Characterizing Locomotor Activity and Internal Load in VR-Based

Exergames for Post-Musculoskeletal Injury Rehabilitation

Elvio R

ubio Gouveia

1,2,3,4

, Pedro Campos

1,5,6

, Krzysztof Przednowek

, Andreas Ihle

4,8,9

Adilson Marques

3,10

, Hugo Sarmento

, Diogo Martinho

1,11

and Bruna Gouveia

1,12,13

LARSYS, Interactive Technologies Institute, 9020-105 Funchal, Portugal

Department of Physical Education and Sport, University of Madeira, 9020-105 Funchal, Portugal

CIPER, Faculty of Human Kinetics, University of Lisbon, Lisbon, Portugal

Center for the Interdisciplinary Study of Gerontology and Vulnerability, University of Geneva, 1205 Geneva, Switzerland

Department of Informatics Engineering and Interactive Media Design, University of Madeira, 9020-105 Funchal, Portugal

Wowsystems Inform

atica Lda, Funchal, Portugal

Institute of Physical Culture Sciences, Medical College of Rzesz

ow University, Rzesz

ow, Poland

Department of Psychology, University of Geneva, 1205 Geneva, Switzerland

Swiss Center of Expertise in Life Course Research LIVES, 1205 Geneva, Switzerland

Environmental Health Institute (ISAMB), Faculty of Medicine, University of Lisbon, 1649-020 Lisbon, Portugal

University of Coimbra, Research Unit for Sport and Physical Education (CIDAF), Faculty of Sport Sciences and Physical

Education, 3004-504 Coimbra, Portugal

Saint Joseph of Cluny Higher School of Nursing, 9050-535 Funchal, Portugal

Regional Directorate of Health, Secretary of Health of the Autonomous Region of Madeira, 9004-515 Funchal, Portugal

Keywords:

VR-Based Exergames, Rehabilitation, Physical Activity.

Abstract:

This study investigated the use of VR-based exergames in musculoskeletal injury rehabilitation, focusing on

locomotor activity and internal load, as well as the inﬂuence of involvement, sensory ﬁdelity, and interface

quality. Thirty-seven participants (aged 19-53) engaged in ﬁve customized VR games designed for rehabili-

tation. These games included ”Weight Transfer,” ”Military March,” ”Side Squat,” ”Progressive March,” and

”Walking along a Straight Line.” Data were collected using HTC Vive Pro hardware and full-body tracking,

with the E4 wristband measuring heart rate and movement and the OMNI scale assessing perceived exertion.

The Witmer-Singer Presence Questionnaire evaluated user experience. The results revealed signiﬁcant differ-

ences in heart rate, movement, perceived exertion, and exercise intensity across the exergames. ”Progressive

March” produced the highest heart rate and intensity, while ”Side Squat” generated the most movement and

exertion. ”Weight Transfer” had the lowest values across all metrics. Additionally, higher levels of presence

in the VR environment were linked to more physical activity. These ﬁndings suggest that this VR-based ex-

ergame session effectively meets each rehabilitation phase’s needs. Higher Presence in VR enhances user

engagement and realism, leading to increased physical activity.

1 INTRODUCTION

Musculoskeletal injuries profoundly impact daily

functioning and overall health, affecting around 40%

of the U.S. population (NHIS, 2012; Katz, 2015).

These impairments, caused by conditions like chronic

joint pain, arthritis, and neurological diseases, can

signiﬁcantly disrupt the performance and participa-

tion of athletes, whether elite or amateur, in sports

activities. Traditional rehabilitation methods, often

repetitive and exhausting, can lead to mental health

challenges and reduced motivation, which hinders re-

covery (Elwyn et al., 2012; Putukian, 2016). There-

fore, well-designed and engaging rehabilitation pro-

grams are essential for restoring function, preventing

long-term disabilities, and ensuring sustained recov-

ery.

In this context, virtual reality (VR) is emerging

as a promising tool in musculoskeletal rehabilitation.

Although evidence supporting its efﬁcacy is currently

limited to speciﬁc areas like upper limb rehabilitation

(Chaplin et al., 2023), VR systems could offer cus-

tomizable treatment platforms that improve patient

engagement, adherence, and rehabilitation outcomes

Gouveia, É., Campos, P., Przednowek, K., Ihle, A., Marques, A., Sar mento, H., Martinho, D. and Gouveia, B.

Characterizing Locomotor Activity and Internal Load in VR-Based Exergames for Post-Musculoskeletal Injury Rehabilitation.

