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95
ENHANCING BALANCE IN PARKINSON’S DISEASE 
PATIENTS: A COMPREHENSIVE LITERATURE REVIEW 
ON THE EFFICACY OF EXERCISE IN AN ENRICHED 
ENVIRONMENT
Ana PONEBŠEK
1
, Friderika KRESAL
1
,
 
Luka ŠLOSAR
2,3
1 
Visokošolski zavod Fizioterapevtika, Ljubljana, Slovenia
2
 Science and Research Centre Koper, Institute for Kinesiology Research, Koper, 
Slovenia 
3 
Alma Mater Europaea – ECM, Department of Health Sciences, Maribor, Slovenia 
Corresponding author:
Ana PONEBŠEK
Visokošolski zavod Fizioterapevtika
Slovenska c. 58, 1000 Ljubljana, Slovenia
E-mail: ponebsekana99@gmail.com
ABSTRACT
Various physiotherapeutic methods and approaches play a significant role in the 
treatment of patients with Parkinson’s disease, including the use of enriched environ-
ments. Virtual reality (VR) as a type of enriched environment has the potential to create 
multiple sensory experiences and feedback, influencing various aspects of the patient’ s 
information processing and response. The suitability for home use and the consider-
able impact on motivation highlight its advantages over alternative approaches. The 
objective of this review is to investigate the impact of VR-based exercise on balance 
outcomes among individuals with Parkinson’ s disease. The inclusion criteria consisted 
of randomized controlled trials (RCTs) that examined the effects of exercise in a VR 
environment on individuals’ static and dynamic balance outcomes. In order to gather 
relevant studies, we conducted a comprehensive search across three databases. From a 
dataset of 625 records, we conducted a comprehensive full-text screening based on spe-
cific inclusion and exclusion criteria. This process resulted in the inclusion of 14 RCTs 
in our review. The emerging evidence regarding exercising in a VR environment does 
not definitively prove its superiority over standard exercise routines. However, studies 
have demonstrated that both the experimental and control groups showed compara-
ble improvements in enhancing static and dynamic balance among individuals with 
Review article                                                       DOI: https://doi.org/10.35469/ak.2023.394
received: 2023-07-03             UDC: 796.413:616.858

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Parkinson’s disease. The comparable improvements in balance observed between the 
experimental and control groups signify the potential effectiveness of VR-based exer-
cises. This underscores the encouragement for further development in this technology, 
particularly focusing on fully immersive VR environments, which may yield superior 
effects in enhancing balance among individuals with Parkinson’ s disease. 
Keywords: virtual reality, Parkinson’ s disease, balance, rehabilitation.
UČINKOVITOST V ADBE V OBOGATENEM OKOLJU ZA 
IZBOLJŠANJE RA VNOTEŽJA PRI PACIENTIH S PARKINSONOVO 
BOLEZNIJO: PREGLED LITERATURE
IZVLEČEK
Pri zdravljenju Parkinsonove bolezni imajo pomembno vlogo različne fizioterape-
vtske metode in pristopi, med katere spada tudi uporaba obogatenega okolja. Navi-
dezna resničnost kot vrsta obogatenega okolja ima potencial za ustvarjanje večkratnih 
senzoričnih izkušenj in povratnih informacij, ki vplivajo na različne vidike obdelave 
informacij in odzivov pacientov. Poleg tega je prednost vadbe v obogatenem okolju 
tudi v tem, da je primerna za domačo uporabo in deluje spodbudno. Namen tega dela 
je s pregledom literature ugotoviti, kakšni so učinki vadbe z navidezno resničnostjo 
na ravnotežje pri pacientih s Parkinsonovo boleznijo. Vključitvena merila vsebujejo 
randomizirane kontrolirane raziskave, ki proučujejo učinke vadbe v okolju navidezne 
resničnosti na statične in dinamične rezultate ravnotežja posameznikov. Za zbiranje rel-
evantnih raziskav smo obsežno preiskali tri baze podatkov. Med 625 zapisi smo temelji-
to preverili celotna besedila, upoštevajoč določena merila za vključitev in izključitev. 
S pomočjo tega postopka smo dobili 14 raziskav, ki smo jih vključili v svoj pregled. 
Na podlagi vključenih raziskav smo ugotovili, da nimamo dovolj dokazov, da bi lahko 
trdili, da vadba v obogatenem okolju pomembno izboljša ravnotežje pri pacientih s 
Parkinsonovo boleznijo v primerjavi s tradicionalno vadbo. Raziskave so pokazale, da 
sta eksperimentalna in kontrolna skupina pokazali primerljive izboljšave v statičnem in 
dinamičnem ravnotežju pri posameznikih. Primerljive izboljšave v ravnotežju, opažene 
med eksperimentalno in kontrolno skupino, kažejo potencialno učinkovitost vadb v 
okolju navidezne resničnosti. To potrjuje potrebo po nadaljnjem razvoju te tehnologije, 
še posebej osredinjenost na imerzivno obliko navidezne resničnosti, ki ima potencial za 
izboljšanje ravnotežja pri posameznikih s Parkinsonovo boleznijo.
Ključne besede: navidezna resničnost, Parkinsonova bolezen, ravnotežje, rehabili-
tacija

