, with therapists and caregivers rating systems as acceptable and easy to integrate into daily routines [ 48 , 49 , 52 ]. Where enjoyment or perceived “exercise-likeness” was measured, exergaming was preferred to matched conventional drills despite physiologically equivalent loads (e.g., seated boxing vs. heavy-bag work) [ 47 ]. Notwithstanding these favorable signals, adverse-event capture was heterogeneous: several short, clinic-based add-ons did not pre-specify taxonomies or surveillance windows, and others relied on spontaneous reporting rather than structured logs, constraints that limit the precision of safety incidence estimates and the comparability of tolerability profiles across protocols [ 50 , 52 ]. Formal risk-of-bias appraisals classified most safety cohorts as RoB 2 (some concerns) or ROBINS-I (serious risk), so the apparent absence of serious adverse events supports only very low to low certainty about the safety profile and warrants cautious implementation with prospective monitoring [ 47 – 55 , 64 , 65 ].

Mechanistic alignment: virtual task demands and measured Sport-Relevant outcomes

Outcomes consistently tracked the representativeness of the virtual task. In subacute stroke, adding canoe-paddling VR, continuous bilateral action with substantial trunk demand, improved seated reach and reduced closed eyes sway beyond usual care, while MFT totals and upper-limb subscores increased more in the VR arm; hand-specific dexterity did not differ, mirroring the task’s proximal emphasis [ 56 , 57 ]. In CP, balance-board “board-sport” challenges (e.g., skiing/slalom, soccer heading) aligned with static/dynamic balance gains and short-distance mobility improvements, whereas racket/striking content (boxing/tennis) preferentially shifted prehension/hand coordination (e.g., QUEST grasp, unilateral MMDT), with neutral effects on global mobility over very short exposures [ 48 , 49 , 52 ]. In MS, weight-shift paradigms with visual feedback led to reproducible sway reductions and gains on Berg and Four Square Step Test (FSST), while effects on 25-Foot Walk and fatigue were smaller and variable, suggesting these tasks principally train stability/agility rather than endurance locomotion [ 53 – 55 ]. Physiological dosing followed the movement archetype. In SCI and stroke, boxing-style exergaming produced moderate cardiovascular load over brief bouts and slightly higher perceived exertion than tennis at comparable oxygen cost; hybrid VR cycling reproduced outdoor cardiometabolic dose while increasing limb activity and mechanical efficiency, consistent with uninterrupted, self-paced cranking without real-world steering constraints [ 47 , 51 , 52 , 65 ]. Across programs, progression was typically governed by in-game scoring and therapist-set difficulty (ball speed/trajectory, opponent behavior, stability challenges), with high acceptability in home settings. However, telemetry-based fidelity, minute-by-minute time-on-task, assistance levels, and difficulty histories were not uniformly reported, limiting fine-grained exposure–response analyses across studies [ 46 – 55 , 64 , 65 ]. These mechanistic inferences rely on small samples and studies rated at some concern or serious risk of bias, so they should be considered provisional explanations that require confirmation in larger, preregistered trials with more rigorous exposure and outcome measurement [ 46 – 55 , 64 , 65 ].

