Introduction

Virtual walking interventions have emerged as innovative rehabilitation methods for individuals with mobility disabilities1,2. Virtual walking refers to the experience of individuals walking in a non- to fully immersive virtual environment while stationary in the physical environment3. Exercise for mobility disabilities improves fitness, physical function, and emotional health4,5. Despite evidence that supports the benefits of traditional exercise, it can be problematic for people with mobility impairments. Non-clinical environments often lack accessible facilities and trained staff, making it difficult for them to exercise. Additionally, they may feel bored with conventional arm exercise equipment6,7. Virtual walking is a potential cost-effective therapeutic tool that can overcome this barrier. Furthermore, studies suggested that the virtual walking technique is superior in providing sensory feedback, intuitive navigation, and cognitive demands8,9. Virtual walking may activate the somatosensory cortex by reinstating sensory input through visual illusion, potentially modulating brain functional reorganization associated with deafferentation-induced neuropathic pain10.

A variety of virtual walking techniques have been proposed11. The earlier virtual walking methods adopted visual illusions, allowing patients to view projected virtual walking legs combined with their real bodies reflected in a mirror, which demonstrated a positive effect on pain12. A 2014 narrative review on virtual feedback included five articles that used walking observation interventions on people with spinal cord injury (SCI), showing a reduction in pain intensity13. However, one recent randomized controlled trial (RCT) for individuals with SCI yielded contradictory findings, as no significant change in pain intensity was observed between groups; however, physical functions such as muscle strength and walking performance improved in the virtual walking group1. Similarly, a 2017 study explored the use of computers to combine live images of participants and walking legs, with 69.5% of participants significantly improving their average pain levels14. More recent advancements in virtual walking interventions incorporate head-mounted devices (HMDs) with multiple sensory inputs, including sound, head and body tracking sensors, and additional input devices like joysticks and data gloves15. For example, a study employed hand controllers to track the arm swings of participants with SCI and transform them into leg movements, allowing participants to view their virtual arms and legs through an HMD. The results showed significant improvements in neuropathic pain (effect size (ES) = 0.31), mood and affect (ES = −0.16), and depression (ES = 0.13)16. However, a subsequent pre-post quasi-experiment study using the same intervention reported a significant decrease in pain intensity but no significant change in pain-related disability or pain interference17. In summary, cumulative trials are characterized by diverse virtual walking methods with mixed and often controversial results. This highlights the pressing need for a scoping review that encompasses all virtual walking modalities to refine the standardizing protocols.

Despite the increasing use of virtual walking interventions, there has yet to be a dedicated review specifically focused on these interventions. A 2021 scoping review examined virtual reality (VR) for managing neuropathic pain in individuals with SCI, including nine studies utilizing virtual walking or limb movement imagery. However, this review did not focus exclusively on virtual walking interventions, and while eight of the included studies reported significant pain reductions, the overall quality of evidence was low18. A subsequent 2024 systematic review expanded the scope to include 46 studies on VR-based rehabilitation for SCI, reporting outcomes related to lower limb mobility, gait, and pain. However, this review lacked both detailed categorization of VR interventions and sufficient RCTs to adequately strengthen its conclusions19. Emerging research suggests that virtual walking may improve not only pain but also physical function, psychological well-being, and underlying neurological mechanisms. Therefore, this scoping review will address the identified gaps by narrowing its focus specifically to virtual walking interventions and systematically mapping the available evidence.

This scoping review aims to 1) synthesize the characteristics of virtual walking interventions, 2) synthesize evidence of the effectiveness, feasibility, and acceptability, and 3) explore potential neurological mechanisms on health-related outcomes.

Results

Study selection, study characteristics, participant characteristics

Figure 1 depicts the study selection process via a PRISMA flow diagram. A total of 3882 articles were identified through searching the specified database and manual searches of the reference lists. After removing 1323 duplicates and screening 2549 titles and abstracts, 141 articles remained. After a full-text review, 13 clinical trials met the inclusion criteria as detailed in Table 11,2,14,16,17,20,21,22,23,24,25,26,27.