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INTRODUCTION
Parkinson’s disease (PD) is a neurodegenerative disorder characterized by 
the degeneration of dopaminergic neurons in the substantia nigra of the basal 
ganglia (Hague, Klaffke, & Bandmann, 2005). This results in a dopamine de-
ficiency that manifests itself in primary motor signs and symptoms such as the 
slowing of movements, tremor, and increased muscle tone that worsen over 
time and negatively affect patients’ balance, gait, functional mobility, and con-
sequently quality of life (Goldman & Tanner, 1998; Müller et al., 2019). The 
main motor features are bradykinesia, rigidity, tremor, and postural instability 
(Ball, Teo, Chandra, & Chapman, 2019; Roytman et al., 2023). Parkinson’s 
disease is not only a motor disorder, but also presents a variety of non-motor 
symptoms (e.g., disturbances in mood, cognition, and sleep) that often affect 
quality of life more than motor symptoms (Postuma, 2017). 
Physiotherapy plays an important role in the treatment of Parkinson’s dis-
ease. The use of various physiotherapy methods can improve balance and 
help patients become more independent. In addition to traditional rehabilita-
tion methods, virtual reality (VR) is becoming an increasingly popular method 
for Parkinson’s patients (Schultheis & Rizzo, 2001). Traditional rehabilitation 
methods include various exercise programs involving balance exercises, such 
as standing on one leg with eyes closed/open, stepping exercises, dual-task ex-
ercises, seated and standing exercises, and exercises on a balance beam or other 
challenging surfaces. Later, balance exercises are supplemented with perturba-
tion (Lewis & Rosie, 2012).
VR as a form of enriched environment holds the potential of a breakthrough 
technology for non-physical rehabilitation by providing multisensory informa-
tion and more realistic simulations to improve patient rehabilitation outcomes 
(Šlosar, Peskar, Pišot, & Marusic, 2023; Meulenberg, de Bruin, & Marusic, 
2022). This computer-generated environment is not static, but responds to the 
user’s movements, gestures, and verbal commands, giving the user the feeling 
of really being in this virtual world (Lewis & Rosie, 2012). With devices that 
allow visual or audio interaction between a person and VR, the person can im-
agine being part of the virtual environment. It can appear in it in the form of an 
imaginary object. In response to the user’s task (in the case of physical therapy, 
movement), the computer program generates changes in the virtual environ-
ment through its sensors that provide feedback on performance. 
VR can stimulate the user’s movement and cognitive processes, increasing 
the patient’s chances of regaining lost motor skills. It can also be used for bal-

