Effects of virtual reality-based interventions on the physical and mental health of older residents in long-term care facilities: A systematic review
基于虚拟现实的干预措施对长期护理机构老年居民身心健康的影响：系统回顾

2.1. Identification of studies and inclusion criteria
2.1.确定研究和纳入标准

Four databases (the Cochrane Library, PubMed, EMBASE, and Web of Science) were searched (from their inception up to May 2022) for original articles. The literature search was conducted using search terms related to virtual reality and older adults. A combination of MeSH and entry terms was used (nursing home OR homes for the aged OR long-term care OR assisted living facilities OR residential facilities OR institutional care OR institutionalized) AND (‘Virtual’ OR ‘Computer aided therap*’ OR ‘Computer assisted therap*’ OR ‘Active gam*’ OR ‘Exergam*’ OR ‘Video gam*’ OR ‘Computer gam*’). The complete search strategies are listed in Appendix 1. The search was limited to publications with humans. Only publications in English were included in this review. The reference lists of all potentially relevant articles and other reviews in the field were reviewed to identify any studies missed in the electronic database search.
对四个数据库（Cochrane 图书馆、PubMed、EMBASE 和 Web of Science）进行了检索（从开始到 2022 年 5 月），以获取原始文章。文献检索使用了与虚拟现实和老年人相关的检索词。使用了 MeSH 和条目术语（养老院或老人院或长期护理或生活辅助设施或住宅设施或机构护理或机构化）和（"虚拟 "或 "计算机辅助治疗*"或 "计算机辅助治疗*"或 "主动游戏*"或 "Exergam*"或 "视频游戏*"或 "计算机游戏*"）的组合。完整的检索策略见附录 1。搜索仅限于以人为对象的出版物。本综述只包括英文出版物。对所有可能相关的文章和该领域其他综述的参考文献目录进行了审查，以确定电子数据库搜索中遗漏的任何研究。

2.2. Study screening and data extraction
2.2.研究筛选和数据提取

Search titles and abstracts were screened by two study authors (GL and XL). The full texts of eligible studies were then independently assessed for inclusion. When a consensus could not be reached, these disagreements were resolved with a third author acting as arbiter (LC).
由两位研究作者（GL 和 XL）筛选检索标题和摘要。然后对符合条件的研究报告全文进行独立评估，以决定是否纳入。如果无法达成共识，则由第三位作者作为仲裁人（LC）来解决这些分歧。

For each included trial, two reviewers (GL and XL) independently extracted all relevant data and trial quality information and entered it into a predesigned data extraction form. The data extracted included citation details, the study design, the study population, intervention details, outcome measures and results.
对于每项纳入的试验，由两名审稿人（GL 和 XL）独立提取所有相关数据和试验质量信息，并将其输入预先设计的数据提取表中。提取的数据包括引用细节、研究设计、研究人群、干预细节、结果测量和结果。

2.3. Study quality assessment and data analysis
2.3.研究质量评估和数据分析

The quality of each trial was appraised using The Cochrane Collaboration's ‘Risk of bias’ tool. The tool covers the domains of sequence generation, allocation concealment, the blinding of outcome assessors, incomplete outcome data and selective reporting. Each domain is classified as having a ‘low risk’, a ‘high risk’ or an ‘unclear risk’ of bias. The domain that assessed the blinding of participants was omitted, as we believed this domain was related to the nature of the intervention and not study quality. The quality of nonrandomized controlled trials was appraised using the Methodological Index for Non-Randomized Studies (MINORS). This index considers noncomparative studies to have good methodological quality if a score of 12 points is obtained, whereas for comparative studies, good methodological quality is considered when a score of 18 points is reached. All the data were checked by a third reviewer, and any discrepancies were discussed until consensus was achieved. We contacted authors by email to obtain any missing information necessary for the review. A trial was excluded if no usable data were listed or if usable data could not be retrieved. Meta-analysis was not conducted due to the variety in the outcomes and the differences in the measurement tools used to measure the outcomes.
使用 Cochrane 协作组织的 "偏倚风险 "工具对每项试验的质量进行评估。该工具涵盖序列生成、分配隐藏、结果评估者的盲法、结果数据不完整和选择性报告等领域。每个领域的偏倚风险分为 "低风险"、"高风险 "或 "不明确风险"。评估参与者盲法的领域被省略，因为我们认为该领域与干预的性质有关，与研究质量无关。非随机对照试验的质量采用非随机研究方法指数（MINORS）进行评估。该指数如果达到 12 分，则认为非比较研究的方法学质量良好；如果达到 18 分，则认为比较研究的方法学质量良好。所有数据均由第三位审稿人进行检查，并对任何差异进行讨论，直至达成共识。我们通过电子邮件与作者取得联系，以获取评审所需的任何缺失信息。如果没有列出可用数据或无法检索到可用数据，则排除该试验。由于结果的多样性以及用于测量结果的测量工具的差异，我们没有进行 Meta 分析。

