Physical and Physiological Impact of Custom-Made Virtual Reality

Exergames for Older Adults

Cíntia França

1,2

, Hildegardo Noronha

, Eva Freitas

, Pedro Campos

1,3

Rui T. Ornelas

2,4

and Élvio R. Gouveia

1,2,4,5

LARSYS, Interactive Technologies Institute, Funchal, Portugal

Department of Physical Education and Sport, University of Madeira, Funchal, Portugal

WoW!Systems Informática Lda, Funchal, Portugal

CIPER, Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal

Center for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, Carouge, Switzerland

Keywords: Aging, Physical Activity, Heart Rate, User Tests.

Abstract: Aging is associated with decreased physical fitness components, such as strength, power, cardiorespiratory

fitness, and balance, resulting in physical limitations on functional activities of daily living. The increasing

population of older adults calls for innovative strategies to support functional health, particularly through

exercise. This study has two main objectives: (1) to introduce a custom-designed virtual reality (VR)

exergame prototype, FitFest, developed to deliver physical activity (PA) sessions for older adults, and (2) to

present the results of a pilot study assessing physical and physiological responses during gameplay. Seven

older adults (mean age 67.0±3.8 years) participated in 18 user testing sessions involving two VR exergames—

Wine Fest and Flower Fest. Each session was monitored for PA intensity and heart rate (HR). The participants

spent most of their time in sedentary behavior (56.5±20.4%), followed by light PA (42.1±19.3%), averaging

436.7 steps and a heart rate of 92.1 bpm per session. Although the differences were not statistically significant,

Wine Fest led to lower sedentary behavior, higher light PA levels, and more total steps than Flower Fest. The

findings suggest that the system can potentially promote light PA among older adults, emerging as a

complementary tool to traditional PA sessions.

1 INTRODUCTION

Aging is associated with decreased physical

fitness components, such as strength, power,

cardiorespiratory fitness, and balance, resulting in

physical limitations on functional activities of daily

living (Paterson et al., 2007). There is evidence that

exercise interventions among older adults can

promote gains in functional capacities, enhancing

physical health and quality of life.

According to the World Health Organization's

physical activity (PA) guidelines, older adults should

accumulate at least 150 minutes of moderate-intensity

or 75 minutes of vigorous activity per week,

emphasizing aerobic capacity (WHO, 2020).

Additionally, performing muscle-strengthening and

balance activities might be crucial to prevent falls,

which has been described as a common and serious

concern among this population (Nascimento et al.,

2022). Approximately one-third of individuals aged

65 years or older living in community settings

experience at least one fall yearly, and one-half fall

more than once (Inouye et al., 2009). Although falls

often occur due to multiple factors, previous research

has related falls to poor balance and strength abilities

and gait disorders (Clemson et al., 2010). For

instance, among 619 older adults aged 69.5 years, gait

speed and body balance presented an inverse

relationship with falls, and in turn, falls negatively

impact health-related quality of life (Nascimento et

al., 2022).

There is a significant body of research advocating

the benefits of PA in reducing the risk of several age-

related morbidities and all-cause mortality (Paterson

et al., 2007). PA programs were associated with

reducing the risk of fall-related injuries by 32% to

40%, delaying the loss of physical function and

mobility (Dipietro et al., 2019). Additionally,

França, C., Noronha, H., Freitas, E., Campos, P., Ornelas, R. T. and Gouveia, É. R.

Physical and Physiological Impact of Custom-Made Virtual Reality Exergames for Older Adults.

DOI: 10.5220/0013681600003988

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 13th International Conference on Sport Sciences Research and Technology Support (icSPORTS 2025), pages 155-162

ISBN: 978-989-758-771-9; ISSN: 2184-3201

155

according to a systematic review and meta-analysis of

longitudinal cohort studies, higher levels of PA were

related to an increase of 39% in the odds of healthy

aging (Daskalopoulou et al., 2017).

The continuous increase of the older adult

population worldwide demands the urgency to

provide ways to maintain and improve functional

health during aging. Due to the exponential

development of technology, exergames have emerged

as exercise platforms among several populations,

including older adults (Ismail et al., 2022).

Exergames are interactive digital tools that combine

exercise and video games. Previous research on using

exergames to improve physical fitness components

among older adults reported beneficial effects on

balance, strength, and aerobic capacity (Agmon et al.,

2011). Moreover, exergames have also been

characterized by the ability to provide mental

stimulation, which is crucial to combat age-related

cognitive declines (Deary et al., 2009). In a recent

systematic review and meta-analysis of randomized

control trials to assess the effects of virtual reality

(VR) exergames on older adults’ cognition and

depression, the findings suggested VR exergames

usage as beneficial for overall cognitive function and

memory (Yen & Chiu, 2021).