Discussion

Our work highlights three cross-cutting signals. First, when the virtual task faithfully captures the information-movement couplings of the target sport, such as the trunk and bilateral upper limb demands of canoe paddling or the anticipatory striking and guard of boxing, short cycle gains arise in the same functional domains. In subacute stroke, paddling paradigms are followed by improvements in postural stability and seated trunk reach [ 56 , 57 ]. In CP, striking games and upper-limb-focused exergames preferentially enhance grasp and prehension [ 50 , 52 , 72 , 75 ]. In SCI and ambulant stroke, boxing-style and striking sessions reliably deliver moderate cardiometabolic doses [ 47 , 64 – 66 , 77 , 80 , 81 ]. Second, “exercise-like” dosing is routinely achievable with sport-simulation VR, especially for upper-limb dominant archetypes, but intensity varies by title, setup, and impairment, underscoring the need for quantification beyond RPE [ 47 , 51 , 52 , 64 , 65 ]. Third, feasibility and acceptability are high across clinic and home settings, with sparse serious adverse events, though safety capture is inconsistent [ 47 – 55 , 64 , 65 ]. Across diagnoses, these signals derive from changes in clinical and laboratory surrogates (e.g., balance, agility, reaction time, and cardiometabolic responses) rather than direct measures of competition performance or confirmed return-to-sport. These cross-diagnostic patterns arise from studies that are predominantly small, single-center trials and non-randomized cohorts with RoB 2 some concerns or ROBINS-I serious risk, so the strength of inference about causal effects and real-world sport performance remains low. This pattern refines broader neurorehabilitation syntheses that pooled heterogeneous VR tasks. By isolating sport-simulation contexts and return to sport proximal outcomes, we show where representativeness matters for transfer [ 62 , 63 ]. Focusing on sport-simulation contexts and return-to-sport–proximal outcomes, this review provides a practice design map that helps clinicians select VR content to train the constraints most pertinent to para sport performance. In contrast with broad stroke and MS overviews, where immersive and non-immersive VR are frequently aggregated and endpoints range from impairment to participation [ 64 , 65 ], we show where and how representativeness matters for transfer-appropriate gains. These distinctions also sharpen where evidence is weakest: durability beyond short cycles, transfer to on-field metrics, and standardized fidelity monitoring (time-on-task, assistance, difficulty trajectories) across platforms. The sport-simulation focus aligns with ecological dynamics and representative learning design, which argue that skill emerges from the continuous regulation of performer task environment constraints and that practice tasks should preserve the specifying information of competition to support transfer [ 66 ]. The short-cycle, domain specific gains we observed are consonant with this theory, as are the dose–response nuances predicted by the Challenge Point Framework (nominal vs. functional difficulty) and the OPTIMAL account of motivation and attentional focus [ 27 , 28 ]. Presence and feasibility, especially in immersive systems, support transfer when the virtual scene achieves high task representativeness, that is, a close correspondence to real-world constraints and information movement couplings. When representativeness is limited or cybersickness intrudes, effects diminish. These mechanisms are widely discussed in motor learning and VR science but have been under-applied to para-sport rehabilitation design. Our review closes that gap empirically by tying which virtual constraints were manipulated to which outcomes shifted. To operationalize these implications for practice, Table 2 synthesizes a clinical-to-performance bridge that links impairment domains to sport-performance constraints, representative VR exemplars, tunable design parameters, aligned return-to-sport outcomes, and safety/implementation notes [ 85 – 107 ]. Table 2 Clinical to Performance Bridge for Sport Simulation Virtual Reality in Neurological Populations Impairment domain Sport‑performance constraints VR sport‑simulation exemplars Key design parameters to manipulate in VR Primary outcomes aligned to return‑to‑sport Safety & Implementation Impaired muscle power/paresis (SCI, stroke, CP) [ 85 – 87 ] Reduced propulsion/acceleration; impaired trunk control Table tennis shadowing; seated rowing/kayak; boxing pad work; wheelchair sprint drills Progressive resistance via ball/paddle speed; trunk–arm coupling; variable practice; external‑focus cues; augmented feedback (KP/KR) Task accuracy/speed; trunk control reach; upper‑limb power/endurance; drill completion time Stabilize seating; integrate assistive devices Spasticity/hypertonia (CP, stroke, MS) [ 88 – 90 ] Movement inefficiency; limited ROM; timing errors Archery aiming; controlled forehand drives; cycling/handcycle ergogames Slow‑to‑fast progression; rhythmic pacing; gentle ROM challenges; constraint‑led simplifications Movement smoothness; consistency; precision‑focused agility tests Embed warm‑up/cool‑down; monitor spasms Ataxia (cerebellar, MS) [ 91 , 92 ] Poor coordination; balance instability; endpoint variability Archery/target drills; paddle cadence matching; balance‑board soccer passes Lower visual gain; stable optic flow; bandwidth feedback; graded variability; brief bouts + rest Endpoint error; trunk sway; anticipation timing; dual‑task balance agility Falls risk controls; seated alternatives Tremor/dyskinesia/dystonia (PD etc.) [ 93 – 95 ] Aiming/tracking errors; intermittent loss of precision Table‑tennis returns; goalball blocks; virtual rifle/archery stability Predictable→stochastic timing; frequency‑matched tasks; external focus; low‑latency HMDs Hit rate; reaction time; movement variability indices Med‑on/off scheduling; fatigue breaks Sensory loss/neuropathy/proprioception [ 96 – 99 ] Delayed reactions; instability; reduced limb awareness Boxing with haptic gloves; football passing with vibrotactile cues; kayak timing with audio‑haptics Multimodal cues (visual‑audio‑haptic); error augmentation→fading; stance/progression controls Step time variability; sway; task accuracy; response time Skin checks with peripherals; calibrate haptics Autonomic dysregulation (thermoregulation, BP/HR; high‑level SCI) [ 100 – 104 ] Heat intolerance; chronotropic incompetence; orthostatic symptoms Seated paddling intervals; wheelchair court drills with HR targets Cool scene design; interval dosing; HR/HRV auto‑monitoring; RPE prompts; auto‑stop rules HR/HRV dose achievement; adherence; adverse event log Cooling strategies; seated starts Cognitive/dual‑task interference (TBI, PD) [ 105 – 107 ] Decision latency; errors under pressure; divided‑attention costs Small‑sided games; boxing with cognitive cues; passing drills with rule switches Graded task switching; contextual interference; autonomy/motivation elements (OPTIMAL) Choice reaction time; decision accuracy; dual‑task gait/agility; error rates Avoid overload; short frequent bouts Legends Virtual reality ( VR ), spinal cord injury (SCI ), cerebral palsy ( CP ), knowledge of performance/knowledge of results ( KP/KR ), multiple sclerosis ( MS ), range of motion ( ROM ), Parkinson’s disease ( PD ), head-mounted display ( HMD ), blood pressure ( BP ), heart rate ( HR ), heart rate variability ( HRV ), rating of perceived exertion ( RPE ), traumatic brain injury ( TBI ), Optimizing Performance Through Intrinsic Motivation and Attention for Learning ( OPTIMAL )