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ance training and visual feedback (Mirelman, Maidan, & Deutsch, 2013). The 
use of VR has a long-term effect on patients, as it can prevent or slow the pro-
gression of movement disorders (Allen, Sherrington, Paul, & Canning, 2011). 
Originally designed for recreation and entertainment, the systems are now also 
used for therapeutic purposes due to their low cost, high availability, and port-
ability (Kong et al., 2016). These devices include the Sony Playstation, Nin-
tendo Wii, and Microsoft Xbox 360 Kinect, also known as exergames. VR en-
courages patients to make lifestyle changes and incorporate exercise into their 
daily lives. In addition, patients can use these devices at home. Due to their 
low cost, these devices are also suitable as rehabilitation aids for patients from 
lower socioeconomic backgrounds (Yong Joo et al., 2010). VR ranges from 
non-immersive to fully immersive, according to the degree of immersiveness 
provided (Piron et al., 2010). Non-immersive VR refers to a virtual experience 
through a computer, but also allows the user to remain aware of and in control 
of their physical environment (Henderson et al., 2013). Common technologies 
in this category include gaming consoles like PlayStation, Xbox 360, and Nin-
tendo Wii, which integrate exercise actions with gaming mechanics. To simpli-
fy the study of the effects of these interventions, Šlosar et al. (2022) categorized 
them as PC-exergames. Research suggests that these systems hold promise in 
ameliorating symptoms in neurological disorders and fostering cognitive and 
motor improvements, including in Parkinson’s disease (Maggio et al., 2019). 
On the other hand, fully immersive VR enables natural interaction with the 
environment by using the entire body of the user, who thus becomes an active 
part of the 3D environment (Tieri, Morone, Paolucci, & Iosa, 2018). The most 
common types of VR technologies are the HMD (Head-Mounted Display) and 
CA VE (Cave Automatic Virtual Environment) systems. When physical activity 
is incorporated into interventions within a fully immersive VR environment, 
Šlosar et al. (2022) suggested the term VR-exergames to name and further in-
vestigate these interventions.
For a more precise analysis of intervention effects, we applied the taxonomy 
introduced by Šlosar et al. (2022) to classify the studies we gathered. In recent 
years, significant progress has been made in the field of technology and rehabil-
itation methods. Therefore, a literature review is needed to update the results of 
the previous literature review, (Chen, Gao, He, & Bian, 2020; Lei et al., 2019) 
in the field of VR training to improve balance in patients with Parkinson’s dis-
ease. The aim of this review is to and analyze the existing studies to determine 
whether exercises in enriched environments improve balance ability in patients 
with Parkinson’s disease.

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METHODS
A literature search was performed across PubMed, PEDro, and Google 
Scholar (first 100 results) utilizing various keywords including “virtual real-
ity,” “VR,” “Parkinson’s disease,” “balance,” “rehabilitation,” and their syn-
onymous terms to locate relevant articles. Supplement A includes the distinct 
search strings employed for each database. 
The inclusion criteria to detect all the relevant articles were (i) The subjects 
of the study were Parkinson’s disease patients who had been formally diag-
nosed by a hospital or by internationally recognized diagnostic criteria. There 
were no restrictions on gender, course of disease, or severity of the disease; (ii) 
randomized controlled trials (RCTs); (iii) studies in which the experimental 
group underwent PC- or VR-based exercise interventions; (iv) studies in which 
outcomes were related to balance, i.e., RCTs that observed whether balance im-
proved in the experimental group at the end of treatment. The exclusion criteria 
comprised publications prior to 2010, RCTs not available under open access, 
irrelevant findings, non-English language studies, and those lacking a control 
group. In line with the Schoneburg et al. (2013) study, balance function is as-
sociated to four posture systems: static balance, dynamic balance, reactive pos-
ture adjustment, and expected posture adjustment. Considering their substantial 
impact on balance among Parkinson’s patients, our primary emphasis was on 
assessing static and dynamic balance as the primary outcomes. 
The screening process commenced by evaluating the titles and abstracts of 
the studies, identifying those most relevant to our topic. The second phase in-
volved examining the full texts to ascertain if they met the aforementioned 
inclusion criteria. The retrieved studies were then classified based on the tax-
onomy proposed by Šlosar et al. (2022): PC-exergame – studies conducted in 
non-immersive environments involving movement; PC-no-exergame – studies 
conducted in non-immersive environments without movement; VR-exergame 
– interventions fully immersing participants in a virtual environment while in-
volving movement; VR-no-exergame – studies wherein participants were fully 
immersed in a virtual environment without movement.

