A Review of Extended Reality Exercise Games for Elderly

Yu Fu

1 a

, Yan Hu

1 b

, Veronica Sundstedt

1 c

and Yvonne Forsell

2 d

Department of Computer Science, Blekinge Institute of Technology, Karlskrona, Sweden

Department of Global Public Health, Karolinska Institutet, Stockholm, Sweden

Keywords:

Virtual Reality, Augmented Reality, Mixed Reality, Extended Reality, Game, Physical Training, Exercise,

Elderly, Old People, Health

Abstract:

With the increasing of ageing all over the world, elderly health attracts more and more attention. This paper

aims to study existing extended reality (XR) game applications for physical exercise through a literature review

with 14 papers as an outcome. Based on these papers, we explored the contributions, opportunities, and

challenges of exercise XR games for the elderly. The papers were analysed based on several perspectives,

including publication information, design and implementation, game information, teamwork and social games,

evaluation, and advantages and disadvantages. We found that the elderly were interested in and accepted the

use of XR games. The positive effect of such games was common in the research results. Even if there were

problems, such as simulator sickness, safety risks, device problems, and cost, there are still opportunities and

space for research and development in the future. The overall positive attitudes toward XR exercise games

for the elderly could be seen by both researchers, developers, and users. However, these game applications

also presented some problems and future improvements are needed. The presented review is beneﬁcial for

researchers and developers to create or enhance future XR applications by learning from existing work.

1 INTRODUCTION

The ageing problem is increasing all over the world.

From the WHO report on ageing and health (WHO,

2019), people live longer, and the age of the popula-

tion is increasing. By 2030, one out of every six peo-

ple in the world will be aged 60 years or over (WHO,

2019)and in 2050, this age group is expected to reach

2.1 billion (WHO, 2019). The ageing problem brings

many issues, especially in terms of health challenges,

such as joint pain, arthritis, diabetes, depression, and

dementia. Moreover, as the age grows, multimorbid-

ity increases. However, there are life style factors that,

directly or indirectly, can improve physical and men-

tal health, such as increased regular physical exercise

and training (WHO, 2019).

According to the WHO, active ageing ”aims to ex-

tend healthy life expectancy and quality of life for

all people as they age”. Herewith, one of the key

goals is maintaining independence. To achieve this,

the level of ADL (activities of daily living) function

https://orcid.org/0000-0003-3520-3302

https://orcid.org/0000-0002-3283-2819

https://orcid.org/0000-0003-3639-9327

https://orcid.org/0000-0002-5118-3148

needs to be sufﬁcient. There is compelling evidence

from longitudinal observational studies that sufﬁcient

levels of physical activity decrease the risk for declin-

ing ADL (Daskalopoulou et al., 2017). Moreover,

another term that is often used is frailty, of which

there are various deﬁnitions, but all of them include a

decrease in physical function or independence (Dent

et al., 2016; Devereux et al., 2019). There is also ev-

idence that physical exercise in already frail elderly

persons has a positive effect (Campbell et al., 2021).

Evidence on what type of physical exercise would

be most effective is limited. The observational stud-

ies include data on various activities such as cycling,

dancing, and walking. The intervention studies have

used various types of exercise programmes (Lindsay-

Smith et al., 2019). However, most physiotherapists

are recommending a combination of strength and aer-

obic exercises.

Exercise at home is often done using, for exam-

ple a treadmill or bicycle. However, it has also pre-

viously been shown that the rate of exercise can de-

cline due to the lack of varied stimuli in the surround-

ing (Lee et al., 2021a). Digital games have proven

beneﬁcial for motivating and engaging by supporting

fun and providing a plentiful user experience (Deterd-

Fu, Y., Hu, Y., Sundstedt, V. and Forsell, Y.

A Review of Extended Reality Exercise Games for Elderly.

DOI: 10.5220/0010907800003123

In Proceedings of the 15th International Joint Conference on Biomedical Engineering Systems and Technologies (BIOSTEC 2022) - Volume 5: HEALTHINF, pages 201-210

ISBN: 978-989-758-552-4; ISSN: 2184-4305

201

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Figure 1: The relationship of AR/VR/AV/MR technique (Milgram and Kishino, 1994).

