Ana Beatriz Januário Silva1,2*
Waleska Maria Almeida Barros2
Robson Feliciano Silva3
Beatriz Machado Silva4
Ana Patrícia da Silva Souza2Karollainy Gomes Silva2José Maurício Lucas Silva2Mayara Luclécia Silva2Maria Eduarda Rodrigues Alves Santos2
Sandra Lopes De Souza2- 1Federal University of Pernambuco, Recife, Brazil
- 2Programa de Pós-graduação em Neuropsiquiatria e Ciências do Comportamento, Centro de Ciências da Saúde, Universidade Federal de Pernambuco, Recife, Pernambuco, Brazil
- 3Centro Integrado de Tecnologias em Neurociência (CITENC), Centro Universitário Osman Lins (UNIFACOL), Vitória de Santo Antão, Pernambuco, Brazil
- 4Aggeu Magalhães Institute (IAM), Recife, Pernambuco, Brazil
Objective: To synthesize information on use of virtual reality (VR) technologies for improving neuromotor outcomes in children with adverse health conditions, focusing exclusively on randomized clinical trials.
Methods: The included studies followed the PICOS strategy, adhered to the methodology suggested by the PRISMA method, and complied with the protocol CRD42023416757 on the PROSPERO platform. Two databases were explored, and data collection was completed on 6 July 2024. The selected articles for this review underwent a methodological bias analysis by Joanna Briggs.
Results: A total of 824 studies were identified. After analysis using the PRISMA method and application of eligibility criteria, nine studies comprised this systematic review. Data from 260 children of both sexes were analysed across three distinct adverse health conditions: developmental coordination disorder, cerebral palsy, and autism spectrum disorder. The articles correspond to the period between 2012 and 2022. Overall, the studies reported positive outcomes regarding improvements in the neuromotor system following virtual reality-based interventions. Manual dexterity improved in two studies, while enhancements were also observed in gross and fine motor skills, balance, and trunk control.
Conclusion: According to this systematic review, motor skills may benefit from virtual reality-based interventions in children with cerebral palsy, developmental coordination disorder, and autism spectrum disorder. Domains such as manual dexterity, balance, motor coordination, and reaction time showed consistently positive outcomes.
Introduction
Sedentary behavior is a risk factor for all-cause mortality and cardiovascular diseases in adulthood (Tremblay et al., 2010). During childhood, the lifestyle developed tends to persist into adulthood, making this stage a critical period for adopting a healthy lifestyle (Yu and Zou, 2023). Adopting healthy habits may include, for example, reducing time spent in sedentary behaviors through increased regular physical activity.
A promising strategy that has gained prominence in the approach to physical activity is Virtual Reality (VR) technology (Peng et al., 2015). In summary, a virtual environment or VR is a simulation of the real world or a projection of a fictional world, generated by computational software that promotes interaction between the individual and the machine (Holden, 2005). VR utilizes technologies such as head-mounted displays, desktop computers, capture systems, motion tracking, and motion-detection gloves to mediate not only interaction but also immersion in computer-generated realities (Zanatta et al., 2023).
In this context, with the technological advancements in healthcare, bolstered by the current digital culture, physical activity is also being utilized as a therapeutic function. It has been integrated into supervised electronic interaction programs, constituting an important alternative for the treatment of cardiovascular diseases (Hammer et al., 2023) and depression (Fernandes et al., 2022). Consequently, commercial electronic games, serious games, and specific VR software have become important health tools, as they allow for human-machine interaction while providing real-time biofeedback (Perez-Marcos, 2018).
The provision of sensor-cognitive-motor stimuli is positive and enhances the use of VR in various adverse health conditions, particularly those that impair the functions of the neuromotor system. These conditions are associated with issues such as reduced autonomy, difficulties in performing daily tasks, and limitations in mobility (Rutkowski et al., 2020). Aiming to understand the improvement of the neuromotor system through VR, this review seeks to synthesize information on the use of VR technologies for exergames in enhancing neuromotor outcomes in children with adverse health conditions, utilizing only randomized clinical trials.
