Research Overview

The effect of VR games on perceived exertion, exercise adherence and health

At Virtually Healthy we have been conducting research into the mental and physical health benefits of virtual reality games. This article will give a brief overview of our recent research project. This project also included motion capture, however that is not discussed here as it is not relevant to the topic at hand and will be used in the creation of our VR health & fitness programmes. A full, more in depth, paper about this project will be published soon.


Gamified virtual reality is a promising solution to the problem of low adherence to exercise. In this study, 20 participants attended for an hour a week for 18 weeks, participating in a total of 36 different VR games. Attendance was recorded, heart rate was monitored throughout each session and questionnaires were completed for each game, including participant’s perceived exertion during each game. Adherence was 90% with a 10% drop-out rate – a drastic improvement when compared to the literature. Perceived exertion was compared to actual exertion, showing a significantly lower perceived exertion than actual exertion. Heart rate was seen to drop to a lower rate than resting in 40% of the sessions (usually whilst in the default/menu scenes before beginning a game). Participants noted various physical and mental health benefits thorughout the study. Overall it was shown that gamified VR can be used to increase engagement in exercise and improve both mental and physical health.


Exercise is a well known treatment and prevention method for a wide range of health conditions. However engagement in exercise programmes for health, as well as general participation in physical activity, is very low. As few as 26.9% of adults in the UK and 23.3% of adults in the US meet the World Health Organisation reccommendations for physical activity. Studys show an average adherence rate of approximately 58% and drop out rates ranging from 25-80% (with an average of ~50%) for research using standard exercise programmes. This is thought to cost the NHS alone £7.4bn a year!

Gamification is the use of gaming elements in a non-gaming context. Research shows that the use of gamification in exercise can positively change behaviour and perception of exercise, overall increasing participation. The image below shows a breakdown of how this works.

VR has been shown to distract users from pain, both physically and mentally. This makes it a promising tool for the implementation of gamification of exercise. Decreased pain during exercise is likely very beneficial for increasing engagement, however little research exists on the subject.


10 male and 10 female volunteers aged between 20 and 58 years took part in this study. Each attended for an hour a week over the course of 18-weeks (initially due to be 20-weeks however this had to be cut short due to the Covid-19 pandemic). Participants played between 1 and 3 different games per session. Over the course of the study, 36 different games were played, all of which were sent to us by the developers. Resting heart rate and weight were recorded at the beginning of each session. Heart rate was recorded throughout each session. At the end of each session participants answered a questionnaire about each game (based on the needs satisfaction questionnaire about exergames), including their rate of perceived exertion (RPE) and aspects such as enjoyment, immerion, motivation and effort as well as any general comments. Attendance was recorded throughout the study and two questionnaires were completed after the final session, one just a week after and a final follow-up questionnaire 9-months after the final session.

It was originally planned to record metabolic rate whilst resting and whilst exercising at the beginning and end of the study to compare fitness levels before and after the study, using a metabolic analyser kindly provided by YUR. However, the final metabolic tests were not able to be carried out.


Overall, there was a 10% drop-out rate, with plausible reasons given (behind on university work and a workload increase). Of the participants who completed the programme, there was 90% attendance, with plausible reasons given for missing sessions (a storm preventing travel, lack of transport, childcare issues, injury, illness, medical issues, exams and work obligations).

RPE was converted to heart rate to compare perceived exertion to actual exertion. A statistically significant difference was found, with perceived exertion significantly lower than actual exertion. A lower than resting heart rate was also observed whilst in the virtual environment (usually whilst in the menu/default scene before beginning a game) in 40% of sessions.

On average, one game induced very light exercise (<50% max heart rate), 14 games induced light exercise (50-63%), 13 games induced moderate exercise (64-76%), 7 games induced hard exercise (77-93%) and 1 game induced very hard exercise (94-99%).