Figure 2: Examples of AR/VR/AV/MR/XR techniques.

ing et al., 2011). Digital games can also support aims

and tasks with serious goals, such as exercise and

training (Deterding et al., 2011; Sauv

e et al., 2017).

These games are also referred to as serious games,

are not only for fun and entertainment, but also activ-

ities such as training, education, or treatment (Djaouti

et al., 2015). However, it is because serious games

have the attributes of games, they are easier to be

accepted and used continuously by users than non-

game activities, to achieve serious goals (Wilkinson,

2016). In addition, ”gamiﬁcation” as a concept is usu-

ally mentioned in relevant studies and developments

summarised from Deterding et al.’ gamiﬁcation re-

search; such term refers to using of design elements

characteristic for games in non-game contexts (Deter-

ding et al., 2011).

Adapting Milgram and Kishino’s description of

the real-world to the virtual world (Milgram and

Kishino, 1994), as shown in Figure 1, mixed reality

(MR, or hybrid reality) is the merging of the real en-

vironment and immersive techniques. According to

their description, in a sense, the transition from real-

ity to virtual reality (VR) is the diminishing composi-

tion of the real world and progressively increasing vir-

tual objects. In the real world, without digital objects,

people interact with the real environment; augmented

reality (AR) is to superimpose 3D virtual objects in

the real world (Azuma et al., 2001); Moreover, aug-

mented virtuality (AV) creates a virtual world, adds

real objects into it (Azuma et al., 2001), instead of

operating in the real environment and with digital ob-

jects, like in AR. It can be understood as the comple-

ment set to AR to a certain extent.

VR simulates a completely virtual world; in other

words, in the VR world, all objects are computer-

generated (Slater and Sanchez-Vives, 2016). Espe-

cially in the use of head-mounted displays (HMDs)

VR (one kind of immersive VR), it cuts off the per-

ception of the real world; users could hear, see and in-

teract with objects from the virtual world (Slater and

Sanchez-Vives, 2016). In addition, extended reality

(XR) is a collection of immersive technologies (in-

cluding AR/VR/MR), which refers to all real and vir-

tual technologies generated by computers (C¸

oltekin

et al., 2020), as shown in Figure 2.

Furthermore, there has been some evidence that

XR games can be good for mental and physical

health (Yu Fu, 2021). XR games are popular for

their unique immersive experience (PERKINSCOIE

and Association, 2021). However, expectations and

opportunities of XR technology go beyond digital

games. From the 2021 XR industry insider survey

by Perkin Coie LLP and XR Association (PERKIN-

SCOIE and Association, 2021), healthcare has once

again become the top application ﬁeld (except for

games and entertainment) considered by industry

practitioners to be most easily subverted by XR tech-

nology. Compared with last year (34% in 2020),

healthcare has a higher percentage of approval (38%

in 2021). The report also pointed out that due to

the impact of the COVID-19 pandemic, people stay-

ing at home for several months have strengthened the

prospects of XR technology at a certain rate of suc-

cess, especially in the ﬁelds of healthcare and educa-

tion. Consumers were more comfortable with the ex-

perience online and virtual. This means opportunities

can be seen of XR techniques combined with games,

to provide solutions for elderly physical health.

As a result, this paper aims to review academic re-

search of XR games for elderly physical exercise and

training. Based on a literature review of existing XR

applications, we analysed such games’ characteristics

and attributes. We also explored opportunities and

challenges, or users’ positive and negative attitudes,

of such applications. This study pays attention to pa-

pers focusing on physical exercise and training, in-

stead of physical exercise with a particular disease as

the background motivation. This approach is different

from XR game applications that focus on rehabilita-

tion, treatment or prevention of certain diseases (such

as stroke rehabilitation, balance training, fall preven-

tion, Alzheimer’s disease, and cognition training). To

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202

achieve the research aim, our study was conducted

with the following two research questions:

• RQ1: What existing research contributions on XR

game applications target elderly physical health

training?

• RQ2: What opportunities and challenges does el-

derly see with XR game applications for physical

health training?

The rest of the paper is organised as follows. Sec-

tion 2 describes the retrieval process for the litera-

ture review. Section 3 presents the review result into

six parts: publication information, design and imple-

mentation, game information, teamwork and social

games, evaluation, and advantages and disadvantages.