Methods
This systematic review adopted the criteria recommended by the PRISMA method (Preferred Reporting Items for Systematic Reviews and Meta-Analyses), as shown in Figure 1. The protocol was registered on 25 April 2023, in the International Prospective Register of Systematic Reviews (PROSPERO) database, obtaining the registration number CRD42023416757.
Figure 1. Flowchart of identification of studies via databases.
Search strategy
Searches were conducted in the databases PubMed (MEDLINE) and PsycINFO using the following keywords: VR, active video game, exergames, child, children, motor performance, motor skill, and motor rehabilitation.
For the PubMed (MEDLINE) database, the following search equation was used: ((((((virtual reality) OR (active video game)) OR (Exergaming)) OR (exergames)) AND (Movement disorder)) OR (neuromotor disorder)) AND (Child). For the PsycINFO database, the search terms were: Any Field: virtual reality OR Any Field: active video game OR Any Field: Exergaming OR Any Field: exergames AND Any Field: Movement disorder OR Any Field: neuromotor disorder AND Any Field: Child AND Age Group: School Age (6–12 years) AND Methodology: Clinical Trial.
The last search was conducted on 6 July 2024, and the results from all databases were compiled in RIS format, and then saved in the virtual library of the reference management software Mendeley (Mendeley version 1.19.8).
Selection of studies and eligibility criteria
Two independent researchers (ABJS and RFS) read all titles by database and abstracts, and the articles that met the review criteria were read in full. The presence of a third researcher (WMB) was requested in cases of disagreement. The studies included in this review followed the following criteria: randomized clinical trials and studies involving children until 12 years old with any adverse health condition who were exposed to treatments involving virtual reality aimed at improving the neuromotor system. Studies were excluded if they: a) did not assess outcomes in the neuromotor system; or b) included only healthy children.
Regarding study selection, the PICOS strategy was used as proposed by Amir- Behghadami and Janati (2020). The population (P) consisted of children with adverse health conditions; the intervention of interest (I) was the use of VR in motor rehabilitation or motor training; for comparison (C), articles that utilized and did not utilize VR-based interventions were selected; the outcomes (O) analysed were those related to the neuromotor system; and we included only studies (S) that were randomized clinical trials.
Data extraction and synthesis strategy
The records from the searches were imported into a Mendeley library (Mendeley 1.19.8), and duplicates were removed. Excel (Microsoft, 2003) was used to extract data from the included studies. Data extraction was conducted independently by two reviewers using a standardized pre-prepared form in Word. In cases of disagreement between the reviewers, a third reviewer assisted in the decision.
To synthesize the data, the information was organized into pre-established tables containing details about the authors, year of publication, sample characterization, study design, characterization of the VR intervention, characterization of the VR equipment, neuromotor outcomes, and study conclusions, in both Word and Excel formats.
Risk of bias
The Joanna Briggs Institute (2014) was used to assess the quality of the included studies, where each study was categorized according to the percentage of positive responses to the questions corresponding to the assessment instrument. As a complementary analysis of the risk of bias, RevMan 5.3.0 software was used to detect intervening factors based on the seven judgment criteria provided by the program, which are: Random Sequence Generation, Allocation Concealment, blinding of participants, and personnel, Blinding of outcome assessment, Incomplete outcome data, Selective reporting, and other bias. Thus, this review presents a low risk of bias, as shown in Figures 2, 3.
Figure 2. Risk of bias graph.
Figure 3. Risk of bias summary.
Results
In this study, a literature search was conducted in two databases (PubMed/MEDLINE and PsycINFO) to obtain information on the use of VR technologies in improving outcomes in the neuromotor system in children with adverse health conditions. After applying the eligibility criteria, nine studies were included (AlSaif and Alsenany, 2015; Chen et al., 2012; 2013; EbrahimiSani et al., 2020; Lu et al., 2018; Meyns et al., 2017; Pourazar et al., 2018; Romano et al., 2022; Şahin et al., 2020). The complete information about the exclusions is presented in Figure 1.