3.1. Description of included studies
3.1.纳入研究的说明

A total of 8491 articles were initially identified from the database searches, and an additional 20 records were found through manual searches. Following the removal of duplicate records and articles that were deemed to be not relevant through manual screening of the titles and, where they were obtainable, the abstracts, there were 44 articles eligible for full-text screening (Fig. 1). Thirty of these studies met the inclusion criteria (see Appendix 2). A summary of the characteristics of the articles is provided in Appendix 2.
通过数据库搜索初步确定了 8491 篇文章，另外通过人工搜索发现了 20 条记录。通过人工筛选标题和摘要（如果可以获得），删除重复记录和认为不相关的文章后，共有 44 篇文章符合全文筛选条件（图 1）。其中 30 项研究符合纳入标准（见附录 2）。附录 2 提供了这些文章的特征摘要。

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Fig. 1. Flow chart of the study selection process for this review.
图 1.本综述的研究选择流程图。

The studies were conducted in Asia (n = 9), Europe (n = 8), North America (n = 4), South America (n = 4), and Oceania (n = 5). Sixteen trials took place before 2020, and fourteen trials were conducted in 2020 and later. A total of 1057 participants met the inclusion criteria in the included studies. The sample size per study ranged from 8 to 106. Except for three studies that did not report sex/gender ratios (Alves et al., 2021; Cheng et al., 2020; Lin et al., 2020), females made up approximately 55% of the total sample. The mean age of the individuals in the included studies, excluding one study that did not report the mean age (Alves et al., 2021), ranged from 66.5 to 87.5 years. The frequency of the virtual reality interventions varied from twice weekly to five times a week, and each virtual reality session ranged from 5 to 60 min, except for two studies that conducted free exercise interventions in which the frequency, duration and type of games were decided based on the participants' wishes (Keogh et al., 2012, Keogh et al., 2014). The overall duration of the virtual reality intervention in each study ranged from 2 weeks to 6 months, except for four studies that conducted a single intervention (Alves et al., 2021; D'Cunha et al., 2021; Loggia et al., 2021; Monteiro-Junior et al., 2017a). None of the included studies had a long-term follow-up after the completion of the intervention. No adverse events were observed, as reported in 9 studies. Because of the heterogeneity in the outcome measures, a meta-analysis was not feasible. We categorized all included articles into different domains according to the different study population classifications for the following analysis.
这些研究分别在亚洲（9 项）、欧洲（8 项）、北美洲（4 项）、南美洲（4 项）和大洋洲（5 项）进行。其中 16 项试验在 2020 年前进行，14 项试验在 2020 年及以后进行。共有 1057 名参与者符合纳入研究的标准。每项研究的样本量从 8 到 106 不等。除三项研究未报告性别比例外（Alves 等，2021 年；Cheng 等，2020 年；Lin 等，2020 年），女性约占样本总数的 55%。除一项未报告平均年龄的研究（Alves 等人，2021 年）外，纳入研究的个体平均年龄在 66.5 岁至 87.5 岁之间。虚拟现实干预的频率从每周两次到每周五次不等，每次虚拟现实时间从5分钟到60分钟不等，只有两项进行自由运动干预的研究根据参与者的意愿决定游戏的频率、持续时间和类型（Keogh等人，2012年；Keogh等人，2014年）。每项研究中虚拟现实干预的总体持续时间从2周到6个月不等，只有四项研究进行了单次干预（Alves等人，2021年；D'Cunha等人，2021年；Loggia等人，2021年；Monteiro-Junior等人，2017年a）。所纳入的研究均未在干预结束后进行长期随访。9项研究均未发现不良事件。由于结果测量存在异质性，因此无法进行荟萃分析。我们根据不同的研究人群分类将所有纳入的文章分为不同的领域，以便进行以下分析。