DOI: 10.5220/0013069500003828

Paper published under CC license (CC BY-NC-ND 4.0)

In Proceedings of the 12th International Conference on Sport Sciences Research and Technology Support (icSPORTS 2024), pages 265-270

ISBN: 978-989-758-719-1; ISSN: 2184-3201

265

(Aderinto et al., 2023). Growing evidence in the lit-

erature supports VR’s potential to offer immersive,

engaging rehabilitation options, improving both per-

formance and health outcomes (Aderinto et al., 2023;

Chaplin et al., 2023). However, the relationship be-

tween immersion, satisfaction, and adherence in VR-

based rehabilitation remains inconsistent, as current

data is still limited (Rose et al., 2018).

Immersion in a virtual environment (VE) pro-

duces the sensation of ”Presence,” the feeling of be-

ing present in the VE (Riva et al., 2003). Presence

is key in VR and is considered an indicator of its

”ecological validity,” referring to the potential trans-

fer of skills acquired in the virtual world to the real

world. The ultimate goal of exergame-based training

is to improve performance using gamiﬁed scenarios,

suggesting that if a link between presence and perfor-

mance is established, exergame designers can manip-

ulate presence to maximize participant performance,

thus making the practice more long-lasting. This is

particularly signiﬁcant as VR training is increasingly

adopted due to cost and time efﬁciency (Stevens and

Kincaid, 2015).

The main objectives of this study were to charac-

terize the locomotor activity and internal load associ-

ated with VR-based exergames used in musculoskele-

tal injury rehabilitation and to examine how different

levels of involvement, sensory ﬁdelity, and interface

quality inﬂuence these factors. The study’s hypothe-

ses are as follows: (i) locomotor activity and internal

load during the proposed VR-based rehabilitation ses-

sion align with the exercise guidelines recommended

by the American College of Sports Medicine in terms

of the intensity characterizing each phase of the ses-

sion, and (ii) higher presence in VR exergames is as-

sociated with higher levels of physical activity.

The results of this study are expected to pro-

vide an important understanding of improving mus-

culoskeletal rehabilitation protocols by aligning VR-

based exergames with recommended training guide-

lines. Furthermore, understanding the locomotor ac-

tivity and internal load in these sessions will help

healthcare professionals optimise exercise intensity

and progression. Additionally, the positive relation-

ship between higher presence and better performance

in VR exergames suggests that immersive environ-

ments can increase patient engagement and physi-

cal effort, leading to better rehabilitation outcomes.

These results have practical value in clinical settings,

allowing healthcare professionals to integrate tailored

and engaging VR exergaming sessions into rehabili-

tation programs for more effective injury recovery.

2 METHODS

2.1 Participants

This study included 37 participants (18 males) aged

between 19 and 53 years (M = 23.69; SD = 6.98),

recruited from an academic institute. The partici-

pants were students enrolled in various engineering,

tourism, physical education, and sports programs. In-

clusion criteria were: (1) students aged 18 years or

older from the academic institute and (2) voluntary

willingness to participate. The only exclusion crite-

rion was the presence of any medical contraindica-

tions to sub-maximal exercise, as per the guidelines

of the American College of Sports Medicine (ACSM,

2022). All procedures were approved by the Faculty

of Human Kinetics Ethics Committee, CEIFMH No.

39/2021. The study adhered to the Declaration of

Helsinki, and informed consent was obtained from all

participants.

2.2 Virtual Reality Gaming

Development

Five customized VR games – ’Weight Transfer’, ’Mil-

itary March’, ’Side Squat’, ’Progressive March’, and

’Walking along a Straight Line’ – were developed to

facilitate a complete rehabilitation session for people

recovering from musculoskeletal injuries. All partic-

ipants followed the same order of games during the

session, aiming to include in the training session a

warm-up and cool-down, stretching exercises, and a

gradual progression of the session’s volume and in-

tensity, as recommended. The creation of these VR

games involved exploratory research, including open

interviews with physiotherapists. The session was set

within a soccer-themed environment, incorporating

speciﬁc soccer elements and gamiﬁcation techniques

to maintain user engagement. Each VR game was de-

signed to address key training domains, such as aer-

obic endurance, upper and lower body strength, and

motor skills. An overview of Exergames, including

purposes, scoring, and the functional ﬁtness capaci-

ties stimulated, can be found in (Gouveia et al., 2023).

The games were developed by two researchers on the

topic of computer engineering.