Fig. 1: PRISMA 2020 flow diagram.
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The flow diagram illustrates the identification, screening and including process of studies. n represents the number of studies.

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Table 1 Overview of Study Design, Population, Health Outcomes, and Feasibility of Virtual Walking Interventions
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Five types of research designs were used: a group pre-post study (35.8% of the studies)14,17,21,25,26, an RCT (28.6% of the studies)1,23,24,27, a controlled experimental study (21.4% of the studies)2,14,16, a feasibility study (7.1%)22, and a pilot experimental study (7.1%)20. More than half of the studies were carried out in hospitals, rehabilitation centers, or clinics (69.2%)1,2,14,20,21,22,23,24,27, and 23.1% of the studies permitted participants to engage in virtual walking at home (n = 3)16,17,26. The studies were mainly published in the USA (n = 4)17,20,21,24 and Spain (n = 3)1,2,14, followed by Turkey (n = 2)23,27 and Switzerland (n = 2)22,26, with two studies undertaken in Canada25 and Australia16, respectively. These studies were published mainly between 2015 and 2021.

A total of 439 participants were included, with ages ranging from 29 ± 3.6 to 60 ± 10.2 years. The participants were categorized into two main groups: those with SCI (84.6%)1,2,16,17,20,21,22,23,24,25,26, and those with pain conditions (lower back pain (7.7%)27, and lower limb neuropathic pain (7.7%))14. The mobility abilities of the participants were consistent with their conditions, as individuals with SCI used wheelchairs for locomotion (84.6%), while the remaining participants were able to walk normally.

Intervention characteristics

As shown in Table 2, the intervention content included virtual walking only or a combination of virtual walking with rehabilitation therapies. The rehabilitation therapies included Transcranial Direct Current Stimulation (tDCS) (n = 2)2,14, Transcutaneous Electrical Nerve Stimulation (TENS) (n = 1)23, and therapeutic exercise (n = 1)1. For the control group, six studies used an active control group, including observing virtual walking (n = 4)1,16,20,24, traditional physical therapy (n = 1)27, and TENS (n = 1)23. One study employed inactive control, focusing on monitoring the stability of pain measurement2.

Table 2 Content, Modality, Interface, Locomotion Method, Instructors, and Side Effects of Virtual Walking Interventions
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The virtual walking modality included virtual illusion (n = 9, 64.3%, one article has both illusion and avatar)1,2,14,20,21,22,24,25,27 and virtual avatar (n = 5, 35.7%)16,17,23,25,26. The virtual walking locomotions were categorized into three different types: ten focused on passive observing moving (71.4%)1,2,14,20,21,22,23,24,25,27, three on arm swing locomotion (21.4%) (one study also included passive observation)14,16,17, and one on foot tracking locomotion (7.2%)26. Regarding passive observing moving, the detailed tasks contain three observations: observing a pre-recorded actor walking from the first perspective20,21,24, observing virtual leg movement combined with one’s own upper body in a mirror from the first perspective1,14,23, and observing a computer-generated overlay of virtual leg movement combined with one’s own upper body from the first perspective2,14,27 or the third perspective22,25. For arm swing, tasks comprise using a handheld controller or arm gesture to control virtual leg movement from the first perspective16,17 or the third perspective14, with the game containing incentive elements16. For foot tracking locomotion, the task is that people lift their feet to control the virtual avatar walking26. Figure 2 illustrates the categorization of virtual walking locomotion types.

Fig. 2: Categorization of virtual walking locomotion types and feasibility.
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The figure categorizes three types of virtual walking locomotion, detailing their associated virtual modality, intervention characteristics, and feasibility for practice.

