Effects of Virtual Reality–Based Physical Exercise Interventions on Behavioral, Executive Function, and Motor Outcomes in Children and Adolescents with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis (Preprint)

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BACKGROUND Background: Physical exercise interventions are widely used as non-pharmacological approaches in the rehabilitation of individuals with autism spectrum disorder (ASD). However, conventional exercise-based programs remain limited in contextual control, task specificity, and participant adherence. With advances in immersive technologies, virtual reality (VR)–based physical exercise interventions have emerged as a novel paradigm that integrates motor training within controllable and interactive environments for individuals with ASD. However, their overall therapeutic efficacy has not yet been systematically evaluated. OBJECTIVE Objective: To systematically review and quantitatively evaluate the effects of VR–based physical exercise interventions on behavioral outcomes, executive function, and motor performance in children and adolescents with ASD. METHODS Methods: Following the PRISMA guidelines, seven electronic databases (PubMed, ProQuest, ScienceDirect, PsycINFO, Scopus, IEEE, and Web of Science) were systematically searched. Study quality and certainty of evidence were assessed using risk-of-bias tools (RoB 2.0 and ROBINS-I) and the GRADE framework. Data analyses were performed using R software (version 4.5.2; R Foundation for Statistical Computing). RESULTS Results: Sixteen studies involving 642 children and adolescents with ASD were included in the systematic review, of which 10 met the criteria for meta-analysis. The meta-analysis showed that VR-based physical exercise interventions significantly improved executive function (SMD = 0.75, 95% CI: 0.33 to 1.16, I² = 0.00%, GRADE= moderate) and motor performance (SMD = 1.01, 95% CI: 0.02 to 2.00, I² = 72.4%, GRADE= low) in children and adolescents with ASD. No significant overall effect was observed on behavioral outcomes (SMD = 1.19, 95% CI: −8.00 to 10.38, I² = 75.7%, GRADE= very low). Subgroup analyses indicated that short-term interventions (5 weeks) produced more consistent improvements in motor performance (SMD = 1.31, 95% CI: 0.44 to 2.18, I² = 0.00%). CONCLUSIONS Conclusion: The available evidence suggests that VR–based physical exercise interventions may improve executive function and motor performance in children and adolescents with ASD. However, evidence regarding their effects on behavioral outcomes remains insufficient and inconsistent. Overall, VR-based physical exercise interventions appear more suitable as an adjunct to conventional exercise or rehabilitation programs. Future research should prioritize high-quality randomized controlled trials with larger sample sizes and extended follow-up periods to clarify optimal intervention conditions and long-term effects.

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