2.3 Software and Hardware

The system integrates HTC Vive Pro hardware, in-

cluding full-body trackers, and Unity3D software for

developing a VR application with full-body tracking.

Trackers placed on key body points allow accurate

icSPORTS 2024 - 12th International Conference on Sport Sciences Research and Technology Support

266

exercise performance monitoring, while inverse kine-

matics (IK) in Unity calculates joint angles for realis-

tic avatar movement. The VR environment, modeled

in Blender as a realistic soccer stadium, enhances im-

mersion, and a customizable avatar increases user en-

gagement. Unity3D’s multi-platform capability and

SteamVR integration support efﬁcient VR application

development across various devices. A detailed de-

scription of Software and Hardware can be found in

(Gouveia et al., 2023).

2.4 Locomotor Activity and Internal

Load

2.4.1 E4 Wristband

The E4 wristband is an advanced device that provides

real-time physiological data through four sensors:

(1) an electrode for Electrodermal Activity (EDA),

(2) a 3-axis accelerometer, (3) a temperature sensor,

and (4) a photoplethysmograph (PPG) that measures

blood volume pulse (BVP), from which heart rate

(HR) and inter-beat interval (IBI) are derived (Em-

patica, 2022). This study focused on the MEMS-type

3-axis accelerometer, which measures the continuous

gravitational force (g) in three spatial dimensions (x,

y, and z) and heart rate calculated from the BVP data.

2.4.2 Rate of Perceived Exertion (RPE) Scale

The RPE is a scale that measures the intensity level

of physical activity. This study used the OMNI rating

of perceived exertion (Robertson et al., 2003). Be-

fore the VR game, all participants were individually

instructed on the speciﬁcs of the OMNI Scale. Then,

right after each VR game, the researcher interviewed

each participant using the OMNI picture system that

elucidated the different levels of effort and the dif-

ferent possible response options (with ‘0 indicating a

minimum response and ’10 indicating a maximum re-

sponse).

2.5 Presence

The Witmer-Singer Presence Questionnaire was used

to characterize the experience in the VR games en-

vironment (Witmer and Singer, 1998; Witmer et al.,

2005). The Presence Questionnaire is a questionnaire

that measures the extent to which a user feels present

in the virtual experience. It consists of 24 questions

divided into four components: involvement, sensory

ﬁdelity, adaptation/immersion, and interface quality.

This instrument uses a scale of 1 to 7, with one being

“Not Convincing” and 7 “Very Convincing”.

Figure 1: Estimated 3-axis Accelerometer Movement

Across Various VR-Based Exergames: A Comparison Be-

tween High and Low Presence Levels.

Figure 2: Estimated heart rate Across Various VR-Based

Exergames: A Comparison Between High and Low Pres-

ence Levels.

Figure 3: Estimated Rated Perceived Exertion Across Var-

ious VR-Based Exergames: A Comparison Between High

and Low Presence Levels.

In this study, we considered a high level of pres-

ence for all participants who scored above the median

(Med = 127).

Characterizing Locomotor Activity and Internal Load in VR-Based Exergames for Post-Musculoskeletal Injury Rehabilitation

267

Table 1: Comparison of Locomotor Activity and Internal Load Across 5 VR-Based Exergames for Post-Musculoskeletal

Injury Rehabilitation.

Weight Transfer (G1) Military March (G2) Side Squat (G 3) Progressive March (G4) Semi-tandem walk (G5) p

Mean SD Mean SD Mean SD Mean SD Mean SD

HR (b/min) 88 19.4 98.9 16.1 100.2 17.3 107.7 21.6 103.3 20.3 <.001

Movement (g) 416643 164887 324539 171375 506299 156377 208196 82355 301632 117662 <.001

RPE (n) 1.7 1.3 3.8 1.5 4.3 1.5 4.1 1.6 2.8 1.2 <.001

Intensity (% HR max) 44.9 10.1 50.4 8.1 51.1 8.9 54.9 10.9 52.6 10.3 <.001

3 RESULTS

The results presented in the table demonstrate sta-

tistically signiﬁcant differences across the ﬁve VR-

based exergames in terms of heart rate (HR), move-

ment (g), rating of perceived exertion (RPE), and ex-

ercise intensity (%HR max), with all p-values less

than .001. Notably, the Progressive March exergame

elicited the highest heart rate (Mean = 107.7 bpm) and

exercise intensity (Mean = 54.9% HR max), while the

Side Squat resulted in the highest movement (Mean

= 506299.2 g) and perceived exertion (Mean RPE =

4.3). Conversely, the Weight Transfer exergame was

associated with the lowest heart rate (Mean = 88.0

bpm), perceived exertion (Mean RPE = 1.7), and ex-

ercise intensity (Mean = 44.9% HR max), highlight-

ing the variability in physical demands across differ-

ent exergames.