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The interface includes a projection screen (42.8%) (a projection screen only (7.1%)20, a combination of mirror (21.4%) or camera (14.3%))1,2,14,22,23. The 3D monitor or 3D screen with glasses accounted for 21.4%21,24,25, followed by HMDs (14.3%)16,17 and computer screens (14.3%)14,26. Only one study used video glasses (7.1%)27.

Regarding the duration of one virtual walking session, 53.8% of the studies set the duration at 11–20 min2,14,17,21,23,24,27, and 15.4% of studies set it at 8–10 min1,20. Concerning the frequency of virtual walking, more than half of the studies (70.0%) reported a frequency of 4–5 times per week or daily2,16,17,22,23,26,27, while 30.0% of interventions were implemented at a frequency of 1–3 times per week1,14,25. Additionally, three studies were one-time interventions and were not included in the frequency calculations20,21,24. The instructors were either therapists or research assistants1,16,17,22,24,26,27. In one study, the therapist implemented additional physical therapy1. Research assistants primarily assisted in setting up VR equipment or playing video (n = 3)16,17,24, while supervising the whole process (n = 3)22,26,27 and collecting data related to the supervision (n = 1)26 were mainly conducted by the therapists. For details, see Table 3.

Table 3 Numerical Summary of Virtual Walking Settings and Intervention Delivery
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Results of virtual walking on health-related outcomes

Both passive observing and arm swing interventions were evaluated for their effects on pain-related outcomes1,2,14,16,17,21,22,23,24,25,27. For passive observing interventions, most studies reported significant improvements in pain intensity or severity post-intervention14,21,22,23,24,27, with two studies showing significant between-group differences compared to active controls21,27. However, two studies found no significant differences between groups1,25. Regarding other pain-related outcomes, such as pain symptoms, pain-related activity interference, and pain qualities, most studies reported significant decreases in the intervention group2,23,24, including two with active controls23,24 and one single-group study2. For arm swing interventions, included studies demonstrated significant improvements in pain intensity or severity post-intervention14,16,17. Regarding other pain-related outcomes, one study found a significant decrease in pain interference in the intervention group16, while another reported no significant changes in pain-related disability post-intervention17.

Both passive observing and arm swing interventions were evaluated for psychosocial outcomes2,16,22,24,27. For passive observing interventions, studies reported significant improvements in depression within groups post-intervention2,22. Significant between-group improvements were also observed for fear of movement and pain unpleasantness, with both studies using active controls24,27. Additional positive effects on mood, anxiety, stress, and catastrophic thinking were noted post-treatment22. However, no significant between-group differences were observed for general well-being or quality of life22,27. For arm swing interventions, only one study examined psychosocial outcomes, reporting improvements in depression, mood, and affect post-intervention. An active control was adopted16.

Physical function outcomes were assessed in passive observing and foot tracking interventions1,26,27. Passive observing interventions showed significant improvements in lower limb muscle strength, walking speed, walking distance, and functional mobility post-intervention1,27, with one study reporting significant between-group differences in functional mobility27. However, no significant between-group differences were observed for balance27. Foot tracking interventions demonstrated significant improvements in functional mobility, balance, and lower limb muscle strength post-intervention compared to active controls26. Functional mobility effects were maintained during follow-up, although walking performance did not show significant changes26. For details, please see Table 4.

Table 4 Graphic representation of the effects of virtual walking on health-related outcomes by included studies
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Only two studies explored the mechanisms underlying virtual walking on neurological-related outcomes17,20, which can be classified into two categories: biochemical mechanism (n = 1) and neurological mechanism (n = 1). For biochemical mechanism, Gustin et al.17 tested the effects of virtual walking for patients with SCI on thalamic γ-aminobutyric-acid (GABA) and neuropathic pain. The GABA increased statistically after virtual walking; however, this change was not significantly related to pain intensity and duration (though the Pearson correlation coefficient was at a moderate level, r = −0.4). For neurological mechanisms, Eick et al.20 used functional magnetic resonance imaging (fMRI) to reveal that there was an activation in the bilateral somatosensory cortex and paracentral lobule for paraplegic patients during the virtual walking process.