Immersive vs. non-immersive VR: what changes for sport-relevant outcomes?

Across diagnoses, immersive systems tended to heighten presence and permit tighter control of optic flow, opponent behavior, and error bandwidth, features theoretically conducive to perception action coupling and skill transfer [ 80 , 108 ]. Stroke trials using game-based paddling, semi-immersive yet highly representative, improved trunk reach and sway beyond usual care [ 56 , 57 ], while walking exergaming with boxing or tennis consistently delivered moderate aerobic intensity despite only modest perceptual differences between titles [ 51 , 52 ]. In SCI, immersive boxing elicited heart rates in the American College of Sports Medicine moderate domain and was preferred to conventional analogs despite comparable physiological load, and hybrid VR cycling reproduced the cardiometabolic dose of outdoor sessions while improving indoor mechanical efficiency via uninterrupted cranking [ 47 , 65 ]. These sport specific signals refine the broader feature from meta-analyses in stroke that show small-to-moderate activity gains with VR augmentation [ 66 – 68 , 109 – 111 ]: posture dominant archetypes (paddling, board-sports) more often translate into balance metrics, whereas striking archetypes bias toward dexterity or anticipatory control. In MS, non-immersive balance board training repeatedly reduced sway and improved Berg/FSST, with smaller and more variable effects on walking speed and fatigue, an observation that parallels disease-specific syntheses reporting reliable balance benefits but modest ambulatory changes [ 71 – 73 , 108 , 112 , 113 ].

Evidence from network and conventional meta-analyses indicates that immersion can yield superior motor outcomes compared with non-immersive or console-based platforms during upper limb rehabilitation after stroke, plausibly by enriching task-relevant information and error signals [ 110 , 114 ]. Conversely, for stance control and weight shift tasks typical of board-sport analogs in MS, non-immersive platforms with clear visual feedback appear sufficient to move sway and clinical balance scales, with incremental value from immersion not yet consistently demonstrated [ 111 , 115 ]. Whether higher presence primarily boosts motivation rather than learning remains debated. Recent reviews suggest that presence interacts with representative task design. Immersion appears most consequential when the target skill depends on time-critical perception (e.g., ball flight, opponent kinematics), whereas for quasi-static postural goals, well-designed non-immersive tasks can achieve comparable outcomes [ 80 , 116 – 118 ]. The pragmatic takeaway is not “immersive VR always better,” but rather “match the medium to the constraint”: deploy immersive scenes when informational fidelity and fast anticipatory decisions drive the target skill, and favor non-immersive systems for stability/agility goals where explicit visual feedback and progressive weight-shift challenges suffice [ 66 – 73 , 80 , 116 ].