Although a significant body of research has

emerged on exergame usage among older adults in

recent years, most studies were conducted using

commercial games and commercial video game

consoles such as Nintendo Wii (Agmon et al., 2011;

Kirk et al., 2013) and Xbox (with Kinect) (Yang et

al., 2020). Overall, commercial game designing

might not be appropriate to all populations, the

systems lack precision in motion detection and fail to

provide a sequential and logical gameplay targeting

multicomponent physical fitness components. On the

other hand, commercial games are typically based on

repetitive movements and scenarios, leading to

boredom or reduced motivation over time.

Additionally, balance stands out among physical

fitness components when promoting exergames

interventions in older adults (Agmon et al., 2011;

Clemson et al., 2010; Yang et al., 2020), probably

because of its relationship with falls. However, it is

worth noting that strength and aerobic capacity are

also two crucial components that must be worked on

within the older adult population (WHO, 2020).

Therefore, the purpose of this study is twofold: (1) to

present a VR custom-made exergame prototype

(FitFest) designed to provide an entire PA session to

older adults, and (2) to evaluate the acute physical and

physiological responses elicited while playing

FitFest.

2 METHODS

2.1 Game Development

2.1.1 Game Concept

FitFest consists of two exergames, composed of five

mini games each, that integrate sociocultural

narratives to create an engaging and enjoyable

exercise experience for older adults. The prototype

was developed through a multidisciplinary

collaboration involving researchers in engineering,

sports science, design and storytelling. Input from the

target population was also incorporated through

qualitative analysis to ensure the games addressed

their preferences and needs (Freitas et al., 2024)

The custom-made exergames were designed to

simulate a complete exercise session, approximately

45 minutes, following a structured sequence of warm-

up, main exercise phase, and cool-down. Exercise

selection was guided by established

recommendations for physical fitness training in

older adults (focusing on balance, cardiorespiratory

fitness, strength, and agility training) (Bushman &

Medicine, 2017). Additionally, recognizing the

progressive cognitive decline associated with aging

(Deary et al., 2009), the game design included

cognitive challenges to stimulate memory and

problem-solving skills—such as catching specific

items and solving puzzles. The FitFest differs

significantly from existing VR games by including

cognitive stimuli, cultural narrative, and physical

movements, aiming to foster the recommended

physical fitness guidelines for the older population.

Reflecting the cultural values emphasized by the

target group (Freitas et al., 2024), each exergame is

based on a traditional festivity from Madeira Island:

(1) Wine Fest – Inspired by Portugal’s rich

winemaking tradition, this game simulates grape

harvesting, sorting, transportation, and

winemaking. Game illustration can be found in

Figure 1.

(2) Flower Fest – Modeled after Madeira Island’s

renowned Flower Festival, this game involves

creating floral arrangements and participating in a

traditional dance and parade celebration. Game

illustration can be found in Figure 2.

Based on the design characteristics, the Wine Fest

was expected to promote more cardiorespiratory

fitness based on the winemaking scenario, which

involved approximately 10 minutes of “stepping

grapes” movements. On the other hand, the Flower

Fest included a traditional dance scenario, with an

icSPORTS 2025 - 13th International Conference on Sport Sciences Research and Technology Support

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estimated duration of 10 minutes, fostering agility

and coordination alongside cardiorespiratory fitness.

Figure 1: Illustration of the Wine Fest scenarios.

Figure 2: Illustration of the Flower Fest scenarios.

To meet different individual profiles that could be

found among the target population, the exergames

include three difficulty levels: (1) elementary, (2)

standard, and (3) advanced, where the speed of the

actions, the amplitude of the movements, and the

amount of cognitive stimulus vary. The difficulty

level provides a game experience that is more

appropriate to the individuals’ capacities and needs.

To ensure that FitFest stood out from

conventional exergames, storytelling was integrated

to create a meaningful connection between the

players and the character’s journey. Players follow

the story of a 65-year-old resident seeking to

rediscover their youth and break free from

monotonous routines by exploring new experiences.

Finally, to guarantee clear instructions during the

game, a mandatory tutorial before each scenario was

included, following previous literature

recommendations in designing exergames for older

adults (Barg-Walkow et al., 2017). During the

tutorial, the players start by watching a short

gameplay video and a person doing the required

gestures. They then must replicate the movements

needed to play, in a controlled setting, ensuring the

movements were understood and the correct posture

was maintained.