3.2. Description of virtual reality-based interventions
3.2.基于虚拟现实的干预措施说明

3.3. Effectiveness of virtual reality-based interventions
3.3.基于虚拟现实的干预措施的效果

3.4. Risk of bias 3.4.偏差风险

The risk of bias in the randomized controlled trials (RCTs) was assessed, as shown in Appendix 3. The overall risk of bias in the included studies was unclear to low. Random sequence generation was reported as adequate in 11 trials (65%). Allocation concealment was reported as adequate in 2 trials (12%). Blinding of the outcome assessor was reported in 9 trials (53%). No trials were able to blind participants or personnel. We deemed 9 trials (53%) to be at low risk of bias in relation to incomplete outcome data. Six studies (35%) were free of selective reporting. We considered that all included studies had no other bias. The largest sources of bias were the influence on allocation concealment and outcome assessments, insufficient evidence showing that the results were not biased by missing data (e.g., lack of intention-to-treat analyses), and a lack of detailed trial protocols. The risk of bias in the non-RCTs was assessed and is presented in Appendix 4. The MINORS ranged from 12 to 22 points, which was considered an indication of moderate methodological quality. For twelve of the checklist items, the studies mostly presented the required information. Shortfalls in the studies included the absence of a description of the unbiased assessment of the study endpoint (69%), loss to follow-up (46%), and insufficient information for calculation of the study size (85%).
如附录 3 所示，对随机对照试验 (RCT) 的偏倚风险进行了评估。纳入研究的总体偏倚风险为不明确至低。据报告，11 项试验（65%）的随机序列生成是充分的。2项试验（12%）的分配隐藏报告为充分。9项试验（53%）报告对结果评估者进行了盲法操作。没有一项试验能够对参与者或工作人员进行盲法操作。我们认为9项试验（53%）因结果数据不完整而存在偏倚的风险较低。6项研究（35%）不存在选择性报告。我们认为所有纳入的研究都没有其他偏倚。最大的偏倚来源是对分配隐藏和结果评估的影响、没有足够的证据表明结果没有受到缺失数据的影响（如缺乏意向治疗分析）以及缺乏详细的试验方案。对非 RCT 的偏倚风险进行了评估，评估结果见附录 4。MINORS 为 12 分至 22 分，表明方法学质量处于中等水平。在核对表的 12 个项目中，大部分研究都提供了所需的信息。不足之处包括缺乏对研究终点无偏见评估的说明（69%）、随访损失（46%）以及计算研究规模的信息不足（85%）。

4.1. Main outcomes 4.1.主要成果

We identified 30 studies on the effectiveness of virtual reality-based interventions conducted in long-term care facilities. Most studies involved virtual reality-based exercise interventions. Most studies also focused on the effects of virtual reality-based interventions on balance, fall risk, functional ability, mobility, physical activity, cognitive function, and depressive symptoms. Many articles were published in 2020 and beyond, indicating an increased focus on virtual reality in recent years. Based on our findings in this systematic review, virtual reality-based interventions could be effective in improving the physical health of older residents in long-term care facilities, but their effectiveness for the mental health was inconclusive. No adverse events were reported, indicating that virtual reality-based interventions could be a safe approach for older residents in long-term care facilities.
我们确定了 30 项在长期护理机构中进行的基于虚拟现实的干预有效性研究。大多数研究涉及基于虚拟现实的运动干预。大多数研究还关注了基于虚拟现实的干预措施对平衡、跌倒风险、功能能力、活动能力、体力活动、认知功能和抑郁症状的影响。许多文章发表于 2020 年及以后，表明近年来人们越来越关注虚拟现实技术。根据我们在这篇系统综述中的发现，基于虚拟现实的干预措施可以有效改善长期护理机构中老年居民的身体健康，但其对心理健康的影响尚无定论。没有关于不良事件的报道，这表明对长期护理机构中的老年居民来说，基于虚拟现实的干预是一种安全的方法。