The feasibility, acceptability, and adverse effects of virtual walking

Four studies reported recruitment rates1,2,24,27 ranging from 80.0% to 98.3% (the median rate is 84.2%). Participants’ drop-out rates in the virtual walking group ranging from 0%24 to 7.7%23 (the median value is 0). Seven studies reported an intervention adherence rate of 97.7–100%1,2,16,20,21,22,24. Our studies reported satisfaction with the intervention1,16,22,25; one showed moderate satisfaction22, another showed 91.7% of the participants would be willing to participate in the intervention again1, and one reported no difficulty in completing the protocol16. One reported positive interaction with a virtual avatar25. Regarding adverse effects, severe adverse effects were not reported in the virtual walking intervention, but three studies reported fatigue1,2,25, one reported dizziness1, one reported feeling blackout after waking up22, and two reported increased pain but disappeared at the end of the session2,25.

The methodological quality of studies

The quality assessment of the studies revealed a total of four RCTs1,23,24,27 and nine quasi-experiment studies2,14,16,17,20,21,24,25,26 out of 13 included studies. Of the RCTs, three studies did not provide details on the method of randomization and allocation (75.0%)23,24,27. For the quasi-experiment studies, six studies (66.7%) lacked a control group design17,20,21,22,25,26, and four studies (44.4%) did not clearly describe the outcomes measurement14,17,21,22. Additionally, most studies did not perform multiple time-point and follow-up assessments (66.7%–77.8%)2,14,17,20,21,25. The detailed results are presented in Supplementary Tables 2, 3.

Discussions

This scoping review highlights that virtual walking can serve as a promising non-pharmacological therapy for improving pain, physical mobility, and psychosocial outcomes such as depression. The intervention is generally well-accepted and satisfying, particularly among individuals with disabilities. However, significant heterogeneity in study designs, locomotion methods, and outcome measures limits direct comparisons and the ability to draw firm conclusions. Future research should focus on clarifying these mechanisms, standardizing protocols, and evaluating long-term effects to optimize its therapeutic potential.

The majority of the populations included were individuals with SCI1,17,20,22,23,24, while other studies focused on conditions such as lower back pain or limb pain14,27. Previous reviews have highlighted the benefits of virtual exercise for patients with mobility limitations, including those with stroke, SCI, or multiple sclerosis28. In particular, patients with SCI often experience neuropathic pain; VR has shown promise as a distraction that can alleviate pain18. Additionally, studies involving patients with mild to moderate depression showed improved depressive symptoms2,16,22, possibly due to the activation of volitional and reward processing circuits. A study pointed out that VR behavior activation for adults with major depressive disorder has been used in a feasibility RCT, showing it is safe and without adverse events29. Future research can explore the efficacy of virtual walking across a broader range of mobility impairments and different levels of depression.

Three types of locomotion methods were classified, with passive observing being prominent1,2,14,20,21,22,23,24,25,27. The intervention was first proposed in 2007, called mirror therapy, which provides visual illusions for patients with SCI and lets them experience the feeling of walking. These effects of pain relief lasted till three months of follow-up12. With the development of VR technology, recent studies have adopted more simulated and interactive locomotion methods, such as arm swing and foot tracking, to provide a more immersive and realistic virtual walking experience16,17. The heterogeneity of locomotion methods highlights the need to tailor interventions to individual patient needs. For patients with limited upper extremity function and mobility impairments, passive observing moving may be appropriate due to its minimal physical interaction23,30. And those with intact upper extremity function can benefit from arm swing locomotion for a more interactive experience16. For those with mild mobility limitations, foot tracking locomotion offers a relatively realistic walking experience26. The integration of AI to analyze users’ behavior and preferences can optimize the interactions between patients and the virtual environment, enhancing patient adherence and interest31.