2.1.2 Hardware

Based on insights from the qualitative analysis (Freitas

et al., 2024) regarding older adults’ preferences and

concerns related to technology use, a wall-projection

system was selected for the FitFest experience. This

setup helps mitigate common issues associated with

headset-based VR systems, such as safety concerns,

balance difficulties, motion sickness, and potential

anxiety. To accurately track participants' movements,

three HTC Vive trackers—positioned at the ankles and

waist—along with two handheld controllers, were

used. This configuration enabled precise tracking of

key body joints while providing a spacious 2-meter-

wide gameplay area, supporting both comfort and

freedom of movement. The gameplay setup is

presented in Figure 3.

Figure 3: FitFest gameplay set-up.

2.1.3 Software

The exergames were developed using the Unity 2022

game engine, employing a 2.5D design that combines

2D elements with 3D environments. This approach

Table 1: Summary of the characteristics of each scenario.

Wine Fest

Scenario Targeted component

Gameplay

movements

Time

(m)

Balance, agility,

strength, and

cardiorespiratory

Grape

harvesting

and storage

2 Balance and agility

Grape

storage and

selection

3 Strength

Grape

transportation

4 Cardiorespiratory Winemaking 10

Problem-solving and

working memory

Puzzle

solving

Flower Fest

Scenario Targeted component

Gameplay

movements

Time

(m)

Balance, agility, strength,

and cardiorespiratory

Flower picking

and storage

Balance, agility, and

strength

Creating

flower

arrangements

Balance, agility, and

cardiorespiratory

Parade 8

Balance, agility, and

cardiorespiratory

Traditional

dance

Problem-solving and

working memory

Puzzle solving 6

Physical and Physiological Impact of Custom-Made Virtual Reality Exergames for Older Adults

157

allowed for efficient development while preserving

visual appeal and providing depth that enhances

gameplay across various scenarios/mini games. The

design emphasizes intuitiveness and affordance to

naturally elicit the appropriate gestures from players.

Details on each scenario can be consulted in Table 1.

2.2 User Tests

A series of user tests was conducted to evaluate the

physical and physiological effects of

the FitFest exergames, focusing on PA intensity and

heart rate (HR) metrics. Additionally, participants’

ratings of perceived exertion were assessed. The

sessions took place at a local community center for

four weeks. Participants performed one exergame

session per week, using Wine Fest and Flower Fest as

alternates. The exergames sessions sequence was

equal for all participants, and the sessions were

supervised by two members of the research team to

ensure safety and protocol adherence.

Prior to testing, participants' height and body mass

were measured using a portable stadiometer (SECA

213, Hamburg, Germany; accuracy: ± 0.1 cm) and a

portable scale (SECA 760, Hamburg, Germany;

accuracy: ± 0.1 kg), respectively. During gameplay,

participants wore an accelerometer to assess PA

intensity and an HR sensor to monitor heart rate and

heart rate variability. After completing each game

scenario, participants rated their perceived exertion

using a 10-point scale using the game interface.

2.2.1 Participants

The study involved a convenience sample of seven

older adults (2 males) aged 67.0 ± 3.8 years, who

collectively completed 18 user testing sessions.

Although the experimental design considered one

session per week for each participant, compliance

was not achieved by all who participated. Two

participants completed the four sessions scheduled,

two participants completed a total of three sessions,

one participant completed two sessions, and two

participants completed only one session. Participants

were selected based on the following inclusion

criteria: (a) age 65 years or older; (b) absence of

physical or cognitive impairments; and (c) no medical

contraindications to physical exercise. All

participants were engaged in activities developed at a

local community center where the study took place.

The procedures implemented were approved by the

Ethics Committee of the University of Madeira

(Nº111/CEUMA/2024) to ensure adherence to data

protection regulations. Participation was entirely

voluntary, and informed consent was obtained from

all participants prior to the study. Data collection

adhered to the principles of the Declaration of

Helsinki and complied with all relevant ethical

guidelines and regulations.

2.2.2 Physical Activity

Physical activity (PA) intensity was measured using

the ActiGraph GT3X+ accelerometer, which

participants wore on their right hip throughout the

entire session. The device was initialized with a

sampling frequency of 30 Hz. Raw data from the

GT3X+ were converted into 10-second epochs for

analysis. Activity classification—including time

spent in sedentary behavior, light, moderate,

moderate-to-vigorous, and vigorous activity—was

determined using ActiLife software (version 6;

ActiGraph, Pensacola, FL, USA), based on validated

cutoff points established in prior research with older

adult populations (Bammann et al., 2021; Barnett et

al., 2016). The number of steps taken during the

session was also recorded. The accelerometer was

programmed individually for each participant prior to

their session, with data collection beginning at the

start of the exergame.