The end questionnaire results suggested that participants would engage with active VR games more regularly than exercising. Although this is only speculative data, combined with the increase adherence, it provides a good basis for the conclusion that VR will likely improve physical and mental health through increased engagement with exercise. When asked if playing VR regularly had any affect on their mental health, 12 participants answered with positive effects, 1 participants answered that it may have had a positive effect and 5 participants answered that it had no effect. The two participants who suffered from depression commented as follows:

“I have found it beneficial for my mental health; it has been good for me to have the weekly activity just for myself which I really enjoy and the [sic] I found the immersive nature of VR helps me to just switch off for a period of time (particularly  when I am feeling anxious)”

“Definitely, it has been a highlight of my week and has always lifted my mood when I was feeling low otherwise”

The table below shows the answers to the questionnaires for all of the games together. The answers appeared to be dependant on the game – a couple of games were not enjoyed by the majority of participants.

The final follow-up questionnaire was completed by 13 of the 18 participants who completed the 18-week programme. Of these, 5 participants now own VR headsets, with all but one stating that it has increased their engagement in exercise – the other participant has used it to replace another form of exercise. Of the remaining participants, 5 of them plan to purchase a headset in the near future. Cost appeared to be the main barrier preventing them from purchasing a VR headset, with space being another issue. Two participants did not want to purchase one.


Compared to approximately 58% adherence and 50% drop-out seen with standard exercise programmes in the literature, 90% adherence with 10% drop-out is a great improvement, showing that gamified VR can greatly increase adherence to exercise. VR also lowerered perception of exertion, which may be a factor which contributes to this increased engagement. As seen in the questionnaire answers, the majority of participants enjoyed playing these VR games and were mostly motivated to get a high score. This shows that VR games can help to overcome the lack of motivation and enjoyment barriers which have been identified as preventing people from participating in exercise regularly. Enjoyment seemed to be dependant on the game – there were a couple of games which most participants did not enjoy, or found uncomfortable to play due to motion sickness.

Increased engagement with exercise is well known to lead to improvements in both physical and mental health. On top of improved mental health through exercise, VR itself has also been shown to help with anxiety and depression. Overall, VR provides a promising platform for the gamification of exercise to improve physical and mental health together.


The sample size used for this study was small, therefore the conclusions made in this study are not generalizable to a wider population. Further research is needed to support these conclusions.


Gamified VR shows a lot of promise for increasing engagement in exercise, reducing perception of exertion and improving both mental and physical health. These findings support previous research, however further research with larger sample sizes, as well as comparison studies to other forms of exercise are still needed.