Section 4 discusses the results and Section 5 sum-

marises the conclusions and future work.

2 RELATED WORK

Miller et al., targeting older adults (over 45 years),

conducted a systematic review (2000 to 2012.07.10)

to discover the effectiveness of using VR/gaming sys-

tems for physical activity in a home; and the evi-

dence to support the feasibility of using such games

for physical activity at home. Based on their review

of 14 included papers, they found there was weak ev-

idence with a high risk of bias to prove the feasibility

and effectiveness of how VR/gaming could address

impairments, as well as activity limitations and par-

ticipation (Miller et al., 2014). Moreover, they found

affect problems of feasibility, such as high dependent

training and assistance, acceptability problems, safety

problems, high cost, etc (Miller et al., 2014). Further-

more, the report pointed out that the higher function

required to use VR gaming activities at home safely;

and the higher dependence of training and assistance

at the beginning of use (Miller et al., 2014). They

also said VR games were good for encouraging moti-

vation; and social engagement (Miller et al., 2014). In

addition, they discussed technology costs for both de-

velopers and end-users; and that the device develop-

ment trend will be more sophisticated motion-sensing

equipment (Miller et al., 2014).

A review study of VR games for the elderly was

also conducted by Campo-Prieto et al. Unlike Miller

et al.’ work, their research focused on immersive

VR (IVR) applied in physical therapy and rehabilita-

tion. In four medical science databases, they retrieved

11 included papers from the 765 publications before

2019.06. Based on those papers, they found few ap-

plications of VR games for elderly health. Among

these, most studies focused on the acceptability and

usage analysis of immersive techniques, such as sim-

ulator sickness and VR headsets (Campo-Prieto et al.,

2021). Moreover, they saw the use of Simulator Sick-

ness Questionnaire (SSQ), Self-Assessment of Com-

munication (SAC), or System Usability Scale (SUS)

to evaluate, and the blood pressure and heart rate

monitor for increasing accuracy in the applications’

protocols (Campo-Prieto et al., 2021).

They claimed there was no signiﬁcant difference

between VR and immersive VR in the literature, but

there was more IVR in physical therapy (Campo-

Prieto et al., 2021). HMD Oculus Rift, HMD HTC

Vive, and Samsung Gear VR Headset were the most

used devices (Campo-Prieto et al., 2021). They also

found the combinations of devices with VR for ex-

ergames, such as a bike or treadmill, were applied

more often (Campo-Prieto et al., 2021). It is worth

noting that they thought therapists and developers

should work together to match the needs of the target

users and improve the attractiveness of user experi-

ences (Campo-Prieto et al., 2021). They also marked

and highlighted the challenges, such as device prob-

lems and content improvements (Campo-Prieto et al.,

2021). They believed immersive VR could help with

traditional treatment and rehabilitation by being in-

centive coupled with fun (Campo-Prieto et al., 2021).

3 SYSTEMATIC LITERATURE

REVIEW

To address RQ1 and RQ2, we explored existing con-

tributions from academic studies for XR game appli-

cations targeting elderly physical exercise and train-

ing, as well as the opportunities and challenges of

features or attributes of such applications. Following

the four steps in the guidelines of Keele et al. (Keele

et al., 2007) as shown in Figure 3, we conducted a sys-

tematic literature review using the Scopus database.

Based on the keywords (augmented reality, virtual re-

ality, mixed reality, health, game, elderly, exercise,

and physical training) and their abbreviations (AR,

VR, and MR) or related words (old), we created the

search string: ((augmented AND reality) OR (ar)

OR (augmented AND virtuality) OR (av) OR (virtual

AND reality) OR (vr) OR (mixed AND reality) OR

(mr)) AND (health) AND (game) AND ( (elderly) OR

(old) ) AND ( (exercise) OR (physical AND training))

for the paper retrieval.

The search results were limited to publication

years (2011-01-01 to 2021-08-31), language (En-

glish), and paper type (article and conference pa-

per). The title, abstract and keywords review nar-

rowed down the 1585 search results to 99, and further

A Review of Extended Reality Exercise Games for Elderly

203

Figure 3: Publication retrieval process.

to 22 by reviewing the introduction and conclusions.