The synthesis of the gathered information was collected from 260 participants in a cumulative sample size from the nine studies. Two studies were conducted in Taiwan (Chen et al., 2012; Chen et al., 2013), two in Iran (EbrahimiSani et al., 2020; Pourazar et al., 2018), one in Italy (Romano et al., 2022), one in Turkey (Şahin et al., 2020), one in Netherlands (Meyns et al., 2017), and one in Saudi Arabia (AlSaif and Alsenany, 2015). The country in which the intervention was conducted could not be identified in the study by Lu et al. (2018).
The age ranges comprised between 6 and 12 years, and all studies included at least one treatment group and one control group. The adverse health conditions identified in the studies included in this synthesis were: developmental coordination disorder (EbrahimiSani et al., 2020), cerebral palsy (Chen et al., 2012; Chen et al., 2013; AlSaif and Alsenany, 2015; Pourazar et al., 2018; Şahin et al., 2020; Romano et al., 2022; Meyns et al., 2017), autism spectrum disorder (Lu et al., 2018). Additional information can be found in Table 1.
Table 1. Description of the studies.
The analysed studies showed a wide variability in the duration of the interventions, with the shortest being 4 weeks (Pourazar et al., 2018; Lu et al., 2018), while the most frequent duration was 12 weeks (Romano et al., 2022; AlSaif and Alsenany, 2015; Chen et al., 2012; Chen et al., 2013). When considering the total cumulative minutes of sessions, the shortest total time was from Pourazar et al. (2018) and Lu et al. (2018), which totaled 300 min. In contrast, the longest time was 1,440 min (Chen et al., 2012; Chen et al., 2013) (Table 1).
Regarding the location of the intervention delivery, 55.5% (5/9) took place in the participants’ homes. The clinical trials conducted by EbrahimiSani et al. (2020) and Lu et al. (2018) were carried out in school settings. Meanwhile, the studies by Pourazar et al. (2018) and Şahin et al. (2020) were conducted in a rehabilitation clinic. As for the most commonly used test among the analyzed studies, the Bruininks-Oseretsky test of Motor proficiency stood out.
The analyzed studies (AlSaif and Alsenany, 2015; Chen et al., 2012; 2013; EbrahimiSani et al., 2020; Lu et al., 2018; Meyns et al., 2017; Pourazar et al., 2018; Romano et al., 2022; Şahin et al., 2020) showed positive results regarding improvements in the neuromotor system following virtual reality-based interventions. Manual dexterity improved in two studies: Romano et al., 2022 (∆TG = 3 vs. ∆CG = −2.6, p = 0.01) and AlSaif and Alsenany, 2015 (TG = 17.3 vs. CG = 11.3). Gross and fine motor skills showed improvements (Şahin et al., 2020), with balance specifically demonstrating greater gains in the treatment group (M = 16.1) compared to the control group (M = 12.7) (AlSaif and Alsenany, 2015), along with gains of up to 17 points on the trunk control scale (Meyns et al., 2017). The complete information regarding the synthesis of the results can be found in Table 2.
Table 2. Description of the interventions of the included studies.
Discussion
This systematic review synthesizes information on the use of virtual reality (VR) to enhance neuromotor function in children with various neuromotor disorders. Data from 260 children and adolescents of both sexes analyzed across three distinct health outcomes: cerebral palsy, developmental coordination disorder, and autism spectrum disorder. VR use showed more consistent improvements among participants with cerebral palsy. Although the limited number of included studies is acknowledged, the evidence observed in these individuals spans multiple muscle groups, motor skills, and physical abilities.
The findings for each disorder are discussed in detail below. We begin with the most represented condition in the reviewed literature.
Cerebral palsy
William John Little first documented cerebral palsy (CP) in 1843 and is currently one of the most prevalent childhood disabilities worldwide, affecting two out of every 1,000 live births. It is characterized by abnormal brain development, which can impact the neuromuscular, sensory, perceptual, cognitive, and/or behavioral systems (Brasil, 2013). This dysfunction can be classified based on the predominant clinical presentation, as follows: (a) spastic–characterized by increased muscle tone; (b) dyskinetic–marked by highly variable muscle tone; and (c) ataxic–characterized by impaired movement coordination (Himpens et al., 2008).
