Sport performance in virtual worlds: a systematic review of sport simulation in neurological paralympic athletes and non-athlete populations

BACKGROUND: Sport-simulation virtual reality (VR) can reproduce sport-specific perceptual-motor constraints with tunable difficulty and augmented feedback, offering a potential bridge from clinic to competition for people with neurological conditions. We systematically evaluated whether immersive and non-immersive sport-simulation VR improves sport-relevant function, delivers an adequate aerobic dose, and is safe versus eligible comparators. METHODS: We searched six databases from inception to 2 July 2025 for peer-reviewed randomized and non-randomized trials in neurological cohorts that implemented virtual environments explicitly simulating recognized sports (e.g., boxing, tennis, canoe paddling, wheelchair court sports). Primary outcomes were sport-specific performance or validated surrogates linked to return-to-sport (balance, agility, gait, dexterity, and reaction time); secondary outcomes included physiological dose (heart rate, heart rate variability, and oxygen uptake), adherence, usability, and safety. Synthesis followed SWiM guidance, and risk of bias was appraised with RoB 2 and ROBINS-I. Thirty-nine studies met inclusion (PROSPERO CRD420251178910) RESULTS: Across diagnoses, feasibility and acceptability were high with few serious adverse events. Sport-simulation VR paddling paradigms in subacute stroke improved seated reach and reduced sway beyond usual care, with concurrent gains in proximal upper-limb function. Boxing- and tennis-based exergames in ambulant stroke and spinal cord injury elicited moderate aerobic intensity, while hybrid arm-crank plus functional electrical stimulation-leg VR cycling matched outdoor cardiometabolic load and improved indoor mechanical efficiency. In cerebral palsy and multiple sclerosis, balance-board“board-sport” tasks consistently improved static/dynamic stability and short-distance mobility over 4-24 weeks, and striking/hand-tracking content more often enhanced manual dexterity. Overall certainty was very low to low owing to short intervention cycles, heterogeneous comparators, and incomplete reporting (randomization/concealment, fidelity, multiplicity). CONCLUSIONS: Sport-simulation VR appears feasible and safe, can deliver a moderate aerobic dose, and yields short-term gains in sport-relevant function that track task representativeness. Future pragmatic trials should preregister a single sport-aligned primary endpoint, embed telemetry and standardized safety taxonomies, and test durability and real-world transfer to on-field performance; to date, no included study has verified actual return-to-sport or competitive on-field participation, and observed effects relate only to clinical or laboratory surrogates of sport function. KEY POINTS: - Sport-simulation VR is feasible and safe across neurological cohorts. - Task representativeness matters: paddling improves trunk/postural control, board-sport tasks may improve balance/mobility and striking tasks enhance dexterity. - Boxing/tennis exergames achieve moderate aerobic intensity, and VR cycling could match outdoor cardiometabolic dose with efficient indoor performance.