1Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul, Korea
2Institute on Aging, Seoul National University College of Medicine, Seoul, Korea
3Department of Rehabilitation Medicine, Seoul National University College of Medicine, Seoul, Korea
Correspondence: Han Gil Seo Department of Rehabilitation Medicine, Seoul National University Hospital, Seoul National University College of Medicine, 101 Daehak-ro, Jongno-gu, Seoul 03080, Korea. Tel: +82-2-2072-1659 Fax: +82-2-6072-5244 E-mail: hangilseo@snu.ac.kr
• Received: February 25, 2026 • Revised: May 31, 2026 • Accepted: July 6, 2026
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (https://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
To evaluate the feasibility, safety, and usability of a novel fully immersive virtual reality (VR) exergame, designed to incorporate cognitive-motor dual-task training for patients with Parkinson’s disease (PD).
Methods
We developed a specialized fully immersive VR exergame program, featuring seven cognitive-motor dual-task games. Prior to the pilot study, we refined the system through two successive usability evaluations involving 17 and 15 rehabilitation experts, respectively, to optimize safety and interface design. Subsequently, four patients with idiopathic PD completed a 30-minute VR exergame session using the finalized system under therapist supervision. We assessed cybersickness using the Simulator Sickness Questionnaire (SSQ) and evaluated usability via the User Experience Questionnaire (UEQ) and a self-developed Custom Usability and Satisfaction Survey.
Results
All participants completed the session without adverse events. Mean SSQ total scores decreased from 14.75±9.43 to 4.75±1.89 without statistical significance (p>0.05). UEQ demonstrated positive experiences, with Attractiveness (1.167), Efficiency (1.063), and Stimulation (1.500) exceeding benchmarks. Custom Usability and Satisfaction Survey scores for interest (6.00/7) and overall satisfaction (6.25/7) were high; however, physical comfort was rated relatively lower (4.25/7) due to the headset weight and safety harness.
Conclusion
The developed fully immersive VR exergame system is feasible, safe, and engaging in patients with PD. Limitations include the small sample size and single-session design. Future research should focus on large-scale randomized controlled trials and hardware improvements to enhance physical comfort for long-term clinical application.
Parkinson’s disease (PD) is a progressive neurodegenerative disorder characterized by cardinal motor symptoms such as bradykinesia, rigidity, tremor, and postural instability, as well as non-motor symptoms including cognitive impairment and mood disorders [1,2]. These symptoms significantly reduce patients’ independence in activities of daily living and overall quality of life [3]. While pharmacological treatments like levodopa are the standard of care, they do not arrest disease progression and may induce complications such as motor fluctuations over time [4]. Therefore, continuous rehabilitation, including physical and cognitive therapy, is essential to maintain functional capacity and delay disability [5]. Recently, there has been a growing emphasis on “dual-task” training, which combines motor and cognitive exercises, as it effectively addresses the complex deficits found in PD [6].
Virtual reality (VR) has emerged as a promising tool in neurorehabilitation, offering immersive and interactive environments that can simulate real-world challenges in a controlled setting [7]. VR-based interventions provide multisensory feedback (visual, auditory, and haptic) which facilitates motor learning and neuroplasticity by activating the brain’s mirror neuron system and motor pathways [8,9]. Furthermore, the gamification elements inherent in VR can enhance patient motivation and adherence to repetitive rehabilitation protocols, which is often a challenge in conventional therapy [10].
Despite these advantages, the clinical application of immersive VR in elderly patients with PD faces notable limitations. First, “cybersickness”—symptoms akin to motion sickness such as nausea and dizziness—remains a significant barrier, particularly in immersive head-mounted display (HMD) systems [11]. Second, many commercial VR games are not specifically designed for patients with motor impairments; they often require rapid reactions or complex manipulations that may exceed the physical capabilities of patients with PD, leading to frustration or safety risks [12]. Consequently, usability issues and a lack of user-centered design can hinder the widespread adoption of VR in this population [13].
To address these challenges, we developed a novel fully immersive VR exergame system specifically tailored to the motor and cognitive characteristics of patients with PD, in collaboration with rehabilitation experts. The system was designed to deliver cognitive-motor dual-task content within a safe standing-position protocol, incorporating a ceiling-mounted safety harness and adjustable difficulty levels. The objective of this study was to evaluate the feasibility, safety, and usability of this self-developed VR system in patients with idiopathic PD. We hypothesized that our PD-specific VR exergames would be safe, well-tolerated, and provide a positive user experience without inducing significant cybersickness.