4.2. Physical health-related outcomes
4.2.与身体健康有关的结果

Virtual reality-based interventions are possibly effective for improving the physical health of older residents in long-term care facilities. However, this evidence lacks certainty. Regarding outcomes including dynamic stability, balance, fall risk, functional ability, mobility, gait, muscle strength, physical activities, and pain, the included studies showed inconsistent results. For outcomes including frailty, sleep quality, health status, and exercise intensity, the studies showed virtual reality-based interventions to be effective, but the number of studies was small.
基于虚拟现实的干预措施对于改善长期护理机构中老年居民的身体健康可能有效。然而，这些证据并不确定。关于动态稳定性、平衡、跌倒风险、功能能力、活动能力、步态、肌肉力量、体力活动和疼痛等结果，所纳入的研究显示出不一致的结果。对于虚弱、睡眠质量、健康状况和运动强度等结果，研究表明基于虚拟现实的干预措施是有效的，但研究数量较少。

Virtual reality-based interventions have the potential to improve the physical health of older residents in long-term care facilities. The included studies showed that virtual reality-based interventions had positive effects for high-risk older adults over 80 years old and older adults with mobility difficulties for whom crutches or wheelchairs are required in long-term care facilities (Cheng et al., 2020; Mugueta-Aguinaga and Garcia-Zapirain, 2017; Swinnen et al., 2021). At the same time, it can improve the physical activity of older adults (Janssen et al., 2013; Keogh et al., 2014; Valiani et al., 2017). Older adults living in long-term care facilities are far less physically active than their community-dwelling counterparts, and insufficient activity negatively affects their health and quality of life (Martinez-Gomez et al., 2016; Pavey et al., 2015; Weeks et al., 2008). A previous review demonstrated the importance of improving physical activity for older residents in long-term care facilities, and interventions should be embedded into long-term care (Barrett et al., 2021). Thus, virtual reality-based training could be an appropriate approach, since it might provide the motivation needed to engage in physical activity (Keogh et al., 2012; Valiani et al., 2017).
基于虚拟现实的干预措施有可能改善长期护理机构中老年居民的身体健康。纳入的研究表明，基于虚拟现实的干预措施对 80 岁以上的高风险老年人和长期护理机构中需要拐杖或轮椅的行动不便的老年人有积极影响（Cheng 等人，2020 年；Mugueta-Aguinaga 和 Garcia-Zapirain，2017 年；Swinnen 等人，2021 年）。同时，它还能提高老年人的身体活动能力（Janssen 等人，2013 年；Keogh 等人，2014 年；Valiani 等人，2017 年）。居住在长期护理机构中的老年人的体育活动量远远低于居住在社区的老年人，活动量不足会对他们的健康和生活质量产生负面影响（Martinez-Gomez 等人，2016 年；Pavey 等人，2015 年；Weeks 等人，2008 年）。之前的一篇综述表明，改善长期护理设施中老年居民的体育活动非常重要，干预措施应嵌入长期护理中（Barrett 等人，2021 年）。因此，基于虚拟现实的培训可能是一种合适的方法，因为它可以提供参与体育活动所需的动力（Keogh 等人，2012 年；Valiani 等人，2017 年）。