In this review, seven out of the nine analyzed studies were conducted with participants diagnosed with either spastic or ataxic cerebral palsy. The studies by Şahin et al. (2020) and Pourazar et al. (2018), included children with spastic cerebral palsy with unilateral anatomical distribution, while AlSaif and Alsenany (2015) and Meyns et al. (2017) included children with bilateral spastic distribution. On the other hand, Chen et al. (2012), Chen et al. (2013) did not specify the anatomical distribution; instead, they classified participants according to levels I and II of the Gross Motor Function Classification System (GMFCS). Romano et al. (2022) was the only study to include children with ataxic cerebral palsy.
It was observed that children with spastic cerebral palsy and unilateral anatomical distribution experienced positive and significant improvements in motor proficiency, running, balance, strength, upper limb coordination, gross and fine motor functions, as well as in simple and discrimination reaction times. Conversely, studies examining the use of VR in cases of cerebral palsy with bilateral anatomical distribution did not identify significant improvements in the neuromotor outcomes assessed.
A randomized clinical trial (Jha et al., 2021) compared the use of VR combined with traditional physiotherapy to traditional physiotherapy alone, evaluating 38 children with bilateral cerebral palsy in terms of gross motor performance, balance, and daily living activities. Overall, the intervention protocol consisted of 60-minute sessions, four times per week, over a 6-week period.
Similar to the findings of AlSaif and Alsenany (2015), the aforementioned authors did not identify significant improvements following the intervention, as measured by the Pediatric Balance Scale (PBS) (43.8 ± 6.1 in the intervention group and 40.2 ± 5.4 in the control group; p = 0.06), the Gross Motor Function Measure-88 (GMFM-88), which evaluates gross motor skills (88.9 ± 6.9 in the intervention group and 86.6 ± 5.1 in the control group; p = 0.254), or the WeeFIM instrument, which assesses functional independence (95.2 ± 12.9 in the intervention group and 89.5 ± 14.2 in the control group; p = 0.201).
Although VR is a promising tool, its use in individuals with cerebral palsy requires studies with greater methodological rigor and more detailed descriptions of the study population in order to better understand the differences based on the type of cerebral palsy and anatomical distribution.
Developmental coordination disorder
Developmental coordination disorder (DCD) is of idiopathic origin and is classified under the neurodevelopmental disorders section and the motor disorders subsection of the DSM-5. Its diagnosis is based on four criteria: (i) acquisition and execution of motor skills inconsistent with the individual’s age; (ii) motor difficulties that significantly interfere with activities of daily living, academic or occupational performance, leisure, and play; (iii) no better explanation for the motor impairments, such as intellectual disability, visual impairment, or other neurological conditions affecting movement; and (iv) onset of symptoms during the early developmental period (Blank et al., 2019).
In the present review, only one study addressing DCD was included. It evaluated 40 children and aimed to assess the effect of a VR training program using the Xbox 360 and Kinect sensor on predictive motor control functions (EbrahimiSani et al., 2020). After 8 weeks, the authors observed that children in the intervention group improved in motor imagery ability (intervention group: 1.56 ± 0.39; control group: 1.86 ± 0.47; p = 0.031) and action planning (intervention group: 16.1 ± 1.77; control group: 2.65 ± 1.75; p < 0.001) compared to the control group.
A systematic review conducted by Mentiplay et al. (2019) also evaluated VR- or video game-based interventions in children with DCD, focusing on motor outcomes. Similarly to EbrahimiSani et al. (2020), they identified a range of positive motor changes, although not specifically in predictive functions. The review included 325 children with DCD, who showed improvements in strength, anaerobic performance, aerobic fitness, and both static and dynamic balance.
In contrast to these designs, another group of authors (Gonsalves et al., 2015). Aimed to identify movement pattern differences between children with DCD and typically developing children using a VR system. A total of 38 children were analyzed, and no significant differences were found in hand path distance during a virtual table tennis game. However, when wrist and elbow angles were analyzed during two specific game movements, children with DCD showed significantly greater wrist extension angles (95% CI = 22.6–47.0; p < 0.001) and greater maximum elbow flexion angles (95% CI = 7.4–37.1; p = 0.04) compared to typically developing peers.