Finally, the full content review and preview and check

stabilised the included papers at 14, which were anal-

ysed further. As previously mentioned, we only in-

cluded research targeting ”pure” exercise and physi-

cal training for the elderly, and excluded papers that

were relevant to treatment/prevention/rehabilitation

of speciﬁc diseases and health issues, such as stroke,

fall, dementia, Parkinson, cognitive training, mem-

ory training, and Alzheimer’s disease. Based on

the convention from the UN, the referring of the el-

derly people was age over 60-year-old (Kowal and

Dowd, 2001). However, in some other research, the

age could be narrowed to 55-year-old (Ferreira and

Kowal, 2006). Thus, to cover more research, as a

baseline for the elderly, we aimed at an age in the

included review papers being 55-year-old or more.

Some papers resulting from the search were also ex-

cluded if the studies did not mention XR (6), be-

ing without game elements (1), having less than four

pages (1), or if the full content was not available (6).

4 RESULTS

Based on the 14 included papers, we analyse the

reviewed research that has been conducted to an-

swer RQ1 and RQ2. There were four papers (Ar-

lati et al., 2019; Pedroli et al., 2018), (Grani and

Bruun-Pedersen, 2017; Bruun-Pedersen et al., 2016)

which came from two projects with different research

content. Thus, we analysed them as four individual

studies. To discover the contributions of the aca-

demic studies of XR game applications for elderly

exercise and physical training and opportunities and

challenges for such game applications, we analysed

the included papers in ﬁve areas as previously men-

tioned. These were: 1) publication information, 2)

design and implementation, 3) game information, 4)

teamwork and social games and 5) evaluation.

4.1 Publication Information

All included papers came from 2016 to 2021; it is

worth noting that no included studies were published

between 2011 and 2015. The included research in

2021 was the highest and reached four papers; the fol-

lowing were three in 2020; two in each of the years

(2016, 2019, 2018); and only one from 2017. The

authors of these 14 papers involved 12 countries and

regions. More than 60% (9/14) of the included pa-

pers are research institutions from Europe and the

United States (Spain, Norway, Australia, Denmark,

US., Italy, Netherlands), followed by Asian countries

and regions (South Korea, Japan, China, Hong Kong

China).

4.2 Design and Implementation

Almost all 14 included papers were conducted by

academic researchers; they usually came from differ-

ent departments, such as medical subjects (neurology,

psychology, geriatrics, etc.), computer and engineer-

ing subjects (electronic information, industrial tech-

nology and automation, etc.), and media and commu-

nication subjects. Two papers included authors from

the hospital or nursing home, and one study men-

tioned software developers in their research.

As shown in Table 1, games with VR technol-

ogy (including immersive and non-immersive VR) ac-

counted for more than 70% (10/14) of the included

articles. Among them, three used a large screen and

other equipment to create a non-immersive VR en-

vironment, one paper used a CAVE, while the other

six applications used HMDs to achieve an immersive

VR experience. Three papers mentioned they used

the AR technique based on Kinect, the same as the

papers in the non-immersive VR technique. Only one

study used MR technology with the HoloLens. It

is worth noting that in the same application, the au-

thors changed and updated their display device from

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204

Table 1: The analysis of the included papers based on technology, game, and evaluation viewpoints.

Technology Game Evaluation

Technique Display Controller/tracker User type Posture Genre Task Number Age Method Index Scale Refer.

Immersive

HMD

limb motion trackers single sitting simulation

handball, football,

gatekeeping

135 62.7 E,Q

usefulness,

user experience

null (Chau et al., 2021)

hand controller,

ankle controller

single stand action game

change action by

different shape and

color, feed animals

20 ≥ 65 E,Q

usefulness,

user experience

Player Experience (PX) (Li et al., 2020)

null single sitting simulation cycling 20 63.6 E,Q

usefulness,

user experience

stress arousal checklist(SAC), simulator

sickness questionnaire (SSQ), ITC sense

of presence inventory (ITC-SOPI), Borg

rate of perceived exertion scale(RPE)

(Sakhare et al., 2019)

Speed sensor single sitting simulation cycling null (Ijaz et al., 2016)

HMD/TV WiFi microcontroller (on pedal) single sitting simulation cycling null (Grani and Bruun-Pedersen, 2017)