4.3. Mental health-related outcomes
4.3.心理健康相关成果

It is difficult to conclude the effect of virtual reality-based interventions on the mental health outcomes of older residents in long-term care facilities. The included studies showed inconsistent results for cognitive functions (Delbroek et al., 2017; Hsieh et al., 2018; Monteiro-Junior et al., 2017a, Monteiro-Junior et al., 2017b; Ogawa et al., 2020; Oliveira et al., 2021a, Oliveira et al., 2021b; Saredakis et al., 2021; Stanmore et al., 2019; Swinnen et al., 2021; Taylor et al., 2018) and depressive symptoms (Cicek et al., 2020; Lin et al., 2020; Monteiro-Junior et al., 2017b; Oliveira et al., 2021a; Saredakis et al., 2021; Swinnen et al., 2021) and no improvements in mood (D'Cunha et al., 2021; Delbroek et al., 2017; Hsieh et al., 2018; Stanmore et al., 2019). A previous meta-analysis found moderate effects of virtual reality exergames on overall cognitive function and memory and a large effect on depressive outcomes in older adults (Yen and Chiu, 2021). This may have to do with the different populations included in these studies. In the future, more studies are needed to explore the impacts of virtual reality-based interventions on the mental health of older residents in long-term care facilities.
基于虚拟现实的干预措施对长期护理机构中老年居民心理健康结果的影响很难下结论。纳入的研究显示，认知功能（Delbroek 等人，2017；Hsieh 等人，2018；Monteiro-Junior 等人，2017a，Monteiro-Junior 等人，2017b；Ogawa 等人，2020；Oliveira 等人，2021a，Oliveira 等人，2021b；Saredakis 等人，2021；Stanmore 等人，2019；Swinnen 等人、2021；Taylor等人，2018）和抑郁症状（Cicek等人，2020；Lin等人，2020；Monteiro-Junior等人，2017b；Oliveira等人，2021a；Saredakis等人，2021；Swinnen等人，2021），情绪没有改善（D'Cunha等人，2021；Delbroek等人，2017；Hsieh等人，2018；Stanmore等人，2019）。之前的一项荟萃分析发现，虚拟现实外部游戏对老年人的整体认知功能和记忆力有中等程度的影响，对抑郁结果有较大影响（Yen 和 Chiu，2021 年）。这可能与这些研究涉及的人群不同有关。未来，需要开展更多研究，探索基于虚拟现实的干预措施对长期护理机构中老年居民心理健康的影响。

4.4. Advantages of virtual reality-based interventions
4.4.基于虚拟现实的干预措施的优势

First, virtual reality-based interventions could provide real-time feedback to create an error-free learning environment, since performance feedback for the status and outcome of a response is generally accepted to be necessary for most forms of learning or skill acquisition (Fu et al., 2015). According to the feedback, the training intensity could be personally tailored to the characteristics of older adults and provide graded progression interventions (Babadi and Daneshmandi, 2021; Stanmore et al., 2019). This finding is consistent with a previous study demonstrating that virtual reality technology could monitor body movements and reactions and provide real-time feedback on exercise performance, resulting in fun and play (Anderson-Hanley et al., 2011).
首先，基于虚拟现实的干预措施可以提供实时反馈，创造一个无差错的学习环境，因为对反应状态和结果的性能反馈被普遍认为是大多数形式的学习或技能习得所必需的（Fu 等人，2015 年）。根据反馈信息，训练强度可根据老年人的特点量身定制，并提供分级进步干预（Babadi 和 Daneshmandi，2021 年；Stanmore 等人，2019 年）。这一发现与之前的一项研究相一致，该研究表明虚拟现实技术可以监测身体动作和反应，并对运动表现提供实时反馈，从而带来乐趣和游戏性（Anderson-Hanley 等人，2011 年）。

Second, Virtual reality-based interventions are mostly conducted in the form of games in the virtual environment through the completion of tasks to achieve the purpose of training. Game training is interesting, and older people like it, which helps improve their motivation for training (Babadi and Daneshmandi, 2021; Hsu et al., 2011; Loggia et al., 2021; Zahedian-Nasab et al., 2021). At the same time, there is a group effect. Through training, communication among older residents in long-term care facilities is increased, life in long-term care facilities is enriched, and self-confidence is improved (Ellmers et al., 2018; Janssen et al., 2013; Keogh et al., 2014; Lin et al., 2020; Taylor et al., 2018). The included studies showed beneficial effects of virtual reality-based interventions on improving wellbeing and life satisfaction in older adults (Cheng et al., 2020; Lin et al., 2020).
其次，基于虚拟现实的干预大多以游戏的形式在虚拟环境中进行，通过完成任务达到训练目的。游戏训练趣味性强，老年人喜欢，有助于提高他们的训练积极性（Babadi 和 Daneshmandi，2021 年；Hsu 等人，2011 年；Loggia 等人，2021 年；Zahedian-Nasab 等人，2021 年）。同时，还存在群体效应。通过培训，长期护理机构中老年居民之间的交流得到加强，长期护理机构中的生活得到丰富，自信心得到提高（Ellmers 等人，2018 年；Janssen 等人，2013 年；Keogh 等人，2014 年；Lin 等人，2020 年；Taylor 等人，2018 年）。纳入的研究表明，基于虚拟现实的干预措施对提高老年人的幸福感和生活满意度有益（Cheng 等人，2020 年；Lin 等人，2020 年）。

