JMIR Publications

ABSTRACT

Background:

Exercise has a positive impact on the health of older adults. However, due to the physical condition, psychological factors, and external environment constraints of older adults, they still face significant challenges in maintaining exercise. Exercise adherence is relatively low. Extended reality (XR) technology offers new ways for older adults to exercise and improve their adherence. Existing research mainly focuses on short-term effects, paying insufficient attention to maintaining long-term engagement and establishing effective incentive mechanisms. By introducing service design methods, user experience, stakeholder collaboration, and adherence support can be better integrated at different stages of exercise intervention, thereby enhancing the willingness and enthusiasm of the elderly to continue to participate in exercise.

Objective:

This review aims to evaluate how XR‑based exercise interventions for older adults over 50 integrate service design strategies to enhance exercise adherence and to identify critical gaps in their long‑term application.

Methods:

A systematic review was conducted across PubMed, Scopus, Web of Science, CINAHL, PsycINFO, and ACM Digital Library (January 2020–July 2025). Eligible studies (1) used XR to support exercise or rehabilitation, (2) included participants with a mean age >50 years, (3) reported at least one service design activity, and (4) provided adherence‑related outcomes. Dual independent screening and structured data extraction were performed.

Results:

A total of 9 studies (n = 242) met the inclusion criteria. Most applied participatory, co‑design, or user-centered design with iterative prototyping, but few advanced to full implementation or applied a complete service design cycle. The user experience was generally positive, but evaluations were primarily based on self-reports with limited objective tracking. Although exercise adherence was generally high in most studies (80%-100%), there was a lack of consistency in how adherence was defined across studies, and no unified measure of exercise adherence was established. Exercise frequency, duration, and attendance were commonly reported, whereas exercise intensity and accuracy were often overlooked. Existing evaluations also lacked long-term tracking of exercise adherence. Regarding intervention delivery settings, most studies were conducted in laboratories, hospitals, and care facilities. Few studies investigated implementation in community settings, which made XR interventions difficult to adapt to the real-world conditions faced by older adults in their daily lives and hindered their promotion and application to a broader community population.

Conclusions:

Current XR exercise interventions for older adults show promising short‑term adherence but rarely embed service design continuity or comprehensive adherence monitoring. The combination of structured service design processes with standardized and multidimensional adherence indicators can provide strong support for participants to continue engaging in XR exercise projects. When implemented in community settings, such interventions can further promote the development of projects towards scalability and adaptability to the needs of the elderly population, ultimately building a more age-friendly XR exercise system. Clinical Trial: OSF Registries osf.io/c7t85; https://osf.io/c7t85