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RESULTS
Study selection and characteristics of included studies
The initial search retrieved a total of 625 articles (480 from PubMed, 100 
from Google Scholar, and 45 from PEDro). After deduplication, 35 articles 
were excluded. Subsequently, 27 articles were excluded based on titles and 
3 based on abstracts, leaving 14 articles for thorough evaluation as potential 
inclusions. Figure 1 illustrates the comprehensive inclusion and exclusion pro-
cess of the articles.
All participants were diagnosed with Parkinson’s disease at different disease 
stages: 4 trials reported Hoehn and Yahr stages 1 to 3, 7 trials reported Hoehn 
and Yahr stages 2 to 3, 1 trial reported Hoehn and Yahr stages 2 to 4, and 2 trial 
did not report any stage. All retrieved studies (van den Heuvel et al., 2013; Lee 
et al., 2015;  Shih, Wang, Cheng, & Yang, 2016; Yang, Wang, Wu, Lo, & Lin, 
2016; Gandolfi et al., 2017; Ribas, Alves da Silva, Corrêa, Teive, & Valderra-
mas, 2017; Santos, Machado, Santos, Ribeiro, & Melo, 2019; Tollár, Nagy, & 
Hortobágyi, 2019; Liao, Yang, Wu, & Wang, 2015; Liao, Yang, Cheng, et al., 
2015; Pazzaglia et al., 2020; Yen et al., 2011; Shen & Mak, 2014) were catego-
rized as PC-exergame studies, excluding Feng et al. (2019). Feng et al. (2019) 
lacked sufficient intervention details, such as specific performance methods, 
exercise intensity progression, and supervision information during training. As 
a result, we included 13 studies in the PC-exergames category, while no studies 
were found for the other categories.
Effects of virtual reality training on static and dynamic balance 
In all 14 studies, outcome measures used for balance assessment included 
the Berg Balance Scale (BBS), Limits of Stability (LOS), One-Legged Stance 
Test (OLS), the Activities-Specific Balance Confidence Scale (ABC), and the 
Sensory Organization Test (SOT). The majority of the studies used the BBS 
as the primary outcome measure for functional balance. The results are shown 
in Table 1. Several studies (Feng et al., 2019; Lee et al., 2015; Gandolfi et 
al., 2017; Tollár et al., 2019; Liao, Yang, Cheng, et al., 2015; Pazzaglia et al., 
2020) demonstrated significant improvements in static and dynamic balance 
among participants in the experimental group. Ribas et al. (2017) and Yen et al. 
(2011) also concluded that the experimental group exhibited statistically signif-

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Figure 1: Flow chart depicting the selection process of identified articles
Included Screening Identification
Records identified through 
database searching
PubMes: n = 480
Google Scholar: n = 100
PEDro: n = 45
Records after duplicates 
removed
n = 590
Studies included in review  
n = 14 
Reports excluded: 
Not relevant outcomes: n = 3
Article not in English: n = 2
No control group: n = 3
Title and abstract screen 
n = 77
Full text articles assessed for 
eligibility 
n = 22
Identification of studies via databases and registers

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icant progress in maintaining balance compared to the control group; however, 
the progress was not sustained over time. Liao, Yang, Wu, et al. (2015) found 
significant improvements in balance among both the experimental group and 
the group that performed traditional exercises, when compared to the control 
group. Shen & Mak (2014) reported that participants in the experimental group 
showed a significantly increased level of self-confidence in maintaining bal-
ance, as assessed by the self-assessment ABC test. Shih et al. (2016) found that 
the experimental group achieved improved postural stability compared to the 
control group, which followed a traditional balance training program. Both ex-
ercise programs were effective in improving functional balance in patients with 
Parkinson’s disease. In the study by van den Heuvel et al. (2013) the results did 
not show a significant improvement in balance among the participants. Simi-
larly, Yang et al. (2016) found that balance improved equally in both groups, 
with no significant differences observed between them. Santos et al. (2019) also 
reported that a combination of traditional exercise and Nintendo Wii training, 
as well as each individual intervention with an equal amount of physiotherapy, 
led to balance improvement. However, when analyzing all the results, no statis-
tically significant differences were found between the two groups.