Dosing, feedback, and representative task design: implications for return-to-sport

Organizing the evidence by movement archetype (boxing/striking, paddling, board-sport balance) and outcome domain (aerobic dose, postural control, dexterity) clarifies dose-response patterns and how feedback interacts with representativeness. Boxing paradigms consistently achieved moderate HR/VO₂ over brief bouts in SCI and ambulant stroke, while tennis elicited slightly lower perceived exertion at comparable oxygen cost, suggesting title-specific perceptual demands with broadly similar metabolic pricing [ 47 , 51 , 52 , 64 ]. In CP and MS, board-based weight-shift programs improved static/dynamic balance and short-distance mobility over 4–12 weeks, whereas striking/hand-tracking tasks preferentially shifted prehension metrics (e.g., QUEST, unilateral MMDT), particularly under shorter exposures [ 48 – 50 , 52 – 55 ].

Two practical questions follow. First, what feedback schedule best supports transfer to on-field skills? Evidence from motor learning indicates that augmented feedback (knowledge of results/performance), when delivered with bandwidths, fading, or task-contingent rules, enhances acquisition while protecting retention; excessively frequent, prescriptive feedback risks dependency [ 119 ]. In our corpus, studies that documented therapist-set difficulty and explicit feedback rules tended to show more consistent gains, but few exported telemetry (e.g., minute-by-minute time-on-task, difficulty level, assistance applied), limiting formal exposure response modeling. Second, how “representative” must the task be? When the virtual task tightly couples information movement variables found in the target sport (optic flow, opponent behavior, paddle/ball dynamics), proximal outcomes shifted in lockstep, paddling VR improved trunk reach and sway; board-sports improved Berg/FSST; striking tasks nudged grasp and anticipatory control, supporting a constraints-led match between practice and performance contexts [ 47 – 55 , 64 , 117 , 118 ].

A third, translational question is equally pressing: can we dose and supervise this effectively at home without compromising safety or fidelity? Stroke telerehabilitation trials and reviews suggest home-based programs can achieve outcomes comparable to in-clinic therapy when monitoring and progression rules are explicit, with acceptable safety profiles and strong adherence under remote supervision [ 120 – 122 ]. In MS and broader neurological cohorts, tele-exercise/tele-VR likewise shows feasibility with favorable adherence and no excess adverse events, provided progression and surveillance are defined a priori [ 123 ]. Together, these strands imply a concrete design target for sport-simulation VR: pre-specify feedback logic (what, when, and how feedback appears), log fidelity (time-on-task, level progression, assistance, HR zones), and align task representativeness with the return to sport construct being trained. Such instrumentation not only operationalizes Challenge Point/OPTIMAL assumptions but also enables reproducible, cross-study comparisons within sport-specific SWiM groupings.