METHODS
Study design and participants
This cross-sectional pilot study was approved by the Institutional Review Board (IRB) of Seoul National University Hospital (IRB No. H-2410-045-1576). The study was performed in accordance with the principles of Good Clinical Practice and the Declaration of Helsinki. We conducted the study on December 5, 2024, and obtained written informed consent from all participants.
The inclusion criteria were: (1) age 19 years or over; (2) clinical diagnosis of idiopathic PD; and (3) disease severity of stage 2–3 on the modified Hoehn & Yahr (H&Y) scale. The exclusion criteria were: (1) significant cognitive impairment (Korean version of the Montreal Cognitive Assessment [K-MoCA] scores below education-adjusted cut-offs: <7 for illiterate, <13 for 0.5–3 years of education, <16 for 4–6 years, <19 for 7–9 years, and <20 for 10 years or over); (2) severe motor fluctuations or dyskinesias preventing a 30-minute session; (3) other neurological diseases; (4) history of epilepsy or vestibular disorders; and (5) any comorbid condition precluding safe exercise.
VR exergames
We developed a novel fully immersive VR exergame system in collaboration with TechVillage Co., specifically designed to address the motor and cognitive characteristics of patients with PD. To ensure clinical feasibility and safety, the system underwent an iterative two-step usability evaluation by rehabilitation experts before the patient pilot study.
The development followed an iterative process composed of a formative evaluation and a summative evaluation by rehabilitation experts. In the first formative evaluation, 17 rehabilitation experts (physiatrists, physical therapists, and occupational therapists) tested the system and provided feedback on potential fall risks and content difficulty, which led to the integration of a ceiling-mounted safety harness and refinement of the game difficulty levels to accommodate varying patient capabilities. In the subsequent summative evaluation, 15 experts evaluated the system according to the IEC 62366-1 standard for medical-device usability engineering [14]. Among the 15 evaluators, 7 completed all 96 sub-tasks without any use error, and overall satisfaction with the system on the post-test questionnaire was 5.9/7 on average. The highest-rated item was “content engagement” for the Punch Master (6.6/7), and the lowest-rated item was the size and weight of the HMD (4.5/7). Detailed evaluation results are provided in Supplementary Material S1.
The seven games were designed to combine task-specific motor demands with concurrent cognitive demands, in line with goal-based dual-task exercise frameworks recommended for PD rehabilitation [15]. Motor components included task-specific actions such as multi-directional stepping, weight shifting, single-leg stance, and reaching. Cognitive components were embedded as response-selection rules that engage inhibition (Punch Master), set-shifting and rule updating (Step Master, Foot Master, Number Master), working memory (Motion Master), reactive control (Boxing Master), and dynamic obstacle avoidance (Block Dodging). The three newly developed games (Punch Master, Step Master, and Motion Master) included multiple discrete difficulty levels (10, 9, and 10 levels, respectively) defined by parameters such as target speed, simultaneity, response interval, and the number of concurrent targets or postures. The three carried-over games (Boxing Master, Foot Master, and Number Master) were adapted from a previously published seated VR exergame protocol for PD [16] and re-implemented in a standing configuration without changing their internal stage structure (9, 9, and 6 stages, respectively). Block Dodging consisted of a single difficulty level in which the approach speed of obstacles was adjustable by the supervising therapist.
The finalized system used the HTC VIVE Pro VR headset (HTC Corp.), which provides room-scale tracking. Participants held controllers and wore additional motion trackers on their ankles for full-body motion capture (Fig. 1). The software comprised seven cognitive-motor dual-task games (Fig. 2):
1. Punch Master: The player punches flying objects (e.g., balls) while avoiding distractors (e.g., bombs), stimulating cognitive inhibition (Supplementary Video S1).
2. Step Master: The player steps on specific colored blocks on a virtual conveyor belt while ignoring others, training quick decision-making (Supplementary Video S2).
3. Motion Master: The player executes specific poses corresponding to numbers, challenging working memory and coordination (Supplementary Video S3).