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Table 1: Summary of the 14 included studies
Study Popu-
lation
Intervention Duration
time 
Outcomes and results
Experimental group Control group
van den Heu-
vel et al.
(2013)
n = 33 Visual feedback training, which 
was explicitly integrated in each 
workstation. Workstations consisted 
of a flat-panel LCD monitor con-
nected to a PC containing, interac-
tive dynamic balance exercises.
(n = 17)
Conventional balance 
training 
(n = 16)
60 min / 10 
treatment 
sessions /
5 weeks
There were no statistically signifi-
cant differences between groups 
in change scores for BBS and 
SLS test.
N.-Y . Lee et al. 
(2015)
n = 20 Dance exercise with Nintendo Wii 
+ neurodevelopment treatment + 
functional electrical stimulation
(n = 10).
Neurodevelopment 
treatment + 
functional electrical 
stimulation 
(n = 10).
30 min / 
5 times per 
week /
6 weeks
Balance had significantly im-
proved in the EXP group while 
CON group showed no significant 
improvement. Balance was meas-
ured by BBS. 
Shih et al. 
(2016)
n = 20 Balance-based exergaming inter-
vention using the Kinect sensor. 
(n = 10)
Conventional balance 
training
(n = 10) 
50 min / 
2 times per 
week/ 
8 weeks 
Both training programs improved 
functional balance in people with 
PD according to the results of 
BBS tests. There were no sig-
nificant differences between the 
groups.
Yang et al. 
(2016)
n = 23 Home-based balance training sys-
tem included 
touchscreen computer and a wire-
less balance board.
(n = 11) 
Conventional balance 
training
(n = 12) 
50 min / 
2 times per 
week / 
6 weeks
After training, both groups per-
formed better in the BBS at post-
test and follow-up than at pretest. 
No significant differences were 
found between these two groups 
at post-test and follow-up.

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Study Popu-
lation
Intervention Duration
time 
Outcomes and results
Experimental group Control group
Gandolfi et al. 
(2017)
n = 76 Balance training with Nintendo Wii 
and balance board.
(n = 38)
Sensory Integration 
Balance Training 
(n = 38) 
50 min / 
3 days per 
week / 
7 weeks 
Significant between-group differ -
ences were found for BBS scores. 
EXP group – progress, according 
to the BBS 
Ribas et al.
(2017)
n =20 The exergaming intervention con-
sisted of Wii Fit games. The device 
used was a Nintendo video game 
console with a Wii Balance Board 
(n = 10)
Conventional exercise 
program
(Warming, stretching 
active and resistance 
exercises)
 (n = 10)
30 min / 
2 times per 
week / 
12 weeks
Significant improvement in bal-
ance relative to BBS in the EXP 
group; this benefit was not sus-
tained after the 60-day follow-up.
Santos et al. 
(2019)
n = 45 EXP1 group
Training with Nintendo Wii 
(n=15)
CON group: active 
assisted and resisted 
movements, based 
on the PNF and gait 
training. 
(n = 15)
50 min / 
2 a week / 
8 weeks
There was no statistically signifi-
cant difference between EXP1, 
EXP2 group and CON group 
according to the BBS. 
EXP2 group: Training with Nin-
tendo Wii + 
active assisted and resisted active 
movements, based on the PNF.
(n = 15)
Feng et al. 
(2019)
n = 28 Balance training with Microsoft 
Xbox 360 Kinect 
(n = 14)
Traditional rehabilita-
tion training (warm 
up exercises, balance 
exercises, exercises for 
physical condition and 
coordination)
(n = 14)
45 min / 
5 times per 
week /
12 weeks
Significant improvement in BBS 
scores in both groups;
BBS were better in EXP group 
than in CON group.

