JMIR Publications

ABSTRACT

Background:

Cognitive-motor dual-task (CMDT) training and immersive extended reality (XR) have each shown promise for cognitive rehabilitation by enhancing motivation and ecological validity. Research on XR-based CMDT systems is growing rapidly, but there is little guidance on how such systems should be designed and evaluated.

Objective:

This scoping review aimed to map how existing XR-based CMDT systems for cognitive rehabilitation synthesize cognitive and motor tasks, support user interaction, deliver feedback, and are evaluated, and to derive a design framework for future systems.

Methods:

Following the PRISMA-ScR guidelines, we searched Web of Science, Scopus, IEEE Xplore, the ACM Digital Library, and PubMed for studies published from 2019 to July 9, 2025. Eligible studies described a head-mounted display–based XR system that delivered CMDT training for cognitive rehabilitation and reported a user-based evaluation. Data were charted across 4 dimensions: dual-task synthesis, XR interaction design, feedback, and evaluation.

Results:

Of 4615 records identified, 25 studies were included. Target populations included general aging populations (n=8), multiple sclerosis (n=4), mild cognitive impairment (n=3), and 7 other conditions. Rigid-timing tasks were the most common synthesis pattern (12/25, 48%), and more than half of the systems (13/25, 52%) were built from basic cognitive and motor tasks rather than contextualized or real-activity scenarios. Most systems (16/25, 64%) confined interaction to a fixed space around the user (narrow virtual reality); only 2 allowed free navigation and 4 used mixed reality. All but 2 systems (23/25, 92%) provided feedback, and 14 adapted difficulty, of which 11 relied on manual level selection, 2 on game metrics, and 1 on heart rate. Twelve studies evaluated efficacy (5 randomized controlled trials, 1 nonrandomized controlled trial, and 6 pre-post studies), whereas the remaining 13 were feasibility or formative studies; most studies (19/21, 90%) involved fewer than 50 participants.

Conclusions:

Diverse CMDT implementations in XR appear feasible across a range of cognitive impairments, but spatial fusion and dynamic adaptive difficulty remain underdeveloped, and evidence of efficacy from controlled trials is limited. We propose a design framework with 3 layers (goals, design elements, and constraints) and 8 design elements across 4 dimensions as an extensible foundation for future XR-based CMDT research. Future work should prioritize advancing spatial fusion, developing personalized adaptive difficulty algorithms, and conducting controlled clinical studies to establish efficacy.