4. Boxing Master: The player punches target pads held by a virtual trainer based on color cues, engaging reaction speed and impulse control (Supplementary Video S4).
5. Foot Master: The player marches in place or shifts weight in response to visual signals, training lower limb agility and cognitive switching (Supplementary Video S5).
6. Number Master: The player hits numerical targets based on rules (e.g., hit even numbers), exercising mental flexibility (Supplementary Video S6).
7. Block Dodging: The player dodges oncoming obstacles by side-stepping or leaning, focusing on dynamic balance and agility (Supplementary Video S7).
Game-by-game difficulty-level parameters and the timing protocol used in the present pilot study are provided in Supplementary Material S2.
Intervention and procedure
This study followed a single-visit protocol supervised by an occupational therapist (Fig. 3). After providing written informed consent, participants underwent screening via the modified H&Y scale and K-MoCA. Baseline cybersickness was assessed using the Simulator Sickness Questionnaire (SSQ).
Participants then performed a single 30-minute immersive VR exergame session consisting of the seven games described above. To minimize fall risk, participants wore a ceiling-mounted safety harness while standing throughout the session. The session began with approximately 3 minutes of warm-up content (light aerobic and reaching movements within the VR environment) so that the participant could acclimatize to the HMD and tracker setup. All participants started each game at difficulty level 1; if the participant successfully completed the level and reported no discomfort, the supervising therapist progressed the participant to higher levels within the same game in order to maintain engagement and increase challenge as performance improved. Each difficulty level was set to a 60-second play duration, and the games were performed in the fixed order Punch Master → Step Master → Motion Master → Boxing Master → Foot Master → Number Master → Block Dodging. Games 1–6 were therefore played for multiple consecutive levels per game to fill the allotted session time, whereas Block Dodging was performed once at its single available level with the therapist adjusting the approach speed of obstacles based on the participant’s tolerance. Brief rest breaks (≥1 minute) were provided between games and were flexibly extended depending on each participant’s level of fatigue or discomfort. The supervising therapist remained adjacent to the participant throughout the session to provide verbal cues and to ensure correct harness and headset positioning; no direct physical assistance was required for any participant to complete the game tasks. Immediately after the session, vital signs were checked and a brief physical examination was performed to identify any adverse events. Finally, participants completed the post-VR assessment, which included the SSQ, the User Experience Questionnaire (UEQ), and the self-developed Custom Usability and Satisfaction Survey.
Outcome measures
To assess VR tolerability, we used the SSQ, a standardized instrument to quantify the severity of simulator sickness symptoms [17]. The SSQ rates 16 symptoms (general discomfort, fatigue, headache, eyestrain, difficulty focusing, increased salivation, sweating, nausea, difficulty concentrating, fullness of the head, blurred vision, dizziness with eyes open, dizziness with eyes closed, vertigo, stomach awareness, burping) on a 4-point scale (0=none, 1=slight, 2=moderate, 3=severe). We administered the SSQ immediately before and after the session to calculate the change in total scores.
User experience was evaluated using the UEQ, a comprehensive framework to assess both pragmatic (e.g., efficiency, perspicuity) and hedonic (e.g., stimulation, novelty) qualities of interactive products [18]. It covers six dimensions (Attractiveness, Perspicuity, Efficiency, Dependability, Stimulation, and Novelty). Scores range from -3 to +3, with values >0.8 indicating a positive experience.
To capture specific user feedback relevant to PD rehabilitation not covered by standard questionnaires, we developed a Custom Usability and Satisfaction Survey. This instrument consists of nine quantitative items rated on a 7-point Likert scale (1=negative/strongly disagree, 7=positive/strongly agree) and one open-ended question. The quantitative items were designed to evaluate three key domains: (1) Emotional Engagement (interest, mood, and motivation), (2) Usability and Safety (perceived difficulty, physical comfort, and sense of safety), and (3) Satisfaction and Future Perspective (overall satisfaction, intention for continued use, and therapeutic expectation). Finally, the open-ended question was included to gather qualitative feedback regarding specific strengths and areas for improvement.
Statistical analysis
Due to the small sample size (n=4), we primarily used descriptive statistics. We used the Wilcoxon signed-rank test to compare pre- and post-VR SSQ total scores. UEQ scores were calculated using the standardized Excel tool (UEQ Data Analysis Tool V14, available at www.ueq-online.org). Statistical analyses were performed using SPSS version 26.0 (IBM Corp.), with significance set at p<0.05.