Third, virtual reality interventions have the potential to provide meaningful activities for older residents in long-term care facilities during lockdowns due to infectious diseases. Many of the studies were reported as being conducted after 2020, which was after the outbreak of COVID-19. The context of the COVID-19 pandemic may have influenced the physical and mental health status of older residents in long-term care facilities, as they were often isolated in their own rooms (Oliver, 2020). Virtual reality-based programmes have the potential to increase activities and reduce social isolation and boredom for older residents in long-term care facilities during lockdowns (D'Cunha et al., 2021; Oliver, 2020).
第三，虚拟现实干预措施有可能在长期护理设施因传染病而关闭期间为老年居民提供有意义的活动。据报道，许多研究都是在 2020 年之后进行的，也就是 COVID-19 爆发之后。COVID-19 大流行的背景可能影响了长期护理机构中老年居民的身心健康状况，因为他们往往被隔离在自己的房间里（Oliver，2020 年）。基于虚拟现实的计划有可能在长期护理机构关闭期间为老年居民增加活动，减少社会隔离和无聊感（D'Cunha 等人，2021 年；Oliver，2020 年）。

4.5. Usability of virtual reality-based interventions
4.5.基于虚拟现实的干预措施的可用性

The potential usability of virtual reality technology in long-term care facilities is uncertain. On the one hand, some studies have suggested that after learning, the staff of long-term care facilities could master the operation method and implement the intervention for older adults, who can practise by themselves after learning (Janssen et al., 2013; Taylor et al., 2018; Valiani et al., 2017). This aspect provides the possibility for the rehabilitation training of older residents in long-term care facilities. Compared with interventions performed by professional therapists, Virtual reality technology interventions could be more cost-effective. On the other hand, due to staff shortages and staff workloads in long-term care facilities, whether and how virtual reality-based interventions can be integrated into daily work remain to be explored.
虚拟现实技术在长期护理机构中的潜在可用性尚不确定。一方面，一些研究认为，长期护理机构的工作人员经过学习后，可以掌握操作方法，对老年人实施干预，老年人学习后可以自己练习（Janssen 等，2013；Taylor 等，2018；Valiani 等，2017）。这为长期护理机构中的老年居民提供了康复训练的可能性。与专业治疗师进行的干预相比，虚拟现实技术干预可能更具成本效益。另一方面，由于长期护理机构的人员短缺和工作量大，基于虚拟现实技术的干预措施能否以及如何融入日常工作仍有待探索。

Devices are needed for the implementation of virtual reality-based intervention. The interaction and immersion of virtual reality systems are increasing from the use of a PC or tablet (nonimmersive) and large monitors (semi-immersive) to head-mounted devices (fully immersive),while among these devices, virtual reality technologies supported by readily available gaming platforms, which represent an inexpensive and inspiring alternative to professional devices, have become increasingly popular, for instance, Nintendo Wii, Microsoft Xbox, or Sony PlayStation, which might be more suitable for adoption (Campo-Prieto et al., 2021, Campo-Prieto et al., 2021). However, because equipment is indispensable, costly devices could still limit the usability of virtual reality-based intervention in long term care facilities.
实施基于虚拟现实的干预需要设备。虚拟现实系统的交互性和沉浸感越来越强，从使用个人电脑或平板电脑（非沉浸式）和大型显示器（半沉浸式）到头戴式设备（全沉浸式），而在这些设备中，由现成的游戏平台支持的虚拟现实技术越来越受欢迎，这些平台是专业设备的廉价和鼓舞人心的替代品，例如任天堂 Wii、微软 Xbox 或索尼 PlayStation，它们可能更适合采用（Campo-Prieto 等人，2021 年；Campo-Prieto 等人，2021 年）。然而，由于设备不可或缺，昂贵的设备仍会限制基于虚拟现实的干预在长期护理机构中的可用性。