CAVE

cycle-ergometer, Arduino,

motion tracking system

hardware interface

single sitting simulation cycling 5 ≥ 59 E,Q usability system usability scale (SUS) (Pedroli et al., 2018)

Non-immersive

(curved

screen)

Arduino, hardware interface,

Hall effect sensor (on chassis),

Inertial sensor (on headset)

single sitting simulation cycling 5 ≥ 65 E,Q

usability,

acceptability

SUS,

SSQ

(Lee et al., 2021b)

big screen

cycle-ergometer, Arduino,

hardware interface

single/

multiple

sitting simulation cycling null (Arlati et al., 2019)

TV Arduino single sitting simulation cycling 24 null E,Q user experience Intrinsic Motivation Inventory (IMI) (Bruun-Pedersen et al., 2016)

null Kinect

single/

multiple

stand simulation bowling 19 68 E,Q

usefulness,

user experience

With the Physical Exercise Adherence

Questionnaire, Game Experience

Questionnaire (GEQ)

unior et al., 2021)

null Kinect single stand simulation put bird to cage 57 ≥ 65 E,Q

usefulness,

usability,

acceptability

SUS, Usefulness

Satisfaction,

Ease of Use,

Happiness,

Importance,

(Mu

noz et al., 2021)

screen

Kinect multiple/single stand action game imitate actions 27 ≥ 65 E,Q

usefulness,

user experience

Exercise Self-Efﬁcacy Scale (ESE) (Jeon and Kim, 2020)

Kinect single stand adventure island adventure 3 43-62 E,I

usability,

user experience

null (Nishchyk et al., 2020)

MR HoloLens multiple stand shooter shooting rabbit null null E,I user experience Game experience questionnaire (GEQ) (Buckers et al., 2018)

Note: 1) In the ”Method” column, ”E” represents the experiment, ”Q” is the questionnaire, and ”I” denotes the interview. 2) In the ”Age” column, the unit is the year; numbers without signs and intervals represent the average. 3) In the Table, ”null” means did not

mention such information in the papers.

A Review of Extended Reality Exercise Games for Elderly

205

a CAVE (Pedroli et al., 2018) to a large screen (Arlati

et al., 2019).

Most of the included papers had indoor bike appli-

cations, that allowed users to interact with a station-

ary bike system. They normally had sensors on them,

such as speed sensor (Ijaz et al., 2016), hall effect sen-

sor, and inertial sensor (Lee et al., 2021b). Except for

sensors, such games usually use the hardware inter-

face on the handlebar for control and interaction (Pe-

droli et al., 2018; Lee et al., 2021b). It is worth noting

that two bicycle-related articles mentioned heart rate

detection. Research in (Sakhare et al., 2019) used the

Borg RPE scale and heart rate to calculate the exercise

intensity, while in (Arlati et al., 2019), the heart rate

was used to adjust the bicycle ergometer to maintain

a constant level of effort.

AR games mainly used the Kinect as the motion

sensor and interactive way to capture the users’ actual

movements and control system. Only one paper (Li

et al., 2020) used two hands and two wearable con-

trollers to detect hand and ankle movements. The MR

study used gesture control with the HoloLens. More-

over, nine papers mentioned development and opera-

tion software, all of them were done in Unity.

4.3 Game Information

Game genres and tasks in the 14 included papers were

overlapping to some extent. We could see seven of

them using an indoor bike as part of their game task.

Except for cycling in a simulation environment, some

studies combined other tasks to train cognition simul-

taneously. For example, in the indoor game from Ar-

lati et al., they asked the user to ﬁnd all animals along

the way that start with a particular letter (Arlati et al.,

2019) and guess the city name based on the land-

mark. The animal was also used in work by Munoz

et al. (Mu

noz et al., 2021) as the game object. Their

application supports shoulder training by asking users

to raise their arms to put a bird into a cage. Chau et

al. studied a set of VR games facing a different group

of users (Chau et al., 2021). They covered physical

training with ball games, such as handball for upper

limbs and football for lower limbs. In addition, Ju-

nior et al. used a bowling game as part of their game

task (J

unior et al., 2021).

