Beyond Effectiveness: Feasibility, Acceptability, Engagement, and Safety of Virtual Reality and Exergaming Interventions in Individuals with Down Syndrome: A Systematic Review

Abstract

Virtual reality (VR) and exergaming are increasingly used in rehabilitation and physical activity programs for individuals with Down syndrome (DS), but implementation-related evidence remains insufficiently synthesized. This systematic review evaluated feasibility, acceptability, engagement, adherence, safety and tolerability, usability, accessibility, support requirements, and sustainability of VR and exergaming interventions in individuals with DS. MEDLINE via PubMed, Scopus, and Dimensions were searched from inception to September 1, 2026. Eligible studies included individuals with DS exposed to immersive or non-immersive VR or exergaming and reported at least one implementation-related outcome. Two reviewers independently performed study selection and data extraction, and risk of bias was assessed using design-specific Joanna Briggs Institute tools. Owing to substantial clinical and methodological heterogeneity, findings were synthesized narratively. Of 381 records identified, 20 reports representing 18 independent cohorts were included. Retention and adherence were generally high where explicitly reported, including 90%–96.5% adherence in several structured programs. Direct measures of acceptability and engagement were less frequently reported but were generally favorable, with variation across games and individuals. No serious intervention-related adverse events were reported in studies explicitly assessing safety, although mild transient symptoms such as dizziness and eye strain occurred in some immersive-VR users. Implementation was commonly supported by familiarization, individualized adaptations, caregiver involvement, professional supervision, and technical assistance. VR and exergaming appear implementable for many individuals with DS, but direct acceptability, long-term sustainability, and systematically assessed safety remain insufficiently studied.