At the same time, it remains to be studied whether it is feasible for elderly individuals to perform the exercises independently after training. Two included studies provided free practise with a virtual reality-based exercise intervention for older adults and showed conflicting results regarding physical function (Keogh et al., 2012, Keogh et al., 2014). The results indicated that the amount of time each person spends exercising per week varies. Therefore, although virtual reality interventions are often considered to improve exercise adherence (Shen and Mak, 2014, Shen and Mak, 2015), free access to the exercise intervention still requires staff to encourage and monitor the frequency of exercise. Future studies need to evaluate whether the same quality and safety of treatment can be achieved when low-supervised interventions are provided (King et al., 2015).
与此同时，老年人在训练后独立完成练习是否可行仍有待研究。纳入的两项研究为老年人提供了基于虚拟现实的运动干预自由练习，结果显示，在身体功能方面存在矛盾（Keogh 等人，2012 年；Keogh 等人，2014 年）。结果表明，每个人每周锻炼的时间各不相同。因此，尽管虚拟现实干预通常被认为能提高锻炼的坚持性（Shen 和 Mak，2014 年；Shen 和 Mak，2015 年），但免费获得锻炼干预仍需要工作人员鼓励和监督锻炼频率。未来的研究需要评估在提供低监督干预时，是否能达到同样的治疗质量和安全性（King 等人，2015 年）。

4.6. Limitations 4.6.局限性

Most studies used commercial exergaming. The intervention programs were not designed specifically for older residents in long-term care facilities, nor were they designed for specific intervention goals. Only two articles included instrumental ADL scenarios and cognitive function training scenarios designed for older adults (Eisapour et al., 2020; Oliveira et al., 2021a). In the future, more studies are needed to design virtual reality-based interventions with more targeted training functions according to the physical and mental characteristics and living environment characteristics of older residents in long-term care facilities to further improve the effectiveness of these interventions (Fu et al., 2015; Hsu et al., 2011; Mugueta-Aguinaga and Garcia-Zapirain, 2017; Stanmore et al., 2019; Taylor et al., 2018).
大多数研究使用的是商业电子游戏。这些干预项目并不是专门为长期护理机构中的老年居民设计的，也不是针对特定干预目标设计的。只有两篇文章包含了为老年人设计的工具性日常活动场景和认知功能训练场景（Eisapour 等人，2020 年；Oliveira 等人，2021a）。未来，需要开展更多研究，根据长期护理机构中老年居民的身心特点和生活环境特征，设计具有更有针对性训练功能的基于虚拟现实的干预措施，以进一步提高这些干预措施的有效性（Fu等人，2015；Hsu等人，2011；Mugueta-Aguinaga和Garcia-Zapirain，2017；Stanmore等人，2019；Taylor等人，2018）。

Older people have different experiences with virtual reality technology, and older people with low experience could experience more difficulty in adopting virtual reality-based intervention, which might influence these older adults in benefiting from such interventions. The feasibility of virtual reality for older adults as an important consideration for implementation has generally been poorly described (Miller et al., 2014). Thus, qualitative insights into older adults' attitudes and experiences towards the use of virtual reality technology are valuable from the ethical and utilitarian perspectives. Future studies should address not only the effectiveness of virtual reality-based interventions but also the feasibility issues specific to implementation in long term care facilities.
老年人对虚拟现实技术有不同的体验，体验较少的老年人在采用基于虚拟现实的干预措施时可能会遇到更多困难，这可能会影响这些老年人从此类干预措施中受益。虚拟现实技术对老年人的可行性是实施干预的重要考虑因素，但对这一问题的描述普遍较少（米勒等人，2014 年）。因此，从伦理和功利的角度来看，对老年人使用虚拟现实技术的态度和经验进行定性分析是非常有价值的。未来的研究不仅要解决基于虚拟现实的干预措施的有效性问题，还要解决在长期护理机构实施的可行性问题。

There are several limitations of this systematic review. First, most of the included studies had relatively small sample sizes. Studies with limited sample sizes are at risk of being underpowered, which may result in less reliability. Second, meta-analysis was not performed due to the heterogeneity among the included studies. Third, the included studies did not conduct follow-up investigations, and there was a lack of evidence for the long-term effects of the interventions. Finally, there have been only limited studies providing limited evidence for the effectiveness of virtual reality-based nonexercise interventions.
本系统综述存在一些局限性。首先，大多数纳入的研究样本量相对较小。样本量有限的研究可能会出现动力不足的情况，从而导致可靠性降低。其次，由于纳入的研究之间存在异质性，因此没有进行荟萃分析。第三，纳入的研究没有进行后续调查，缺乏干预措施长期效果的证据。最后，只有有限的研究为基于虚拟现实的非运动干预措施的有效性提供了有限的证据。