Game genres were not only the above three kinds

of simulation games, but also action, adventure, and

shooter games. Li et al. provided a VR game to im-

pact the elderly’s cognitive and physical health (Li

et al., 2020). They asked users to change their posture

and location by following different shapes and colours

of objects and feeding animals. Jeon and Kim also de-

signed an action game for elderly exercise; the game

task was following the non-player character’s actions,

thereby achieving the aim of physical training (Jeon

and Kim, 2020). Furthermore, an adventure game was

also in the included papers. Nishchyk et al. created

an AR game based on a story on an island with a pi-

rate, their parrot, and treasure chests (Nishchyk et al.,

2020). Game tasks embodied physical exercise and

revolved around treasure hunting, including climbing

stairs and ”ﬂying” by controlling the parrot. More-

over, users of the VR game by Buckers et al. were

tasked with shooting rabbits (Buckers et al., 2018) to

exercise the whole body.

From the view of using posture, except for the

seven bike applications that asked users to sit on an

indoor bike, almost all other seven studies used a

standing posture. Even someone who only focuses

on upper limbs’ training was also using a standing

posture (Mu

noz et al., 2021). The game elements,

such as rewards, avatars, and points, were used in the

included papers. Among those elements, the points

were the most used.

4.4 Teamwork and Social Games

The work presented by J

unior et al. not only con-

tributed an application but also compared the differ-

ence of ﬁtness test, physical exercise adherence, and

game experience between a team member user or a

single user before and after use (J

unior et al., 2021).

They pointed out that although the single playing re-

sults of the physical ﬁtness test had improved, the in-

crease had signiﬁcantly improved in the team playing

scenario. Moreover, the score of sensory and imag-

inative immersion in the team was higher. Further-

more, a teammate can provide support when players

feel sad, pain, or difﬁculties, to help them continue

playing. Moreover, Arlati et al. provided a social VR

bike game (Arlati et al., 2019). They implemented the

VR training with other players. Through multiplayer

mode, users were allowed to have voice contacts with

others, training collaboratively or competitively. It

can not only help with physical health but also reduce

the risk of social isolation. Furthermore, Buckers et

al. created a virtual dodgeball game (Buckers et al.,

2018). Two users were playing together to shoot balls

in the direction of a rabbit target. They believed those

games were more attractive and engaging.

It is worth noticing, multiple-user games typically

run online, but single-user games are not. They usu-

ally use ofﬂine mode. However, there were excep-

tions. The one was a single-user game, which could

connect with the web client (Mu

noz et al., 2021). And

the other one was a multiple-user game, which could

identify two users in ofﬂine mode. Thus, the website

HEALTHINF 2022 - 15th International Conference on Health Informatics

206

is not necessary (Jeon and Kim, 2020).

4.5 Evaluation

From an evaluation point of view, except for the three

included papers, which did not mention assessment

as part of their applications, we found similar meth-

ods and tools in different studies. The main evalua-

tion method was combining an experiment and ques-

tionnaire to learn the effectiveness and usefulness by

comparing the health situation before and after use

and obtaining the satisfaction level in subjective user

feedback at the end of the experiment. Standardized

scales were the most common tool for the question-

naire method in the included papers, as shown in Ta-

ble 1. Usability, simulator sickness, game/player ex-

perience received the most attention of the included

papers. The number of participants ranged from 3 to

135 in the included studies. Typically, the intervie-

wees were classiﬁed as experiment and control groups

randomly. However, some studies also tried to com-

pare the differences between age groups to divide the

respondents by age (elderly vs younger).

4.6 Advantages and Disadvantages

Based on the evaluation result from the included pa-

pers, we could see an overall positive attitude of

XR game applications for physical health and exer-

cise training from the elderly, but still some prob-

lems to address in the future. Some previous stud-

ies pointed out that older people have a negative ten-

dency towards new technologies (Hauk et al., 2018;

Lee et al., 2003). However, the evaluation results

from the included papers were all positive. Sakhare

et al. claimed that age did not signiﬁcantly affect

the feasibility of VR for the elderly (Sakhare et al.,

2019). Even the most outstanding progress during

the experiment was the group of the oldest people

(75–80) (Mu

noz et al., 2021). Positive comments

also covered high levels of learnability, ease and con-

ﬁdence in use and acceptability (Lee et al., 2021b).

