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Many adults are physically inactive. While the reasons are complex, inactivity is, in part, influenced by the presence of negative feelings and low enjoyment during exercise. While virtual reality (VR) has been proposed as a way to improve engagement with exercise (e.g., choosing to undertake exercise), how VR is currently used to influence experiences during exercise is largely unknown. Here we aimed to summarize the existing literature evaluating the use of VR to influence motivation, affect, enjoyment, and engagement during exercise. A Population (clinical, and healthy), Concept (the extent and nature of research about VR in exercise, including underpinning theories), and Context (any setting, demographic, social context) framework was used. A systematic search of Medline, Scopus, Embase, PsycINFO, and Google Scholar was completed by two independent reviewers. Of 970 studies identified, 25 unique studies were included (n = 994 participants), with most (68%) evaluating VR influences on motivation, affect, enjoyment, and engagement during exercise in healthy populations (n = 8 studies evaluating clinical populations). Two VR strategies were prominent – the use of immersion and the use of virtual avatars and agents/trainers. All studies but one used virtual agents/trainers, suggesting that we know little about the influence of virtual avatars on experiences during exercise. Generally, highly immersive VR had more beneficial effects than low immersive VR or exercise without VR. The interaction between VR strategy and the specific exercise outcome appeared important (e.g., virtual avatars/agents were more influential in positively changing motivation and engagement during exercise, whereas immersion more positively influenced enjoyment during exercise). Presently, the knowledge base is insufficient to provide definitive recommendations for use of specific VR strategies to target specific exercise outcomes, particularly given the numerous null findings. Regardless, these preliminary findings support the idea that VR may influence experiences during exercise via multiple mechanistic pathways. Understanding these underlying mechanisms may be important to heighten effects targeted to specific exercise outcomes during exercise. Future research requires purposeful integration of exercise-relevant theories into VR investigation, and careful consideration of VR definitions (including delineation between virtual avatars and virtual agents), software possibilities, and nuanced extension to clinical populations.

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Background Large systematic reviews have pointed to the efficacy of cognitive training and physical exercise on cognitive performance in older adults, making them the most common interventions in multidomain dementia prevention trials. However, it remains unclear to which extent combinations of these interventions yield additive effects beyond their individual components and what combination strategies are most beneficial. Our aim therefore was to synthesize the evidence from randomized controlled trials of combined cognitive and physical training on cognitive, physical, psychosocial and functional outcomes in older adults with or without cognitive impairment, and to compare and rank the efficacy of the three main types of combined intervention delivery formats (simultaneous, sequential or exergaming) relative to either intervention alone or control conditions. Methods and Findings We systematically searched MEDLINE, Embase and PsycINFO from inception to 23 July 2019. Change from baseline to post-intervention were extracted for each outcome and results were analyzed using random-effects models. The overall efficacy of combined interventions was assessed using multivariate pairwise meta-analysis and the comparative efficacy across different intervention delivery formats and control conditions was investigated using network meta-analysis. A total of 47 trials encompassing 4052 participants were eligible, including cognitively healthy older adults (k=30), mild cognitive impairment (k=13), dementia (k=2) and Parkinson disease (k=2). Due to the small number of identified studies in dementia and Parkinson disease, these were excluded from the pooled analyses and instead summarized narratively. Relative to any control condition, combined interventions were associated with small and heterogeneous effects on overall cognitive (k=41, Hedges g = 0.22, 95% CI 0.14 to 0.30, prediction interval -0.34 to 0.78) and physical function (k=32, g = 0.25, 95% CI 0.13 to 0.37, prediction interval -0.46 to 0.96). Cognitive and physical effects were similar for cognitively healthy older adults and those with mild cognitive impairment. No robust evidence for benefit on psychosocial function (k=9) or functional abilities (k=2) was found. The efficacy of simultaneous and sequential training for cognition exceeded all control conditions apart from cognitive training alone, with small to moderate effect estimates and moderate certainty of the evidence. The efficacy of simultaneous and sequential training on physical outcomes was comparable but not significantly greater than physical exercise alone. Exergaming was ranked low for both outcomes and superior only to passive control. The certainty of the evidence was low for physical outcomes, and we were not able to compare interventions in Parkinson disease and dementia. Conclusion Combined cognitive and physical training, delivered either simultaneously or sequentially, is efficacious for cognitive and physical outcomes in cognitively healthy and mildly impaired older adults, but not superior to cognitive or physical exercise alone in each domain. There is little systematic evidence to support potential additive effects of combined interventions or the use of exergaming in older adults. Given simultaneous training is as efficacious but less burdensome than sequential design, the former may be better suited for practical implementation to promote cognitive alongside physical health in late life. More research is needed to establish the effects of combined interventions on everyday function and well-being.