Regarding settings, most studies were conducted in clinical environments, likely due to equipment and space constraints. In-home settings, virtual walking interventions are increasingly feasible, with studies showing the use of both screens and HMDs. People can choose interfaces according to their own needs and functional ability. For example, passive observing tasks can use projection or computer screens, arm swing locomotion often requires HMDs for greater immersion, and foot tracking requires screens with cameras to capture movement. HMDs are promising for home use, as they offer a more immersive experience compared to 2D or 3D screens32,33,34. In this context, using gesture-based interventions on affordable mobile VR platforms, such as Google Cardboard, presents a viable alternative35.

The dosage in virtual walking is critical, as it influences the effects. Studies with longer sessions did not always show significant pain reduction. Roosink et al.25 conducted two 90 min sessions, but the pain intensity did not significantly change. In another study set of 20 sessions, decreased pain intensity was observed; however, the long-term benefit remains unclear16, suggesting the need to establish a dose-response relationship. This study also pointed out that the safe maximum of participants’ exposure to immersive gameplay was 20 min for 2 sessions and at least 4 h apart within 2 weeks, which provides a reference for future research16.

Virtual walking interventions may have potential benefits for various health-related outcomes, including pain relief, psychosocial well-being, and physical function. Most passive observing interventions and arm swing interventions demonstrated moderate effect sizes in improving pain intensity for individuals with SCI and lower back or limb pain14,17,22,23. Although the protocols differed between individuals with SCI and those without neurological impairments, both emphasized the use of visual illusions and walking simulations16,22, this component of virtual walking can restore congruence between sensory and visual input, potentially reversing maladaptive neural changes and reducing pain in the short term36. Improvements were also observed in various dimensions of pain, such as pain quality, pain function, and pain symptoms, potentially due to differences in virtual settings and intervention content1,24,25. For example, neuropathic pain phenotypes such as cold sensitivity, deep pain, and skin sensitivity showed significant reductions in the arm swing intervention, likely due to the recalibration of specific areas affected by neuropathic pain through visual input24. Future studies should identify specific pain phenotypes that benefit most from virtual walking and explore the underlying neurological pathways involved.

Combination therapies, such as tDCS and TENS, showed promising effects when integrated with virtual walking1. tDCS may enhance virtual walking’s effects by activating descending pain modulation pathways, such as the anterior cingulate cortex and other areas related to pain perception2. TENS, on the other hand, appears to target pain intensity more directly, leading to greater reductions in pain-related impacts on relationships and sleep23. These findings suggest that virtual walking could serve as a non-pharmacological adjunct for pain management. Future studies should explore its long-term effects and synergistic potential with other non-pharmacological therapies.

Virtual walking also showed potential benefits for psychosocial outcomes, including improvements in depression, anxiety, stress, mood, and affect2,16,22,27. Both passive observing and arm swing interventions showed small effect sizes for these outcomes, likely due to the emotional distraction and engagement provided by the virtual environment37,38. Fear of movement and pain unpleasantness, which are closely linked to anxiety and depressive symptoms, showed large effect sizes in both passive observing and foot tracking interventions, possibly due to virtual walking’s effectiveness in acute pain relief39. However, changes in quality of life were not significant, potentially due to the short intervention duration22,27. Given the limited number of studies and the inclusion of only one RCT on mood-related outcomes, future RCTs are needed to further investigate the effectiveness of virtual walking on psychosocial well-being.

The large effect size for physical function was observed in a foot-tracking locomotion RCT for individuals with lower back pain, followed by those with SCI. Foot tracking interventions use movement observation and repetitive motivational scenarios to stimulate the action processing system, promoting muscle strength and mobility recovery1,26,27. For individuals with SCI, virtual walking offers a convenient and engaging method of exercise, with evidence suggesting its ability to modulate cortical sensorimotor integration40. More rigorous studies are warranted to determine whether the benefits of virtual walking interventions can be generalized to other populations with neurological disorders.