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Study Popu-
lation
Intervention Duration
time 
Outcomes and results
Experimental group Control group
Tollár et al. 
(2019)
n = 74 EXP1 group: Exergames used the 
visual feedback modules of the 
Xbox 360 core system. 
(n = 25)
CON group: 
Wait-listed CON group 
continued with their 
habitual activity. 
(n = 24)
60 min / 
5 times per 
week / 
5 weeks 
EXP1 group: patients had better 
results in BBS score compared to 
the EXP2 group.
EXP2 group: stationary cycling 
(CYC) patients participated in a 
spinning class.
(n = 25)
Liao, Yang, 
Wu, et al. 
(2015)
n = 36 EXP1 group: Training with Nin-
tendo Wii (strength and balance 
exercises)
(n = 12)
CON group: did not 
undergo the structured 
exercise program but 
received fall-preven-
tion education instead.
(n = 12)
60 min / 
2 times per 
week / 
6 weeks
Both the EXP1 and EXP2
groups showed significant im-
provements in SOT test.
EXP2 group: Traditional exercises 
such as stretching, strengthening,
balance exercise, and treadmill 
training
(n = 12)
Liao, Yang, 
Cheng, et al.
(2015)
n = 36 EXP1 group: Training with Nin-
tendo Wii (strength and balance 
exercises)
(n = 12)
CON group: 
fall-prevention educa-
tion
(n = 12)
60 min / 
2 times per 
week / 
6 weeks
Patients in the EXP1 group had 
better results in the LOS and SOT 
test than participants in control 
group.
EXP2 group: traditional exercise 
(stretching, strengthening and bal-
ance exercises)
(n = 12)

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Study Popu-
lation
Intervention Duration
time 
Outcomes and results
Experimental group Control group
Pazzaglia et al. 
(2020)
n= 51 Exercise to improve balance with 
the NIRV ANA system. 
(n = 25)
Conventional reha-
bilitation program 
(exercises of motor 
coordination, balance 
training, start and stop 
exercises, and walking 
training)
(n = 26) 
40 min / 3 
times per 
week / 6 
weeks
EXP group improvement in bal-
ance according to BBS scale 
scores compared to the CON 
group.
Yen et al. 
(2011)
n = 42 EXP1 group: The hardware system 
for balance training includes dy-
namic balance board LCD screen, 
and a personal computer. 
(n = 14) 
CON group: 
They did not receive 
did not receive any 
physical therapy 
(n = 14)
30 min / 
2 times per  
week / 
6 weeks 
According to the SOT test, the 
EXP1 group made a significant 
improvement compared to the 
CON group, but this improvement 
was not sustained.
EXP2 group: conventional balance 
training,
(n = 14)
Shen & Mak, 
(2014)
n = 51 A computerized dancing system 
(KSD Technology Co. Ltd., Shenz-
hen, China)
(n = 26)
Training that 
emphasized improving 
the strength of the hip 
(flexion, 
extension, and abduc-
tion) and knee (flexion 
and extension) 
(n = 25)
15–60 min 
/ 5 times 
per week / 
12 weeks
The ABC scale analysis showed 
that there were no significant dif-
ferences between the two groups. 
The EXP group performed better 
on the SLS test.
Legend: BBS – Berg Balance Scale, ABC – activities-specific balance confidence scale, SLS – Single Leg Stance, SOT – Sensory Organization Test, LOS – Limits of Stability, 
EXP – experimental group, CON – control group, PNF – proprioceptive neuromuscular facilitation, PD – Parkinson disease

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DISCUSSION
The literature review examining the impact of VR-based exercises on the 
static and dynamic balance outcomes of Parkinson’s disease patients indicates 
that existing studies lack definitive evidence to establish the superiority of ex-
ercise in a virtual environment over standard exercise. The considerable vari-
ability in exercise methods makes it difficult to draw firm conclusions regarding 
the effect of PC-exergame training on the balance ability of Parkinson’s disease 
patients.
Although most studies did not demonstrate the superiority of PC-exergames 
over standard exercise, a study by Liao, Yang, Cheng, et al. (2015) revealed that 
Wii Fit-based exercises were more effective than traditional exercise in improv-
ing dynamic balance. One potential explanation for improved balance lies in 
personalized therapy protocols tailored to meet individual therapeutic needs and 
preferences. Wii Fit exercises provide external feedback during training in both 
auditory and visual forms. The participants were able to make corrections based 
on feedback to enhance their motor performance. Some of the Wii Fit exercises 
require either attention or problem-solving ability. Lee et al. (2015) observed 
a similar positive impact when introducing an innovative training method for 
elderly individuals diagnosed with Parkinson’s disease, employing Nintendo 
Wii dance games. Compared to the control group, balance of the experimental 
group was significantly enhanced. The experimental group received 30 more 
minutes of treatment per session comparing to control group and the difference 
in training time probably influenced the results. Another potential confounding 
factor in the study is that participants received traditional physiotherapy ac-
companied with Nintendo Wii. It is challenging to determine whether changes 
in clinical trials should be attributed to traditional balance training or VR. 
Unlike the previously mentioned studies, van den Heuvel et al. (2013) did 
not integrate Nintendo Wii into their setup. Instead, they employed a mobile 
workstation setup equipped with a force plate for the intervention within the 
experimental group. However, this approach did not demonstrate superior ef-
fectiveness compared to conventional therapy. 
The diversity of devices utilized in these studies poses a challenge in reach-
ing definitive conclusions. Devices ranged from common gaming consoles like 
Nintendo Wii and Xbox Kinect to specialized rehabilitation systems such as 
the NIRV ANA and the computerized dancing system (KSD Technology Co. 
Ltd., Shenzhen, China). Moreover, the varied frequency (ranging from 2 to 5 
times per week) and duration (lasting 5 to 12 weeks) of training sessions add 
complexity in establishing effective protocols. This wide array of intervention 