RESULTS
Baseline characteristics
Four patients with idiopathic PD participated in this study (Table 1). The mean age was 73.75±7.63 years, and two were male. Regarding disease severity, one participant was at modified H&Y stage 2, one was at stage 2.5, and two were at stage 3. The mean disease duration was 12.25±4.03 years, and the mean K-MoCA score was 25.00±2.94. All participants were tested in their “ON” state under stable dopaminergic medication.
Feasibility and safety
All participants successfully completed the 30-minute VR exergame session without dropouts or adverse events. No participant requested to terminate the session early, and all tolerated the intervention well with the provided short breaks.
Cybersickness (SSQ)
Mean SSQ total scores decreased from 14.75±9.43 before the session to 4.75±1.89 after the session (Table 2). The change was not statistically significant (p>0.05), and given the very small sample size we refrain from drawing inferential conclusions. Descriptively, however, no participant showed a clinically meaningful increase in SSQ score after the intervention, and most pre-existing symptoms (general discomfort, fatigue, and headache) improved or disappeared post-session. Only minor increases (1 point) were noted in sweating for two participants and fullness of the head for one participant.
User experience (UEQ)
The UEQ dimensions of Attractiveness (1.167), Efficiency (1.063), and Stimulation (1.500) exceeded the positive benchmark cut-off of 0.8 (Table 3). Other dimensions also showed positive trends but remained below the threshold: Perspicuity (0.688), Novelty (0.625), and Dependability (0.375). These scores indicate that while the games were engaging and stimulating, some participants initially felt uncertain in the VR environment but found the games relatively easy to learn.
As shown in the detailed item analysis (Fig. 4), participants rated the system highly on items such as “understandable,” “interesting,” “pleasant,” “efficient,” and “practical.” Notably, despite the novelty of the VR environment, users perceived the interaction as “easy to learn” and “secure,” supporting the system’s usability for patients with PD.
Custom usability and satisfaction survey
The custom survey indicated high levels of interest (6.00/7), mood (6.25/7), and overall satisfaction (6.25/7) (Table 4). The lowest mean score was for physical comfort (4.25/7), which participants attributed to both the VR equipment and the safety harness.
In the open-ended feedback, participants suggested: (1) incorporating walking exercises, (2) simplifying the equipment setup to be as intuitive as watching television, (3) ensuring game instructions perfectly match the gameplay, and (4) providing a wider range of difficulty levels.
DISCUSSION
This pilot study demonstrated that our self-developed fully immersive VR exergame system is feasible, safe, and usable in patients with idiopathic PD. Despite the advanced age of the participants and their lack of prior VR experience, all participants completed the 30-minute dual-task session without any adverse events or significant cybersickness. The UEQ and custom satisfaction survey revealed favorable scores in attractiveness, stimulation, and overall satisfaction, suggesting that the gamified elements were well accepted by this small sample. Although the descriptive change in SSQ scores was in the direction of improvement, the change was not statistically significant and the small sample size precludes inference; what can be concluded is that the intervention was well tolerated and did not provoke clinically meaningful cybersickness. We did not assess therapeutic outcomes (e.g., motor function, cognition, balance, or gait) in this single session; therefore, the present results should be interpreted as supporting feasibility for future efficacy trials, rather than as evidence of clinical benefit.
Our findings are consistent with prior reports describing high tolerability and acceptability of VR-based interventions in patients with PD [19,20]. However, most prior studies have focused on non-immersive systems (e.g., monitor-based) [20], which may offer lower levels of user engagement compared to immersive environments. A recent feasibility study by Yun et al. [16] supports our results, demonstrating that fully immersive VR exergames with dual-task components are feasible and can effectively engage patients with PD. However, exercises in that study were performed while seated to minimize the risk of falls. Limiting movement to a seated position inherently restricts the training of dynamic standing balance and gait. In contrast, our study differentiates itself by implementing a fully immersive, standing-position protocol reinforced by a ceiling-mounted safety harness. This setup allowed participants to safely perform dynamic lower limb movements—such as multi-directional stepping and single-leg standing—without the fear of falling.