Biofeedback, multisensory Integration, and the neural basis of VR-Induced gains

Sport-simulation VR can also be conceptualized as an enriched biofeedback environment that continuously maps task performance to augmented multisensory cues. Real-time visual and auditory feedback on movement accuracy, spatiotemporal timing, and joint loading enables users to adjust technique in ways that resemble biomechanical biofeedback systems for running injury prevention, where continuous feedback on impact and kinematics modifies gait patterns and loading profiles [ 124 ]. Neurofeedback studies in sport show that training based on EEG-derived performance markers can modulate attention, sensorimotor rhythms, and competitive outcomes, indicating that closed-loop feedback on neural activity can shape task-specific cortical recruitment [ 125 ]. Emerging EMG-driven visual biofeedback frameworks that extract muscle synergy patterns and translate them into intuitive kinematic displays reinforce this principle at the muscle level and support motor relearning in rehabilitation contexts [ 126 ]. Classical and contemporary biofeedback reviews in neuromotor rehabilitation converge on the view that task-oriented, repetitive training with amplified sensory cues can enhance neural plasticity by engaging underused sensorimotor pathways and establishing new sensory-motor engrams [ 127 ]. VR-based stroke rehabilitation studies that combine functional imaging or electrophysiology with behavioural outcomes demonstrate changes in interhemispheric balance, cortical connectivity, and motor maps that correlate with gains in motor function, supporting the interpretation that multisensory, biofeedback-rich virtual environments can drive experience-dependent reorganization in networks that underpin balance, dexterity, and sport-relevant function [ 128 ]. These closed-loop properties are consistent with Hebbian plasticity principles, in which repeated pairing of task-relevant sensory information with successful motor output strengthens synapses within corticospinal and cerebellar circuits. Immersive scenes that synchronise visual optic flow, vestibular input, and haptic cues may facilitate multisensory integration and recalibration of body schema, processes that are frequently disrupted after stroke, spinal cord injury, and cerebral palsy. Integration of biofeedback mechanisms with the Challenge Point and OPTIMAL frameworks suggests that sport-simulation VR should deliver feedback at individually calibrated difficulty levels, supporting autonomy and an external focus of attention while avoiding over-constraining exploratory behaviour [ 27 , 28 ]. In para-sport and adaptive sport pathways, these neuroplastic mechanisms may allow athletes with neurological impairments to rehearse complex or higher-risk movement strategies in safer virtual conditions while progressively shaping neural and mechanical readiness for real-world competition. Translating these mechanistic insights into pragmatic, sport-aligned clinical trials is therefore a critical next step, as outlined in the following roadmap for future return-to-sport studies.

Future trials for return to sport: a translational roadmap

The present evidence base is still shaped by short-cycle trials, heterogeneous outcomes, and incomplete reporting in key RoB domains, which together constrain causal inference and generalizability. Two linked trajectories can lift certainty. Mechanistically, future studies should pair sport-linked functional outcomes (e.g., seated reach, MFT, FSST, accurate interception) with physiology and neurophysiology that index the trained constraints: trunk and shoulder-elbow kinematics under controlled changes in optic flow; heart-rate/HRV dose maps and metabolic work during striking versus racket tasks; and, where feasible, functional near-infrared spectroscopy/electroencephalography markers of cortical engagement acquired with short-separation controls and assessor blinding [ 53 – 55 , 71 – 73 ]. Translationally, pragmatic RCTs should adopt theory led representative learning design, preregister a single primary endpoint aligned to return-to-sport, blind assessors, and apply multiplicity control for secondary and device derived metrics. Hybrid effectiveness designs that embed tele-VR (home practice with remote monitoring) are well suited to test durability and adherence at scale, supported by safety signals showing favorable profiles for telerehabilitation in neurological cohorts [ 129 , 130 ]. For non-randomized studies at high RoB, we recommend making the hypothesis-generating role explicit, for example, to screen which combinations of immersion, feedback, and dose are most promising within a given para-sport, then advancing the most compelling candidates into confirmatory randomized, propensity-adjusted, or stepped-wedge trials when individual randomization is infeasible.

Factorial or adaptive trials should quantify the marginal value of immersion and information fidelity for transfer, using anticipation/decision-accuracy endpoints and monitoring cybersickness and adherence [ 53 – 55 ]. Sequential multiple assignment randomized trial (SMART) designs should optimize dose difficulty trajectories, testing whether time spent in pre-specified HR/HRV zones predicts gains on sport-aligned outcomes (e.g., FSST, validated interception accuracy). Assessor-blinded RCTs should compare bandwidth/faded vs. continuous prescriptive feedback, with 1–3 month retention as the primary endpoint and planned multiplicity control for device-derived metrics. Representative learning designs should randomize task-constraint fidelity (optic flow, opponent behavior, equipment dynamics) and expect proportionally larger improvements in the matching outcome domain (e.g., trunk sway for paddling, Berg/FSST for board sports, and interception error for striking). Finally, telemetry-enabled tele-VR protocols should benchmark home vs. clinic in non-inferiority designs on a single, sport-aligned primary endpoint, using standardized safety taxonomies and prespecified surveillance windows.

