VR-based exercise improves executive function in children with autism, meta-analysis findsVR Exercise Shows Promise for Executive Function in Children with Autism

BACKGROUND: In addition to core behavioral symptoms, children and adolescents with autism spectrum disorder (ASD) frequently exhibit impairments in executive function and motor performance. Although virtual reality (VR)-based physical exercise interventions are increasingly used in ASD rehabilitation, evidence regarding their multidimensional effects remains limited. OBJECTIVE: This study aimed to systematically review the effects of VR-based physical exercise interventions on behavioral outcomes, executive function, and motor performance in children and adolescents with ASD. METHODS: PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) 2020 guidelines were followed. PubMed (National Library of Medicine), Embase (Elsevier), Web of Science, Scopus (Elsevier), and other databases were searched from inception to May 7, 2026. Eligible studies included randomized and nonrandomized trials involving participants aged 6-18 years with ASD. The interventions consisted of VR-based exercise programs involving physical activity participation, including active video games, motion-sensing interactive training, and augmented reality-based exercise training. Risk of bias was assessed using Risk of Bias 2 (RoB 2; Cochrane Bias Methods Group) and Risk of Bias in Nonrandomized Studies of Interventions (ROBINS-I; Cochrane Bias Methods Group), and certainty of evidence was evaluated using the Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) framework. Random-effects meta-analyses were conducted using Hedges g standardized mean differences (SMDs). RESULTS: A total of 15 studies involving 439 children and adolescents with ASD were included; among them, 9 studies were eligible for meta-analysis. Behavioral outcomes were reported in only 3 studies. Owing to substantial heterogeneity in study designs and assessment instruments, we did not conduct a meta-analysis for these outcomes. Current evidence suggests inconsistent effects on social interaction and stereotyped behaviors. VR-based physical exercise interventions may improve executive function (SMD 0.75, 95% CI 0.32-1.18; I²=0.0%; P=.01; GRADE moderate). However, the prediction interval crossed the line of no effect (-0.12 to 1.63). VR-based physical exercise interventions were associated with improvements in motor performance (SMD 1.08, 95% CI 0.08-2.08; I²=74.3%; P=.04; GRADE low). However, the wide prediction interval suggests substantial between-study variability (-1.31 to 3.47). CONCLUSIONS: Current evidence suggests a relatively consistent positive effect of VR-based physical exercise interventions involving physical activity participation on executive function in children and adolescents with ASD. However, substantial uncertainty remains regarding their effects on motor performance and behavioral outcomes. Unlike previous reviews that primarily focused on general VR interventions, social skills training, or single functional outcomes, this systematic review specifically examined the multidimensional effects of VR-based physical exercise interventions. The findings suggest that VR-based physical exercise interventions may be implemented as adjuncts to conventional exercise or rehabilitation programs rather than as stand-alone interventions. Future large-scale, high-quality randomized controlled trials with larger sample sizes, standardized intervention reporting, and long-term follow-up are needed to further clarify the optimal implementation conditions and underlying mechanisms of different forms of VR-based exercise training.