While some earlier studies reported high attrition rates in VR interventions for elderly populations due to severe cybersickness or dizziness [21], our study showed high tolerability with minimal symptoms. This discrepancy can be attributed to several design choices. First, we intentionally simplified the visual background of the games to reduce optical flow and minimize cognitive overload, which is known to exacerbate cybersickness in patients with neurological disorders [22,23]. Second, we utilized high-specification hardware (HTC VIVE Pro) with a high refresh rate and low latency. Previous guidelines suggest that system latency and dropped frames are significant factors contributing to user discomfort in VR [24]. These factors likely contributed to the positive user experience observed in our study compared to earlier trials using lower-fidelity devices.
The intervention was structured around cognitive-motor dual-task content, which has been associated with improvements in dual-task gait performance and motor-cognitive interference in PD in prior systematic reviews [6]. We did not, however, evaluate dual-task performance, motor function, or cognition in the current study, so any inference about the therapeutic effect of dual-task training in our system must await future controlled trials with appropriate outcome measures. From a delivery standpoint, VR may help standardize dual-task stimuli and provide consistent multisensory feedback that is more difficult to achieve in conventional one-on-one therapy. The gamification element of our system also provides immediate visual and auditory feedback, which is a recognized design principle for promoting engagement and motor learning in rehabilitation contexts [10].
This study has several limitations that should be addressed in future research. First, this was a pilot feasibility study with a small sample size and no control group, limiting the generalizability of the findings. Second, the intervention consisted of a single session, so we could not evaluate the long-term therapeutic effects or retention of motor learning. Third, although the safety harness prevented falls, some participants reported physical discomfort due to the weight of the HMD and the pressure of the harness, as reflected in the lower “physical comfort” scores in our survey. Future studies should involve larger randomized controlled trials to verify clinical efficacy and focus on hardware improvements—such as lighter headsets and more ergonomic wearable sensors—to enhance comfort for prolonged use.
In conclusion, this pilot study demonstrates that our self-developed fully immersive VR exergame system is feasible, safe, and engaging in patients with idiopathic PD. By incorporating a ceiling-mounted safety harness and high-fidelity hardware, we successfully implemented a dynamic standing-position protocol without inducing significant cybersickness or adverse events. We did not assess therapeutic outcomes; whether this system actually improves motor or cognitive function in patients with PD must therefore be tested in future randomized controlled trials with objective outcome measures and adequate sample sizes. The high user satisfaction and positive usability scores observed here support proceeding to such efficacy trials, and ongoing hardware refinement (e.g., lighter HMDs, more ergonomic wearable sensors) is needed to enhance physical comfort for prolonged use.
CONFLICTS OF INTEREST
Han Gil Seo has stock ownership in TechVillage Co. as an advisor.
Byung-Mo Oh is the Editor-in-Chief, and Han Gil Seo is an Editorial Board member of Annals of Rehabilitation Medicine. The authors did not engage in any part of the review and decision-making process for this manuscript. The other authors declare that they have no competing interests.
FUNDING INFORMATION
This research was conducted as a part of the digital healthcare medical device technology development support program supported by Chungbuk Technopark.
AUTHOR CONTRIBUTION
Conceptualization: Yun SJ, Kim M, Seo HG, Oh BM. Methodology: Lee SH, Yun SJ, Kim M. Data curation: Lee SH, Yun SJ, Kim M. Formal analysis: Lee SH, Yun SJ, Kim M. Funding acquisition: Seo HG. Investigation: Lee SH, Yun SJ, Kim M. Software: Lee SH, Yun SJ, Kim M. Visualization: Lee SH, Yun SJ, Kim M. Project administration: Seo HG. Resources: Yun SJ, Kim M, Seo HG. Supervision: Seo HG, Oh BM. Validation: Seo HG, Oh BM. Writing – original draft: Lee SH. Writing – review and editing: Lee SH, Yun SJ, Kim M, Seo HG, Oh BM. Approval of final manuscript: all authors.
DATA AVAILABILITY STATEMENT
The datasets generated and/or analyzed during the current study are available from the corresponding author on reasonable request, in accordance with data sharing policies and participant confidentiality agreements.
A demonstrator wearing a ceiling-mounted safety harness and a head-mounted display (HMD), holding hand-held controllers, with motion trackers attached to both ankles.
Fig. 2.