The exergames had a signiﬁcant main effect on

movement F(4, 25) = 37.01, p <.001, and a partial

eta squared of .856. The comparison of movement

across ﬁve exergames between high and low levels of

presence revealed a signiﬁcant difference, F(1, 28) =

4.30, p = .047, partial eta squared = .13, indicating

that the high presence group engaged in more physi-

cal activity during the analyzed games (Figure 1).

The exergames had a signiﬁcant main effect on

heart rate F(4, 30) = 6.415, p <.001, and a partial eta

squared of .461. The comparison of heart rate across

ﬁve exergames between high and low levels of pres-

ence revealed a non-signiﬁcant difference, F(1, 28) =

.08, p = .78, partial eta squared = .003, indicating no

differences between high presence and low presence

during the game (Figure 2).

The exergames had a signiﬁcant main effect on

Rated Perceived Exertion F(4, 30) = 25.948, p <.001,

and a partial eta squared of .776. The comparison of

heart rate across ﬁve exergames between high and low

levels of presence revealed a non-signiﬁcant differ-

ence, F(1, 33) = 2.10 p = .16, partial eta squared =

.06, indicating no differences between high presence

and low presence during the game (Figure 3).

4 DISCUSSION

The ﬁrst purpose of this study was to characterize the

locomotor activity and internal load associated with

VR-based exergames. We found signiﬁcant variabil-

ity in physical demands across different VR-based ex-

ergames, with each game setting distinct heart rate,

movement, perceived exertion, and exercise intensity

levels. “Progressive March,” a game focused on aer-

obic and lower body strength typically included in

the conditioning phase of a session, was the most

demanding, showing the highest heart rate and ex-

ercise intensity, making it practical for cardiovascu-

lar improvement, as expected. The “Side Squat”

exergame, focused on lower body strength, induced

the most movement and perceived effort, indicat-

ing strong muscular activation. In contrast, “Weight

Transfer,” an exergame focused on balance, was the

least demanding and suitable for the ﬁrst phase of

a rehabilitation session (warm-up), characterized by

light-to-moderate-intensity activity.

The ﬁrst point to highlight in this study’s results is

the statistically signiﬁcant differences in HR, move-

ment (g), RPE, and exercise intensity (%HR max)

parameters across the different VR-based exergames.

This outcome suggests that each exergame imposes

varying levels of physical demand, which aligns with

expectations for a Post-Musculoskeletal Injury Reha-

bilitation training session. In this context, the design

of this session is considered a typical single exercise

training session, which generally consists of the fol-

lowing phases: (i) Warm-up/Initiation, (ii) Condition-

ing, and (iii) Cool-down (ACSM, 2022). The warm-

up or initiation phase serves as a transitional stage

that allows the body to adapt to the exercise session’s

changing physiological, biomechanical, and bioener-

getic demands. It should include light-to-moderate

intensity activities, speciﬁcally targeting the muscle

groups that will be engaged during exercise (Mc-

Gowan et al., 2015; Garber et al., 2011). During

the conditioning phase, training exercises can include

aerobic, resistance, ﬂexibility, or sports activities, de-

pending on the speciﬁc goals of the session (ACSM,

2022). Finally, the cool-down phase allows the body

icSPORTS 2024 - 12th International Conference on Sport Sciences Research and Technology Support

268

to return to near-resting levels. Low-to-moderate in-

tensity ﬂexibility exercises, such as static stretching,

can also be incorporated during this phase to help the

body reach a more relaxed physiological state (Behm,

2024).

As shown, the characterization of locomotor ac-

tivity and the internal load associated with this VR-

based exergame session for rehabilitation following

musculoskeletal injuries adheres to the exercise train-

ing session components suggested by the American

College of Sports Medicine. The ”Weight Transfer”

game, which is the ﬁrst game in the session (i.e.,

warm-up or initiation phase), was identiﬁed as the

least demanding exergame, with the lowest heart rate

values (88.0 bpm), perceived exertion (RPE = 1.7),

and exercise intensity (44.9% HR max), as expected.