Annesi, J. J. (2003). Effects of a cognitive behavioral treatment package on exercise attendance and drop out in fitness centers. European Journal of Sport Science, 3(2), 1–16.
Asztalos, M., Wijndaele, K., De Bourdeaudhuij, I., Philippaerts, R., Matton, L., Duvigneaud, N., Thomis, M., Duquet, W., Lefevre, J., & Cardon, G. (2008). Specific associations between types of physical activity and components of mental health. Journal of Science and Medicine in Sport.
Borg, G. (1998). Borg’s perceived exertion and pain scales. Human Kinetics.
Centers for Disease Control and Prevention. (2018). Exercise or Physical Activity. 
Centers for Disease Control and Prevention. (2020). Perceived Exertion (Borg Rating of Perceived Exertion Scale).
Chao, Y. Y., Scherer, Y. K., & Montgomery, C. A. (2015). Effects of using nintendo wii exergames in older adults: A review of the literature. Journal of Aging and Health, Vol. 27, pp. 379–402.
Deterding, S., Dixon, D., Khaled, R., & Nacke, L. (2011). From game design elements to gamefulness: Defining “gamification.” Proceedings of the 15th International Academic MindTrek Conference: Envisioning Future Media Environments, MindTrek 2011, 9–15.
Hawley-Hague, H., Horne, M., Skelton, D. A., & Todd, C. (2016). Review of how we should define (and measure) adherence in studies examining older adults’ participation in exercise classes. BMJ Open, 6(6).
Hoolahan, K. (2019). Exploratory research on the gamification of exercise for Fibromyalgia using virtual reality. Virtual Reality International Conference, 59–63
HTC. (2020). Vive Series. Vive.
Ioannou, A., Papastavrou, E., Avraamides, M. N., & Charalambous, A. (2020). Virtual Reality and Symptoms Management of Anxiety, Depression, Fatigue, and Pain: A Systematic Review. SAGE Open Nursing, 6, 237796082093616.
Jekauc, D. (2015). Enjoyment during Exercise Mediates the Effects of an Intervention on Exercise Adherence. Psychology, 6, 48–54.
Kujala, U. M. (2009). Evidence on the effects of exercise therapy in the treatment of chronic disease. British Journal of Sports Medicine, Vol. 43, pp. 550–555.
Linke, S. E., Gallo, L. C., & Norman, G. J. (2011). Attrition and adherence rates of sustained vs. intermittent exercise interventions. Annals of Behavioral Medicine, 42(2), 197–209.
National Institute for Health and Care Excellence, (2018). Physical activity and the environment. Nice.
Oculus. (2020). Oculus Quest.
Oesch, P., Kool, J., Fernandez-Luque, L., Brox, E., Evertsen, G., Civit, A., Hilfiker, R., & Bachmann, S. (2017). Exergames versus self-regulated exercises with instruction leaflets to improve adherence during geriatric rehabilitation: a randomized controlled trial. BMC Geriatrics, 17(1), 77.
Pavey, T., Taylor, A., Hillsdon, M., Fox, K., Campbell, J., Foster, C., Moxham, T., Mutrie, N., Searle, J., & Taylor, R. (2012). Levels and predictors of exercise referral scheme uptake and adherence: a systematic review. Journal of Epidemiology and Community Health.
Peng, W., Lin, J.-H., Pfeiffer, K. A., & Winn, B. (2012). Need Satisfaction Supportive Game Features as Motivational Determinants: An Experimental Study of a Self-Determination Theory Guided Exergame. Media Psychology, 15, 175–196.
Physical Activity Guidelines Advisory Committee. (2008). Physical Activity Guidelines Advisory Committee Report, 2008.
Rosenberg, D., Depp, C. A., Vahia, I. V, Reichstadt, J., Palmer, B. W., Kerr, J., Norman, G., & Jeste, D. V. (2010). Exergames for Subsyndromal Depression in Older Adults: A Pilot Study of a Novel Intervention.
Scholes, S. (2017). Health Survey for England 2016 Physical activity in adults Health Survey for England 2016: Physical activity in adults. NHS Digital, December, 1–112.
Strazdins, L., Broom, D. H., Banwell, C., McDonald, T., & Skeat, H. (2011). Time limits? Reflecting and responding to time barriers for healthy, active living in Australia. Health Promotion International, 26(1), 46–54.
Street, T. D., Lacey, S. J., & Langdon, R. R. (2017). Gaming Your Way to Health: A Systematic Review of Exergaming Programs to Increase Health and Exercise Behaviors in Adults. Games for Health Journal, 6(3), 136–146.
Tanaka, H., Monahan, K. D., & Seals, D. R. (2001). Age-predicted maximal heart rate revisited. Journal of the American College of Cardiology, 37(1), 153–156.
Tobi, P., Estacio, E. V., Yu, G., Renton, A., & Foster, N. (2012). Who stays, who drops out? Biosocial predictors of longer-term adherence in participants attending an exercise referral scheme in the UK. BMC Public Health, 12(1), 1–7.
Warburton, D. E. R., Nicol, C. W., & Bredin, S. S. D. (2006). Prescribing exercise as preventive therapy. Canadian Medical Association Journal, Vol. 174, pp. 961–974.
Zeng, N., Pope, Z., Lee, J., & Gao, Z. (2018). Virtual Reality Exercise for Anxiety and Depression: A Preliminary Review of Current Research in an Emerging Field. Journal of Clinical Medicine, 7(3), 42.
Posted on: January 15, 2021, by :

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