Virtual reality exergames: (A) The instructional screen displaying how to perform the task. (B) Punch Master, (C) Step Master, (D) Motion Master, (E) Boxing Master, (F) Foot Master, (G) Number Master, and (H) Block Dodging.
Fig. 3.
Study flow. H&Y, modified Hoehn & Yahr; K-MoCA, Korean version of the Montreal Cognitive Assessment; VR, virtual reality; SSQ, Simulator Sickness Questionnaire; UEQ, User Experience Questionnaire.
Fig. 4.
Mean scores for each of the 26 items of the User Experience Questionnaire (UEQ).
Table 1.
Individual baseline characteristics of the participants (N=4)
Characteristic
P1
P2
P3
P4
Sex
Female
Female
Male
Male
Age (yr)
75
81
63
76
Modified H&Y stage
3
2
3
2.5
K-MoCA (score)
22
25
29
24
P1–P4, Participants 1 through 4; H&Y, modified Hoehn & Yahr; K-MoCA, Korean version of the Montreal Cognitive Assessment (maximum total=30 points).
3. Schrag A, Jahanshahi M, Quinn N. What contributes to quality of life in patients with Parkinson's disease? J Neurol Neurosurg Psychiatry 2000;69:308-12.
5. Abbruzzese G, Marchese R, Avanzino L, Pelosin E. Rehabilitation for Parkinson's disease: current outlook and future challenges. Parkinsonism Relat Disord 2016;22 Suppl 1:S60-4.
6. Johansson H, Folkerts AK, Hammarström I, Kalbe E, Leavy B. Effects of motor-cognitive training on dual-task performance in people with Parkinson's disease: a systematic review and meta-analysis. J Neurol 2023;270:2890-907.
7. Triegaardt J, Han TS, Sada C, Sharma S, Sharma P. The role of virtual reality on outcomes in rehabilitation of Parkinson's disease: meta-analysis and systematic review in 1031 participants. Neurol Sci 2020;41:529-36.
8. Levin MF, Weiss PL, Keshner EA. Emergence of virtual reality as a tool for upper limb rehabilitation: incorporation of motor control and motor learning principles. Phys Ther 2015;95:415-25.
10. Lohse K, Shirzad N, Verster A, Hodges N, Van der Loos HF. Video games and rehabilitation: using design principles to enhance engagement in physical therapy. J Neurol Phys Ther 2013;37:166-75.
12. Barry G, Galna B, Rochester L. The role of exergaming in Parkinson's disease rehabilitation: a systematic review of the evidence. J Neuroeng Rehabil 2014;11:33.
13. Tuena C, Pedroli E, Trimarchi PD, Gallucci A, Chiappini M, Goulene K, et al. Usability issues of clinical and research applications of virtual reality in older people: a systematic review. Front Hum Neurosci 2020;14:93.
14. International Electrotechnical Commission (IEC). IEC 62366-1:2015/Amd 1:2020 Medical devices — part 1: application of usability engineering to medical devices [Internet]. IEC; 2020 [cited 2024 Nov 27]. Available from: https://www.iso.org/standard/73007.html
15. Pimenta Silva D, Pona-Ferreira F, Cacho R, Santos B, Lobo T, Bouça-Machado R, et al. Integrating virtual reality into multidisciplinary care for Parkinson's disease: a narrative review. J Parkinsons Dis 2025;15:459-79.
16. Yun SJ, Hyun SE, Oh BM, Seo HG. Fully immersive virtual reality exergames with dual-task components for patients with Parkinson's disease: a feasibility study. J Neuroeng Rehabil 2023;20:92.
18. Laugwitz B, Held T, Schrepp M. Construction and evaluation of a User Experience Questionnaire. In: Holzinger A, editor. HCI and usability for education and work. Springer; 2008. p. 63-76.
19. Mirelman A, Maidan I, Deutsch JE. Virtual reality and motor imagery: promising tools for assessment and therapy in Parkinson's disease. Mov Disord 2013;28:1597-608.
20. Gandolfi M, Geroin C, Dimitrova E, Boldrini P, Waldner A, Bonadiman S, et al. Virtual reality telerehabilitation for postural instability in Parkinson's disease: a multicenter, single-blind, randomized, controlled trial. Biomed Res Int 2017;2017:7962826.