Additionally, we emphasize the convergence of re-

sults between heart rate and exercise intensity for in-

ternal load assessment. This result is signiﬁcant be-

cause, in the absence of HR monitors, RPE can be

reliably used as a safe and accurate alternative (Borg,

1998). The ”Progressive March” game, correspond-

ing to the conditioning phase, was characterized as

the most demanding exergame, producing the highest

average heart rate (107.7 bpm) and exercise intensity

(54.9% HR max). This game aims to improve car-

diovascular ﬁtness and promote greater physiological

adaptations. Finally, we highlight the ”Side Squat”

game, also part of the conditioning phase, where we

observed the highest movement activity and perceived

exertion. Once again, we found a convergence be-

tween the highest average movement (506299.2 g)

(external training load) and the highest perceived ex-

ertion (RPE = 4.3) (internal training load). This fur-

ther validates using RPE as a reliable tool for evaluat-

ing exercise intensity (Borg, 1998).

The second aim of this study was to compare the

impact of Presence (i.e., involvement, sensory ﬁdelity,

adaptation/immersion, and interface quality) on loco-

motor activity and internal load during the VR expe-

rience. As expected, players with higher Presence in

the virtual environment engaged in more physical ac-

tivity, although Presence did not signiﬁcantly affect

heart rate or perceived exertion (internal load). Our

study supports the hypothesis that high levels of Pres-

ence can enhance user engagement and realism, lead-

ing to greater locomotor activity (Luo et al., 2023).

Sensory ﬁdelity and interface quality directly inﬂu-

ence user immersion, fostering a more natural phys-

ical response, which, in turn, elevates exertion lev-

els (Zhang and Song, 2022). These ﬁndings are fur-

ther supported by a study that examined the relation-

ship between presence and performance during a psy-

chomotor task in a virtual environment, suggesting

that a higher sense of presence in virtual simulations

may positively inﬂuence performance and contribute

to skill acquisition during virtual training (Stevens

and Kincaid, 2015). The relationship between Pres-

ence, deﬁned as the sensation of ”being there” in a vir-

tual environment (VE), and its impact on locomotor

activity observed in our study aligns with the theory

of Presence and Immersion by Ijsselsteijn and Riva

(Riva et al., 2003). This supports the idea that greater

immersion leads to heightened engagement, as users

immersed in the virtual environment are more likely

to interact physically and respond naturally to the vir-

tual stimuli.

Some limitations must be acknowledged when in-

terpreting our results. The small and homogeneous

sample, which is all students from speciﬁc academic

programs, restricts the generalizability of the ﬁndings

to a broader population. Additionally, external fac-

tors such as prior experience with VR and varying

ﬁtness levels were not controlled, which could inﬂu-

ence locomotor activity and internal load. These un-

controlled variables might affect the accuracy of as-

sessing the relationship between Presence and phys-

ical engagement in the virtual reality environment.

Further research is needed to address these limita-

tions and enhance the study’s applicability. These

limitations suggest that further research with larger,

more diverse samples and greater control over exter-

nal inﬂuences is needed to validate and extend the

study’s ﬁndings. On the other hand, the strengths of

this study include the comprehensive characterization

of locomotor activity and internal load across vari-

ous VR-based exergames for rehabilitation. It effec-

tively demonstrates how different exergames impose

distinct physical demands, validating the use of RPE

as a reliable intensity measurement. Additionally, it

explores the impact of Presence on user engagement

and physical activity, emphasizing the importance of

immersive design for effective rehabilitation

5 CONCLUSSION

The main conclusion is that VR-based exergame ses-

sions present varied physical demands and effectively

meet the needs of each rehabilitation session phase.

The “Progressive March” promoted cardiovascular

ﬁtness, while “Weight Transfer” was the least de-

manding and appropriate for warm-up. The study also

validated the use of the RPE scale as a reliable tool for

assessing exercise intensity, particularly when heart

rate monitors are unavailable. Additionally, higher

levels of presence in the virtual environment corre-

lated with increased locomotor activity, emphasizing

Characterizing Locomotor Activity and Internal Load in VR-Based Exergames for Post-Musculoskeletal Injury Rehabilitation

269

the importance of sensory ﬁdelity and immersion for

enhancing user engagement and physical responses.

FUNDING

ACKNOWLEDGEMENTS

This work is part of the eGames Lab research

project. The Portuguese Recovery and Resilience

Program (PRR) funded the research through

IAPMEI/ANI/FCT under Agenda C645022399-

00000057 (eGamesLab).

ERG, BRG, and PC are also supported by

FCT projects: 10.54499/LA/P/0083/2020,

10.54499/UIDP/50009/2020, and 10.54499/UIDB/

50009/2020.

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