Two studies in this review investigated the neurological mechanisms underlying the effects of virtual walking on pain17,20. Regarding the biochemical level, although previous research linked neuropathic pain to reduced thalamic GABA levels41, recent evidence suggests that GABAergic neurons in the central amygdala could help regulate immune responses involved in pain39. At the neurological level, the included study found that virtual walking activated the bilateral somatosensory cortex in patients with neuropathic pain compared to healthy controls, suggesting that this activation may play a role in pain modulation20. The somatosensory cortex activation may provide afferent inputs that counteract the loss of sensory signals, potentially reversing maladaptive cortical reorganization—a process linked to ongoing pain relief in individuals with spinal cord injury42. Together, these findings indicate that virtual walking may modulate multiple neural pathways, especially those associated with sensory processing and motor imagery, which could contribute to its analgesic effects42. Future studies should explore how these mechanisms including possible changes in GABAergic activity, contribute to pain reduction.

A few studies reported on the clinical feasibility (n = 5)1,2,22,24,27, with participants expressing great satisfaction and acceptance. Satisfaction levels appeared to be influenced by the locomotion methods and the degree of immersion. For instance, some participants reported difficulty in fully immersing themselves when viewing avatars from a third-person perspective22. Using HMDs and ensuring greater visual congruence between virtual leg and real arm movements were identified as strategies to improve satisfaction25. Although feedback was largely positive, minor adverse effects such as fatigue, mild headaches, and dizziness were reported, though these effects were transient1,2,22,25. Fatigue may stem from prolonged screen use, as a VR risks review pointed out that using HMDs for over 26.22 min can induce visual fatigue43. Dizziness, likely caused by mismatched visual and physical inputs, may lead to motion sickness44. Incorporating simultaneous haptic feedback on feet or lower limbs, along with techniques like peripheral blurring and field of view reduction, could help mitigate these effects45,46.

This review has several limitations. First, the small number of included studies limits the ability to generalize findings. Second, there was methodological variability among the studies, as they featured three different locomotion methods, and two-thirds were non-randomized controlled trials. As a result, the effects of virtual walking interventions should be interpreted with caution. Third, only English-language articles were included, which introduces potential publication and language bias. This means the findings may not fully represent research conducted in non-English-speaking settings or published in non-English journals. These limitations highlight the need for more large-scale, high-quality randomized controlled trials to strengthen the evidence base for virtual walking interventions.

In conclusion, this scoping review suggests that virtual walking may have potential benefits for individuals with SCI or lower back pain, including improvements in pain, function, mobility, and depression. The intervention is associated with only mild side effects, which tend to diminish over time. Virtual walking encompasses three locomotion methods and is typically delivered through screens; however, portable HMDs are also feasible for implementation in home settings. Preliminary findings also suggest that the somatosensory cortex is activated during virtual walking, but the specific mechanisms for virtual walking and psychosocial-related outcomes need further identification. Given the promising effects of virtual walking on health-related outcomes, future studies with more rigorous designs (e.g., RCTs), larger sample sizes, and inclusion of patients from different mobility levels are recommended to enhance the validity and representativeness of findings. Additionally, studies should explore the feasibility of implementing virtual walking interventions in accessible settings, such as home-based environments, and consider tailoring the choice of interfaces (e.g., HMD for immersive experiences or projection screens for users with upper limb impairments) to meet the specific needs and preferences of different populations. Finally, future research is encouraged to explore the specific neurological mechanisms underlying the effects of virtual walking on health-related outcomes, particularly its impact on pain and psychosocial outcomes. It could provide insights to maximize the therapeutic effectiveness.