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types and frequencies significantly contributes to result heterogeneity, present-
ing difficulties in establishing conclusive findings. To reduce variability in re -
sults, future studies should research tailored interventions for different diseases 
stages. It is well known that Parkinson’s disease patients often have a preserved 
ability to cycle (Licen, Rakusa, Bohnen, Manganotti, & Marusic, 2022). This 
represents a unique aspect of their motor function that must be considered when 
designing research studies. If the ability to cycle is preserved in Parkinson’s 
disease, comparing the effectiveness of exergame / VR interventions with tradi-
tional cycling could be problematic because of the potential overlap in benefits 
and the need for differentiated evaluation methods to distinguish the respective 
effects.
Reviewing the literature it emerges that the PC-exergame technology for 
home-based training can be an effective option, particularly for individuals 
with limited access to rehabilitation centers and hospitals and could be used 
as a low-supervision home-base technology to obtain a therapeutic effect in-
dependently (Yang et al., 2016). However, a notable concern with home-based 
exercise lies in the possibility of users adopting compensatory movements 
to boost game performance. This inclination might lead patients to prioritize 
achieving high game scores over enhancing movement quality, potentially di-
minishing the genuine training effects. Before introducing computer games at 
home, it’s essential to prevent compensatory movements from affecting game 
performance. Supervised exercises by a physiotherapist can ensure safety and 
discourage compensatory actions. This supervision is especially vital for older 
adults unfamiliar with new technologies. 
Literature review is subject to certain limitations that should be considered. 
A significant limitation is the inclusion of various forms of exercise in the VR-
exergaming category. In the future, as more studies become available, it would 
be advisable to perform sub-analyses that differentiate between different types 
of exercises. For instance, the Shen & Mak (2014) study incorporated dancing, 
while others focused on strength and balance exercises.
We included studies involving participants clinically diagnosed with Parkin-
son’s disease, without any limitations on gender, age, disease duration or sever-
ity, and these studies exhibited variations in the types of technology employed 
and the duration of interventions. These factors may have introduced biases in 
the results and hindered direct comparisons. Future studies with improved tech-
nology and research methodologies are necessary to address the limitations and 
provide clearer insights into the effectiveness of exercise in enriched environ-
ments Additionally, these future investigations should incorporate innovative 
technologies that enable a holistic understanding of motor control strategies in 

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Parkinson’s disease (Marusic et al., 2023), thus advancing our comprehension 
of the condition’s intricacies.
CONCLUSIONS
The literature review encompasses scientific publications that explore the 
use of VR as a treatment modality for individuals with Parkinson’s disease, 
specifically focusing on the impact of training in an enriched environment on 
balance improvement. Some findings (although limited) suggest that exercise 
in an enriched environment can yield comparable outcomes to standard reha-
bilitation approaches, making it a viable option for balance rehabilitation in 
clinical settings. Additionally, it can serve as an adjunctive technology in the 
overall treatment plan for individuals with Parkinson’s disease, aiming to en-
hance balance outcomes.
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