From an implementation standpoint, telemetry-enabled fidelity should move from optional to mandatory: all platforms can export time-on-task, difficulty levels, assistance used, and HR/HRV traces, enabling exposure–response modeling and reproducibility across laboratories. Pragmatic multicenter trials could benchmark tele-VR versus clinic-based VR with non-inferiority margins on a single, sport-aligned primary endpoint (e.g., FSST or validated interception accuracy), while tracking safety events using standardized taxonomies and surveillance windows. To deepen external validity, studies should stratify by impairment class (e.g., lesion level in SCI, ataxic subtype), specify assistive technology interfaces (wheelchair, orthoses, haptics), and include 3–6-month retention and field-transfer assessments (e.g., observed drills or on-water tests in sailing programs). At a systems level, core outcome sets aligned to return-to-sport, covering a primary performance metric, an aerobic/HRV index, and a patient-reported participation measure, would harmonize reporting and, coupled with prospective registration and blinded analysis plans, directly address the recurrent D3-D5 weaknesses observed in RoB 2/ROBINS-I appraisals.

Assessing rigor: strengths and limitations of this systematic review

A key strength of this review is its intentionally narrow scope. By including only virtual environments that explicitly simulate recognized sports, we excluded generic VR tasks that blur clinical interpretation and focused on interventions whose information, movement demands plausibly align with return-to-sport capacities. Building on that boundary, we organized evidence using a SWiM framework that grouped studies by diagnosis, movement archetype, and outcome domain. This structure allowed us to connect constraints and design features, such as optic flow, opponent behavior, and trunk demand, to specific functional readouts, offering clinicians and performance teams a transparent constraint to outcome map rather than a single pooled estimate that would obscure representativeness and task specificity. Our risk-of-bias appraisal using RoB 2 and ROBINS-I further anchored the synthesis by guiding how much weight to place on each signal, increasing confidence where outcome measurement and handling of missing data were sound, and tempering inferences where randomization/concealment, fidelity monitoring, or multiplicity control were underreported. We did not conduct a meta-analysis because heterogeneity in immersion level, scene fidelity, comparator type, dosing schedules, and outcome taxonomies would have produced a mathematically tidy but clinically ambiguous summary, at odds with SWiM recommendations on when pooling is appropriate. Instead, we graded certainty narratively, elevating findings from trials with low risk in key domains and treating high-risk or poorly reported signals as hypothesis-generating.

Several limitations should be acknowledged. We restricted inclusion to peer-reviewed, English-language publications, which introduces potential language and publication bias and may underrepresent high-quality work published in other languages or in the grey literature. Although our search spanned six major databases, studies indexed only in regional sources or unpublished theses and conference proceedings may have been missed. Data extraction and risk-of-bias judgments were performed in duplicate with prespecified forms, yet our synthesis necessarily relied on what was reported, and incomplete descriptions of allocation concealment, fidelity, and adverse-event surveillance limit the precision of effect estimates. Most studies were short in duration, follow-up was uncommon, on-field or ecologically valid sport-performance endpoints were sparse, and telemetry (time-on-task, assistance, difficulty histories) was inconsistently captured. These shortcomings mirror patterns noted in broader VR syntheses in stroke, MS, and CP, heterogeneous protocols, small samples, and brief exposures, but in a sport-simulation frame they translate into concrete priorities for future work: exporting fidelity logs, standardizing safety taxonomies and surveillance windows, broadening language coverage and grey-literature capture, and privileging outcomes that are demonstrably proximal to return-to-sport. The current evidence base therefore supports only inferences about proximal capacities such as balance, trunk control, agility, and cardiometabolic fitness, and does not yet justify strong claims about actual return-to-sport or sustained competitive participation.