Based on these findings, it can be concluded that VR systems go beyond rehabilitation and training purposes, enabling the identification of differences in motor execution and body skills between children with neuromotor disorders and those with typical development—highlighting the need to further explore virtual environments even in typically developing populations.
Autism spectrum disorder
Although this systematic review, through a rigorous study selection process, included only one study addressing autism spectrum disorder (ASD), virtual reality (VR) has played multiple roles in this condition, ranging from diagnostic support (Alcañiz et al., 2022; Robles et al., 2022) to interventions aimed at enhancing motor learning in children (Biffi et al., 2018). An open-label, randomized controlled trial (Chu et al., 2023) although not directly assessing neuromotor outcomes in children with ASD, compared a digital therapy based on an interactive video game with learning style profile training—an intervention designed as a comprehensive, multidimensional correction tool that aligns the core challenges of autism with diagnostic and treatment frameworks.
In this study, 78 children with a mean age of 5.02 ± 0.52 years were evaluated over 20 weeks and 40 sessions. The results showed that children with ASD who participated in the digital immersion program demonstrated better use of their bodies and objects compared to those who underwent only the learning style profile training (95% CI = 1.211; p = 0.03). Although these findings are not entirely aligned with the age range and specific neuromotor outcomes targeted by this review, they suggest a positive effect of VR on neuromotor abilities—an effect not observed in the study by Lu et al. (2018), which did not report significant changes.
Exergames and custom intervention
Studies involving the development of interventions based on virtual reality and gamification should consider fundamental concepts for their application, such as the characterizing goal and target user groups, respectively: the main objective of the game and the targeted audience, as proposed by Göbel and Maddison (2017). These authors argue that the commercial technology used to implement VR can belong to two distinct classifications: a) those focused on entertainment; and b) serious games, which are not designed for entertainment and usually have well-defined characterizing goals and target user groups.
Commercial technologies for entertainment are widely used in studies exploring VR systems in exergames in the field of pediatric health (Andrade et al., 2019; Comeras-Chueca et al., 2021; Hassan et al., 2022; Ramírez-Granizo et al., 2020; Singh et al., 2025). Although not originally designed for a specific health purpose, the results of interventions based on this type of technology show various benefits in the pediatric population. On the other hand, VR-based serious games have a methodologically more robust and specialized construction for each target audience in question.
In this review, only two studies fit the characteristics of serious games proposed by Göbel and Maddison (2017): the study by Romano et al. (2022), which reported an improvement in finger dexterity (p = 0.01) but not in global mobility ability in children with ataxia. Their intervention used the Niurion® Kit–P2R software, which has both a well-defined characterizing goal and target user group, in addition to specialized software and hardware; and the study by Lu et al. (2018), which investigated outcomes related to direction-following, psychomotor skills, and hand-eye coordination in children with Autism Spectrum Disorder. After the intervention using the Pink Dolphins Game, the children in the treatment group showed better performance in the aforementioned outcomes compared to those in the control group (p = 0.036). The Pink Dolphins Game, like the Niurion intervention, has clear features regarding characterizing goal and target user group, reinforcing its classification as a serious game.
Both studies used commercial VR technologies based on serious games that, although methodologically more robust in construction, are poorly explored in the literature. This raises the issue of limitations in comparing results, since, due to their limited exploration, no other study was found involving either of the two serious games. Thus, this weakens the external validity of the studies, does not provide a basis for comparison and discussion, and does not represent the robustness necessary to ensure data validity, making the reported benefits more fragile. Given this, the collective authors of this review emphasize the need to expand investigations into serious games aimed at children’s health.
Therefore, it can be concluded that beyond its use for rehabilitation or training to recover motor function in children with neuromotor disorders, VR can also be applied to the development of movement assessment models and even serve as a diagnostic aid. In summary, VR systems, whether based on commercial video games or specifically designed health-focused software, appear to be promising tools for improving the quality of life, health status, and autonomy of these individuals. Nevertheless, to better understand the impact of these technologies on neuromotor outcomes in children and adolescents with neurodevelopmental disorders, further research is required.