2.2.3 Heart Rate

During the exergame sessions, participants wore a

Polar H10 sensor to monitor heart rate (HR). The

device was secured to the chest using the

manufacturer-provided strap, ensuring optimal skin

contact. This placement allowed the sensor’s

electrodes to capture accurate, real-time HR data

throughout the session.

2.2.4 Rate of Perceived Exertion

The rate of perceived exertion (RPE) scale

(Robertson, 2004) was incorporated into the

exergame after each scenario conclusion. Using the

10-point scale (1 – extremely easy, 10 – extremely

hard), participants had to move to the right or left side

to indicate the number that would better correspond

to their effort. After selecting the number that best

represented their perceived effort, participants raised

one hand above their head to confirm their choice.

Since each exergame consists of five scenarios, this

process was repeated five times during the session.

2.3 Statistical Analysis

Descriptive statistics are presented as mean ±

standard deviation and were used to analyze physical

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activity (PA) intensity and heart rate (HR) during

the FitFest exergames. To compare differences

between the Wine Fest and Flower Fest games in

terms of PA intensity, HR, and RPE, the Mann-

Whitney U test was applied. Statistical analyses and

graphical presentations were performed using IBM

SPSS Statistics 29.0 (SPSS Inc., Chicago, IL, USA)

and GraphPad Prism version 10 (GraphPad Software,

San Diego, CA, USA). The threshold for statistical

significance was set at p < 0.05.

3 RESULTS

Due to inconsistencies in the data collection process

(accelerometer malfunction), two user testing

sessions were excluded from the analysis of physical

activity (PA) intensity and heart rate (HR). As a

result, 16 sessions were included in the final

analysis—11 for Wine Fest and 5 for Flower Fest.

Table 2 presents the descriptive statistics for PA

intensity and HR across all analyzed sessions.

Overall, the FitFest exergames were primarily

characterized by sedentary behavior (56.5 ± 20.4%),

followed by light-intensity activity (42.1 ± 19.3%).

On average, participants completed approximately

436.7 steps per session, with a HR of 92.1 bpm.

Table 2: Descriptive statistics for PA intensity and HR

while playing the FitFest exergames.

Variable

FitFest

Overall

Wine Fest

Flower

Fes

M ± SD M ± SD M ± SD

Sedentary

behavior (%)

56.5 ± 20.4 53.6 ± 22.1

62.9 ±

16.2

Light PA (%) 42.1 ± 19.3 44.7 ± 20.4 38.4 ± 17.0

Moderate PA (%) 1.4 ± 2.4 1.7 ± 2.8 0.6 ± 0.8

Moderate-to-

vigorous PA (%)

1.4 ± 2.4 1.8 ± 2.8 0.8 ± 0.9

Total steps (n) 436.7 ± 308.7 502.9 ± 345.4

291.0 ±

143.1

Steps/minute (n) 10.8 ± 7.9 12.8 ± 8.7 6.5 ± 3.4

Average HR(bpm) 92.1 ± 14.5 92.1 ± 16.6 92.2 ± 9.7

Minimum HR

(bpm)

115.0 ± 25.3 115.2 ± 29.7

114.4 ±

13.5

Maximum HR

(bpm)

71.8 ± 12.0 71.6 ± 11.7 72.0 ± 14.2

M ± SD (mean ± standard deviation) PA (physical activity), HR

(heart rate)

Figures 4, 5, and 6 present the comparison between

the two exergames in terms of physical activity (PA)

intensity, step count, and heart rate (HR)

measurements. Wine Fest elicited lower levels of

sedentary behavior (53.6 ± 22.1% vs. 62.8 ± 16.2%),

higher levels of light-intensity PA (44.7 ± 20.4% vs.

36.4 ± 17.0%), and a greater average number of steps

(503.0 ± 345.4 vs. 291.0 ± 143.1) compared to Flower

Fest. However, these differences did not reach

statistical significance. HR values were similar across

both exergames, with an average of 92.1 bpm.

Figure 4: Comparison between exergames regarding PA

intensity.

Figure 5: Comparison between exergames regarding the

number of steps.

Figure 6: Comparison between exergames regarding heart

rate.

The analysis of perceived exertion (RPE), as

shown in Figure 7, revealed higher exertion levels

during scenarios 3 and 4, which primarily involved

tasks targeting strength and cardiorespiratory fitness.