Methods

This scoping review followed the methodological guidance outlined in the Joanna Briggs Institute’s (JBI) Manual for Evidence Synthesis and is reported in accordance with the PRISMA Extension for Scoping Reviews (PRISMA-ScR) checklist47. The scoping review was registered in the Open Science Frame (OSF) at https://osf.io/rv6g5/.

Selection of studies

The inclusion and exclusion criteria were developed following the Population, Concept, and Context (PCC) framework. The population consisted of adults aged 18 years or older, with no restrictions on specific diseases or demographic characteristics (e.g., ethnicity or socioeconomic status). The concept focused on virtual walking interventions or interventions incorporating virtual walking components and reporting health-related outcomes. The context included a variety of interventional study designs, such as RCT, quasi-experimental studies, and other experimental studies. Studies were excluded if they were abstract-only, conference proceedings, protocols, or lacked full-text availability. Only studies published in English were included. This broad inclusion aimed to comprehensively map the landscape of research on virtual walking interventions, as detailed in the introduction.

The search strategies were developed by using combinations of keywords surrounding “virtual reality”, “walking”, and “clinical trials”. These strategies were collaboratively formulated and refined by two reviewers (D.Y.S. and L.J.Y.). The detailed search strategies, including search strings and database-specific adjustments, are provided in Supplementary Table 1. Two independent reviewers (D.Y.S. and L.J.Y.) screened all records, with a third reviewer (L.Y.) mediating any discrepancies through consensus.

Twelve databases (PubMed, Web of Science, ClinicalTrials, Science Direct, Embase, Cumulative Index to Nursing and Allied Health Literature (CINAHL), Cochrane Library, Psycho Info, IEEE Xplore and Education Resources Information Center (ERIC), ProQuest Dissertations & Theses (PQDT) and Bielefeld Academic Search Engine (BASE)) were systematically searched from 01/01/2014 to 08/10/2024. Reference lists of included studies were also screened. Although the concept of virtual walking was first introduced in 2007, and a review conducted in 2014 that included virtual walking studies as part of its analysis12,13, significant advancements have been made in virtual walking interventions. To highlight the latest developments, this scoping review focuses on literature from 2014 to 2024.

Data extraction

Two independent reviewers (D.Y.S. and L.J.Y.) developed an extraction template and independently extracted data from the included studies. The following data were collected: author, publication year, country, study design, sample size, setting, population, intervention-related content (including treatment details, virtual modality, interface, locomotion method, and whether the intervention involved virtual walking exclusively), intervention dosage, instructors, control types, and health-related outcomes. For health-related outcomes, the extracted data were categorized into three key fields: pain, psychosocial outcomes, and physical function. The categories reflect the most commonly reported outcomes in the included studies and align with the World Health Organization’s International Classification of Functioning, Disability, and Health (ICF) framework for rehabilitation and disability research48.

Assessment tools, results, neurological mechanisms, feasibility and acceptability, and side effects were also extracted. Feasibility indicators comprised the recruitment rate (the percentage of participants who gave consent divided by the number of eligible participants) and the drop-out rate (the percentage of participants who dropped out of the intervention after randomization divided by the total number of participants who agreed to consent). Acceptability indicators included participants’ satisfaction with the interventions and the adherence rate (the percentage of participants who completed the intervention protocol as the researchers defined). Discrepancies were reconciled by consulting a third investigator (L.Y.)

Quality of assessment

Two reviewers (D.Y.S. and L.J.Y.) independently evaluated the methodological quality of the included studies, with discrepancies reconciled by consulting a third investigator (L.Y.). RCT was assessed by the JBI critical appraisal tool for RCTs, which consists of 13 items rated as “yes”, “no”, “unclear”, or “not applicable”49. Quasi-experiment study (QES) was assessed using the JBI critical appraisal tool for QES, which contained nine items with the same rating system49.

Synthesis of results

A narrative summary of the included studies was synthesized to map the literature according to the research questions. The data were presented using descriptive tables and diagrams and then summarized based on inductively developed objectives.