Others were being innovative, fun, interactive, and

exciting (Chau et al., 2021), interesting and engag-

ing (Nishchyk et al., 2020) or beneﬁting physical and

mental health (Mu

noz et al., 2021; J

unior et al., 2021;

Li et al., 2020; Jeon and Kim, 2020).

Challenges could be classiﬁed as simulator sick-

ness, device problems, and improved content. Three

papers used the simulator sickness questionnaire.

They have similar results, that there were symptoms

such as dizziness, nausea, and disorientation dur-

ing use, but they were all mild and acceptable (Lee

et al., 2021b; Chau et al., 2021; Sakhare et al., 2019).

Sakhare et al. believed the signiﬁcant effect factor of

sickness was time, not age. The research by Chau et

al. can also support this view. They found that over

half of the uncomfortable reports came from the ﬁrst

four times of use (Chau et al., 2021). There was a pa-

per that not only pointed out the simulator sickness

problem but also provided some solutions, such as

limiting the viewing range and reducing the content,

using more realistic VR photography technology, sta-

bilizing the viewpoint, using active VR experiences

instead of passive, and based on curved TV instead of

HMD (Lee et al., 2021b).

Device problems were mainly focused on the low

user experience of HMD and controller/sensor. Chau

et al. said they would enhance the HMD to be more

portable and adjust the sensor to be unnecessary to

upright operation (Chau et al., 2021). The negative

user feedback of VR headset was received from Lee

et al.’ research and Li et al.’ study. The weight of the

HMD might lead the disorientation caused by head

pressure (Lee et al., 2021b). The VR HMD was a

bit heavy, and with improper wearing, mistakes could

easily be made (Li et al., 2020).

The content enhancements were not common

comments and were usually speciﬁc to the applica-

tion. The application by Chau et al. was advised to

improve the scoring system to enhance the sense of

accomplishment and add personalized scoring (Chau

et al., 2021). There was a similar improvement re-

quirement in rewards for the application design by

Arlati et al.. It was asked to increase the value re-

wards to enhance motivation and enjoyment (Arlati

et al., 2019). Their research also found that game

content full of memories for users was more popu-

lar (Chau et al., 2021). Furthermore, J

unior et al.

thought avatars in games are a stimulus to increase

participation (J

unior et al., 2021). Moreover, the feed-

back needed to be added when the player made mis-

takes; and the skip function for jumping the back-

ground story video was the suggestion for the work

by Nishchyk et al. (Nishchyk et al., 2020). Com-

ments from the study of Pedroli et al. were focused

on virtual environment and interaction, such as en-

hancing realism and improving proactive interaction,

increasing objects’ identify, and reducing interfer-

ence (Pedroli et al., 2018). In addition, improving the

sense of reality was also repeatedly raised by respon-

dents (Bruun-Pedersen et al., 2016).

5 DISCUSSION

Based on the results, with the similar consequence

of related studies (Yu Fu, 2021; Fu et al., 2021), al-

A Review of Extended Reality Exercise Games for Elderly

207

though not rich, we could see increased attention of

XR game applications to the physical health of the

elderly. Although papers before 2016 were not in-

cluded, the rise in academic research was obvious in

the following years. Signiﬁcantly, the included arti-

cles in the ﬁrst three quarters of 2021 had exceeded

the previous full year and doubled than 2019 and

2018. Moreover, judging from the data in this review,

the number of researches on such applications in Eu-

rope and the United States has obvious advantages.

Especially Italy and Denmark have more than two

included papers. Furthermore, since such applica-

tions are interdisciplinary, the academic background

of the researchers was mainly computer and engineer-

ing, but it tended to be diversiﬁed.

Immersive techniques did not have equal atten-

tion. Augmented virtuality exercise game for the el-

derly was not included in this review. There was only

one paper in the search result, which used the AV

technique for the elderly but was excluded due to the

target health problem belonging to mental health. In

addition, the VR technique was much more focused

than AR/MR. Especially the immersive VR (with

HMDs) contributed to the most previous solutions for

elderly physical exercise, including the most used ap-

plication: indoor cycling, and other types of games

with more room for development, such as bowling,

ball games, and action games. Although immersive

VR was the mainstream, HMD was the main display

device in this review. There were still three included

papers using the large screen as the display in non-

immersive VR, consideration of safety, experience,

and cost. The replacement of the CAVE mentioned

in the results is also out of this consideration.