In contrast, scenario 2—focused on agility and

coordination—was perceived as less physically

demanding by participants.

Physical and Physiological Impact of Custom-Made Virtual Reality Exergames for Older Adults

159

Figure 7: Rate of perceived exertion results for each

scenario.

4 DISCUSSION

This study examined the physical and physiological

responses of a custom-made VR exergame

system, FitFest, among older adults. The overall

analysis indicated that gameplay was primarily

characterized by sedentary behavior, followed by

light-intensity PA. Among the two exergames, Wine

Fest promoted slightly higher PA intensity and a

greater number of steps than Flower Fest, though

these differences were not statistically significant.

According to ACSM guidelines, moderate-

intensity PA is recommended for achieving

substantial health benefits in older adults, particularly

in cardiorespiratory fitness (Bushman & Medicine,

2017). However, FitFest did not elicit moderate-to-

vigorous PA levels. One explanation is that gameplay

included tutorial segments and interactive rating tasks

using the Borg scale between scenarios, which

contributed to reduced active time. While these

features were designed to enhance clarity and provide

recovery, they also limited continuous exertion.

Nevertheless, literature supports that even light-

intensity activities can offer health benefits

(Chodzko-Zajko et al., 2009).

The mean heart rate (HR) recorded during FitFest

gameplay aligns with light PA, corresponding to

approximately 60% of the age-predicted maximal HR

(153 bpm using 220 – age) (Fletcher et al., 2013).

Although this formula may underestimate true

maximal HR in older adults (Tanaka et al., 2001), it

remains widely accepted for clinical applications.

According to the literature, light PA is significantly

and positively related to physical health and well-

being in older populations (Buman et al., 2010).

Compared to previous studies using Kinect-based

balance-focused exergames (80–87 bpm) (Ogawa et

al., 2019) and Nintendo Wii Sports (94 ± 10 bpm)

(Kirk et al., 2013), FitFest HR values are within a

similar range, reflecting its multicomponent design

encompassing strength, balance, agility, and aerobic

tasks.

Perceived exertion ratings (RPE) revealed that

strength and aerobic scenarios were considered the

most demanding, consistent with current PA

guidelines (Chodzko-Zajko et al., 2009).

Interestingly, a cool-down scenario focused solely on

cognitive tasks was also perceived as moderately

intense. This may relate to the cognitive challenge

posed, as older adults commonly experience age-

related cognitive decline (Deary et al., 2009). Prior

research suggests that lower self-efficacy may

increase perceived exertion in older adults during

cognitively demanding tasks (Hu et al., 2007).

Therefore, cognitive components of exergames

should be tailored to avoid inducing frustration or

discouragement.

This exploratory study presents several

limitations. First, the small sample size and uneven

distribution of sessions between the participants limit

generalizability. All the participants were recruited

from a local community center, where the study took

place, and there is a need to increase the sample size

and the number of sessions for future validation of the

FitFest. Second, the short-term nature of the testing

does not allow for assessment of long-term benefits

or sustained engagement. Third, all participants

played at the same difficulty level to ensure standard

procedures during testing, which may not reflect

individual physical or cognitive capacities.

Personalized assessments and adaptive difficulty

scaling are recommended for future implementations

since they might promote gameplay scenarios more

appropriate to the individuals’ characteristics and

enhance challenge. Future research can explore users’

HR responses to adapt the difficulty level during

gameplay. Additionally, the inclusion of tutorials and

inter-scenario tasks (which corresponded to an

estimated total time of 6 minutes), while necessary for

clarity, may have affected overall activity intensity

and increased time spent in sedentary behavior.

Lastly, the lack of a control group limits the

interpretation of the FitFest effects, which should be

tackled in future longitudinal studies.

Despite these limitations, this study provides

valuable insights into the potential of FitFest, a

custom-made multicomponent VR exergame, to

promote light-intensity PA among older adults. While

it may not be a substitute for moderate-to-vigorous

PA interventions, FitFest can be a complementary

tool to traditional exercise programs implemented in

community centers to increase activity levels and

engagement. Besides, by including cognitive

stimulus, FitFest aligns physical and cognitive tasks,

which are crucial among older populations. Future

developments should focus on individualization and

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increased intensity based on real-time adapted

difficulty. Also, reducing passive time by including

shorter tutorials and seamless scenario transitions to

maximize benefits should be considered.

ACKNOWLEDGEMENTS

The authors would like to thank all participants.

FUNDING

This research was funded by the Portuguese Recovery

and Resilience Program (PRR), IAPMEI/ANI/FCT

under the Agenda C645022399-00000057

(eGamesLab).

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