Final considerations
According to this systematic review, motor skills may benefit from virtual reality-based interventions in children with neuromotor disorders, with the most consistent evidence found for children with cerebral palsy, particularly those with unilateral involvement. Motor domains such as manual dexterity, balance, motor coordination, and reaction time showed positive outcomes across various studies.
However, efficacy appears to vary depending on the specific disorder, the type and distribution of the condition, and the VR technology employed. The high heterogeneity of intervention protocols underscores the need for methodological standardization in studies to facilitate the comparison of results.
In particular, future research should prioritize the development and investigation of purpose-built serious games for specific conditions, which are currently underrepresented. These not only offer more tailored interventions but also have the potential to contribute to intervention standardization, thereby enabling better conclusions regarding the observed disorder. Additionally, the use of various assessment tools increases the risk of confounding bias, underscoring the need for standardization in measurement approaches.
Finally, it is important to recognize that VR’s role extends beyond rehabilitation; it also shows promise as a sophisticated and potentially low-cost tool for motor assessment, providing valuable insights into movement patterns. The author collective emphasizes that more methodologically rigorous and better-targeted research is essential to fully understand the impact of these technologies on neuromotor outcomes.
Author contributions
ABS: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review and editing. WB: Data curation, Methodology, Supervision, Visualization, Writing – review and editing. RS: Conceptualization, Data curation, Formal Analysis, Methodology, Supervision, Writing – review and editing. BMS: Funding acquisition, Project administration, Visualization, Writing – original draft, Writing – review and editing. APS: Investigation, Project administration, Resources, Software, Writing – review and editing. KS: Investigation, Resources, Software, Validation, Visualization, Writing – review and editing. JS: Data curation, Funding acquisition, Methodology, Project administration, Validation, Writing – review and editing. MyS: Conceptualization, Investigation, Writing – original draft, Writing – review and editing. MrS: Project administration, Software, Supervision, Validation, Writing – review and editing. SL: Conceptualization, Data curation, Formal Analysis, Funding acquisition, Investigation, Methodology, Project administration, Resources, Software, Supervision, Validation, Visualization, Writing – original draft, Writing – review and editing.
Funding
The author(s) declare that no financial support was received for the research and/or publication of this article.
Acknowledgments
Coordenação de Aperfeiçoamento de Pessoal de Nível Superior (CAPES) and Conselho Nacional de Desenvolvimento Científico e Tecnológico (CNPq) for their support and assistance.
Conflict of interest
The authors declare that the research was conducted in the absence of any commercial or financial relationships that could be construed as a potential conflict of interest.
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Keywords: VR, active video game, exergames, child, children, motor performance, motor skill, motor rehabilitation
Citation: Silva ABJ, Barros WMA, Silva RF, Machado Silva B, Souza APdS, Silva KG, Silva JML, Silva ML, Santos MERA and Lopes De Souza S (2025) The use of virtual reality technologies in children with adverse health conditions: can it improve neuromotor function? a systematic review of randomized clinical trials. Front. Virtual Real. 6:1542804. doi: 10.3389/frvir.2025.1542804
Received: 10 December 2024; Accepted: 15 September 2025;
Published: 03 October 2025.
Edited by:
Derek Ham, Carnegie Mellon University, United StatesReviewed by:
Veronica Lopez-Virgen, University of Colima, MexicoRuixue Liu, Northwest Normal University, China
Copyright © 2025 Silva, Barros, Silva, Machado Silva, Souza, Silva, Silva, Silva, Santos and Lopes De Souza. This is an open-access article distributed under the terms of the Creative Commons Attribution License (CC BY). The use, distribution or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited and that the original publication in this journal is cited, in accordance with accepted academic practice. No use, distribution or reproduction is permitted which does not comply with these terms.
*Correspondence: Ana Beatriz Januário Silva, YW5hYmVhdHJpenBlcnNvbmFsQG91dGxvb2suY29t