Addressing the attributes and characteristics of the

elderly, the existing research showed the considera-

tions in the use of posture, motivation to use, and

interaction methods as well. It can be seen that the

included papers prefer to use a sitting posture rather

than standing. Similar to the related work (Miller

et al., 2014; Campo-Prieto et al., 2021), gamiﬁcation

technique and game elements were applied to increase

the fun and interest, thereby motivating users to con-

tinue using the applications to achieve the exercise

aim. The interaction and control should be simple and

directed to the elderly. So the less equipment, the eas-

ier interface, the better experience could be a develop-

ing trend. Although we were targeting speciﬁcally the

elderly’ physical health, it is undeniable that physical

and mental health affect each other. A study by Sauv

et al. also suggest the effect of digital games, for

the elderly, to include three dimensions of quality of

life: psychological, physical, and social (Sauv

e et al.,

2017). The existing research mentioned this from two

views: double tasks and social games. Some design

their exercise games with mental training tasks (Arlati

et al., 2019; Pedroli et al., 2018) or with beneﬁts for

cognition and attention (Li et al., 2020). Others added

features for multi-user mode to allow teamwork and

social interaction in their games (J

unior et al., 2021;

Arlati et al., 2019), which was beneﬁcial for the men-

tal health of users.

For the opportunities of XR game applications for

the elderly physical health, we could see evidence of

acceptance of those techniques by the elderly. They

have positive attitudes towards such techniques ap-

plied for their physical health improvements. The ef-

fectiveness of those VR exercise games was proven

acceptable as well. What needs attention in the study

and development of such games is the more straight-

forward operation in design, clear training of use for

users, ﬁxing the challenges of simulator sickness and

content, as well as device improvements. As the re-

sults of an earlier survey (Fu et al., 2021), the ﬁrst

three obstacles to mass adoption are user experience,

content offering, and cost to consumers.

Some included papers evaluate the simulator sick-

ness of their games. They claimed the test results

were acceptable (Chau et al., 2021). However, this

is based on the anticipation and avoidance of uncom-

fortable situations in the design and implementation

stages. For example, Lee et al. propose to stabilize

the viewpoint, reduce the viewing range, etc., to re-

duce VR dizziness (Lee et al., 2021b). Moreover,

there was evidence that with an increased use time,

the uncomfortable symptoms were reduced (Sakhare

et al., 2019). The comments for content improve-

ment were the most speciﬁc and detailed, such as

adding a skip function for jumping the background

video, more motivating elements (score, rewards, un-

lockable levels, etc.), and error operation feedback to

user (Nishchyk et al., 2020). Except for the sugges-

tions about rewards, avatars, in-time feedback, and

the shared memory content being the more popular;

we need to see the importance of user participation

in the design and evaluation. The experience of VR

games is more dependent on the device than AR.

The uncomfortable weight and cables and low expe-

rience of HMDs were also mentioned in previous sur-

veys (Fu et al., 2021; Yu Fu, 2021).

6 CONCLUSIONS AND FUTURE

WORK

Aiming in discovering the existing research contri-

butions on XR game applications that target elderly

HEALTHINF 2022 - 15th International Conference on Health Informatics

208

physical health training, and its opportunities and

challenges in study and development, this study con-

ducted a systematic literature review using the Scopus

database. From the 1585 search results, we included

14 papers for a deeper analysis. Based on the included

papers, we summarised and analysed their publication

information, design and implementation, game infor-

mation, teamwork and social games, evaluation, and

advantages and disadvantages. Through the above re-

sults, we found that the interests and acceptance of the

elderly in XR games and the positive health effects of

continuous use are opportunities and space for devel-

oping such software further. Moreover, the reduction

of discomfort and safety risks in use, the improve-

ment of hardware technology, and the improvement

of content are the main challenges that research and

development need to face in the future. This paper is

helpful for researchers and developers working in the

area, which give full play to advantages and reduce

negative impacts of the XR technique and game tech-

nology, in their studies and projects of elderly phys-

ical health. Future work could extend the search to

more databases and narrow down the application con-

tent and technical scope to ﬁnd more detailed refer-

ences.

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