21. Brooks JO, Goodenough RR, Crisler MC, Klein ND, Alley RL, Koon BL, et al. Simulator sickness during driving simulation studies. Accid Anal Prev 2010;42:788-96.
22. Abdalhadi A, Koundal N, Moosavi MS, Lou R, Yusoff MZB, Merienne F, et al. Enhancing user experience in virtual reality through optical flow simplification with the help of physiological measurements: pilot study. Sensors (Basel) 2026;26:610.
23. Fernández-Cañas M, Ortiz-Gutiérrez RM, Martín-Casas P, Estrada-Barranco C, Marcos-Antón S, Blázquez-Fernández A, et al. Cybersickness evaluation in immersive virtual environments: a systematic review with implications for neurological rehabilitation. J Clin Med 2026;15:46.
24. Porcino TM, Clua E, Trevisan D, Vasconcelos CN, Valente L. Minimizing cyber sickness in head mounted display systems: design guidelines and applications. 2017 IEEE 5th International Conference on Serious Games and Applications for Health (SeGAH). IEEE; 2017. p. 1-6.
Feasibility and Usability of Immersive Virtual Reality Exergames for Patients With Parkinson’s Disease: A Pilot Study
Fig. 1. A demonstrator wearing a ceiling-mounted safety harness and a head-mounted display (HMD), holding hand-held controllers, with motion trackers attached to both ankles.
Fig. 2. Virtual reality exergames: (A) The instructional screen displaying how to perform the task. (B) Punch Master, (C) Step Master, (D) Motion Master, (E) Boxing Master, (F) Foot Master, (G) Number Master, and (H) Block Dodging.
Fig. 3. Study flow. H&Y, modified Hoehn & Yahr; K-MoCA, Korean version of the Montreal Cognitive Assessment; VR, virtual reality; SSQ, Simulator Sickness Questionnaire; UEQ, User Experience Questionnaire.
Fig. 4. Mean scores for each of the 26 items of the User Experience Questionnaire (UEQ).
Graphical abstract
Fig. 1.
Fig. 2.
Fig. 3.
Fig. 4.
Graphical abstract
Feasibility and Usability of Immersive Virtual Reality Exergames for Patients With Parkinson’s Disease: A Pilot Study
Characteristic
P1
P2
P3
P4
Sex
Female
Female
Male
Male
Age (yr)
75
81
63
76
Modified H&Y stage
3
2
3
2.5
K-MoCA (score)
22
25
29
24
Participant
Pre-VR session
Post-VR session
Difference
1
18
5
-13
2
26
6
-20
3
4
2
-2
4
11
6
-5
Average
14.75±9.43
4.75±1.89
-10.00±8.12
UEQ dimension
P1
P2
P3
P4
Mean score
Variance
Attractiveness
-0.17
1.83
1.00
2.00
1.167a)
0.98
Perspicuity
-0.25
0.50
0.00
2.50
0.688
1.56
Efficiency
0.25
1.50
0.75
1.75
1.063a)
0.47
Dependability
-0.75
0.00
0.00
2.25
0.375
1.69
Stimulation
0.00
2.25
1.75
2.00
1.500a)
1.04
Novelty
-0.50
1.25
1.75
0.00
0.625
1.10
Participant
Interest
Mood
Motivation
Difficulty
Physical comfort
Safety
Overall satisfaction
Continued use intention
Therapeutic expectation
Total
1
7
7
5
6
5
7
7
7
4
55
2
6
6
6
5
5
5
6
6
5
50
3
6
6
5
5
4
3
6
5
5
45
4
5
6
6
6
3
5
6
6
6
49
Average
6.00
6.25
5.50
5.50
4.25
5.00
6.25
6.00
5.00
49.75
Table 1. Individual baseline characteristics of the participants (N=4)
P1–P4, Participants 1 through 4; H&Y, modified Hoehn & Yahr; K-MoCA, Korean version of the Montreal Cognitive Assessment (maximum total=30 points).
Table 2. Simulator Sickness Questionnaire
Values are presented as mean±standard deviation.
VR, virtual reality.
Table 3. User Experience Questionnaire
P1–P4, Participants 1 through 4.
Above cut-off (+0.8).
Table 4. Custom Usability and Satisfaction Survey (7-point Likert scale)
, Seo Jung Yun, OT, PhD1