Conclusions

In neurological populations, sport simulation VR is feasible and acceptable, can deliver a moderate cardiometabolic dose in upper-limb dominant archetypes, and produces short-term gains in sport-linked function that scale with the representativeness of the trained task. Trunk centric paddling improves seated reach and sway, board-based balance tasks improve stability and short-distance mobility, and striking paradigms preferentially enhance dexterity and anticipatory control. The overall certainty is very low to low, reflecting the predominance of RoB 2, some concerns across most randomized trials, two high-risk RCTs, and serious ROBINS-I ratings in most non-randomized cohorts, despite generally robust outcome measurement and low missing data. Durable transfer to on-field performance remains to be established. The translational path is clear: design representative tasks, titrate functional difficulty and augmented feedback, embed telemetry and safety monitoring, and preregister a single sport-relevant primary endpoint. Sport-simulation VR currently appears to be a feasible and safe option to train components that are theoretically relevant for return-to-sport decisions in neurological rehabilitation, yet confirmation that these gains translate into sustained sport participation will require adequately powered trials with explicit sport endpoints.

Supplementary Information

Supplementary Material 1: Supplementary Table 1, "Summary of included studies" has been added as supporting information and is available alongside the article.

Abbreviations

Two-dimensional

Acquired brain injury / severe acquired brain injury

American college of sports medicine

Activities of daily living

Adverse event / serious adverse event

ASIA Impairment scale (american spinal injury association)

Augmented reality

Active video games

Box and block test

Blood-oxygen-level dependent (signal)

Blood pressure

Cave automatic virtual environment

Confidence interval (95% confidence interval)

Center of pressure

Cerebral palsy

Chair stand test

Cervical vestibular evoked myogenic potential

Diffusion tensor imaging / fractional anisotropy

Eyes closed (posturography condition)

Electroencephalography

Event-related desynchronization

Functional electrical stimulation

Functional magnetic resonance imaging

Functional near-infrared spectroscopy

Four square step test

High-intensity interval training

Head-mounted display

Heart rate

Maximal heart rate

Heart rate variability

Immersive virtual reality

Knowledge of performance / knowledge of results

Magnetoencephalography

Motor evoked potential

Metabolic equivalent(s) of task

Manual function test

Minnesota manual dexterity test

Multiple sclerosis

Neurodevelopmental treatment

Optimizing performance through intrinsic motivation and attention for learning (theory)

Pediatric balance scale

Parkinson’s disease

Positron emission tomography

Population, intervention, comparator, outcome

Preferred reporting items for systematic reviews and meta-analyses

International prospective register of systematic reviews

Quality of life

Randomized controlled trial

Cochrane risk of bias 2 tool

Risk of bias in non-randomized studies—of interventions

Rating of perceived exertion

Spinal cord injury

Short-interval intracortical inhibition / intracortical facilitation

Single-photon emission computed tomography

(Postural) sway velocity

Synthesis without meta-analysis

Traumatic brain injury

Tele-rehabilitation virtual reality

Transcranial magnetic stimulation

Oxygen consumption / peak oxygen consumption

Virtual reality

Virtual reality sickness questionnaire

Cohen’s kappa (inter-rater reliability)

Publisher’s Note

Springer Nature remains neutral with regard to jurisdictional claims in published maps and institutional affiliations.

Acknowledgements

None.

Authors’ contributions

Conceptualization, R.S.C., A.C., and A.Q.; methodology, R.S.C., A.C., M.G.M., F.S., and M.L.; validation, M.G.M., F.S., D.B., and A.Q.; investigation, R.S.C., A.C., M.G.M., F.S., D.B., and M.L.; resources, R.S.C. and M.L.; data curation, A.C., M.G.M., F.S., D.B., and M.L.; writing original draft preparation, R.S.C., A.C., and M.G.M.; writing review and editing, R.S.C., A.C., M.G.M., F.S., D.B., M.L., and A.Q.; visualization, A.C., M.G.M., and F.S.; supervision, R.S.C. and A.Q.; project administration, R.S.C. and A.Q.; funding acquisition, R.S.C. and A.Q. All authors have read and agreed to the published version of the manuscript.

Funding

This work was supported by Current Research Funds 2025, Ministry of Health, Italy. The funder had no role in the design of the study, in data collection, analysis, and interpretation, or in writing the manuscript.

Data availability

No datasets were generated or analysed during the current study.

Declarations

Ethics approval and consent to participate

As this systematic review involves secondary data analysis from previously published studies, no new ethical approval was required.

Consent for publication

Not applicable.

Competing interests

The authors declare no competing interests.

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