Acceptability, Feasibility, and Initial Efficacy of Virtual Reality as a Home-Based Exercise Modality for Young Adults

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Runswick, Megan Smith, Harry Rowland, Lakshmi Mahendru, and 5 more This is a preprint; it has not been peer reviewed by a journal. https://doi.org/ 10.21203/rs.3.rs-5486191/v1 This work is licensed under a CC BY 4.0 License Status: Published Journal Publication published 08 Dec, 2025 Read the published version in Virtual Reality → Version 1 posted You are reading this latest preprint version Abstract Exercise is a powerful tool for supporting physical and mental health, yet many people do not meet recommended levels of engagement. Virtual reality (VR) offers an immersive platform to make enjoy able and interactive exercise available in the home. However, there is a need to understand the acceptability, feasibility, and initial efficacy of engaging in VR exercise across extended durations within different real-world settings. In this mixed-methods study, 20 young adult participants (male = 10, female = 10), completed an eight-week VR exercise programme that included four weeks of autonomous training at home and a matched four weeks of organized sessions in a counterbalanced crossover design. To establish initial efficacy, measures of psychological and physical well-being were taken before, at the mid-point, and post VR exercise. To assess acceptability and feasibility, adherence was measured throughout, and ten participants completed follow-up interviews about their experiences. Results showed higher session completion rates in organised sessions (79%) compared to at home (51%) and likely positive effects on physical fitness and psychological wellbeing early in the intervention. Gamification and immersion were discussed as key positives for engagement, with space identified as a key barrier for use at home. In conclusion, VR may offer an alternative gateway into exercise that is feasible and acceptable for use in the home and organised exercise settings. Physical Activity VR XR Gamification Home Exercise Mental Health Figures Figure 1 Figure 2 Figure 3 Figure 4 Figure 5 Figure 6 Introduction Exercise has numerous positive effects on physical and mental health, including the prevention and alleviation of symptoms in various chronic conditions (Warburton et al., 2006 ; Warburton & Bredin, 2017 ). The World Health Organization (WHO) recommends that adults get 150–300 minutes of moderate aerobic activity per week and that children and adolescents average 60 minutes per day (420 minutes per week) for optimal health and wellbeing (Bull et al., 2022). Despite the known benefits of exercise, relatively few individuals engage with recommended levels (Garber et al., 2011 ; Haskell et al., 2007 ). There is emerging evidence that life expectancy is plateauing, long-term conditions develop at younger ages, and younger people are less active than previous generations (DuGoff et al., 2014 ; Kandola et al., 2020 ; Vancampfort et al. 2017 ). There is, therefore, a continuing need to develop strategies to support sustained commitment to exercise and physical activity across the lifespan. New technological developments, such as exergames in virtual reality (VR), can offer new ways to address this need (Ng et al., 2019 ), but research is required to understand the practical implementation of these new technologies. VR is a versatile technology providing diverse user experiences that exist across a spectrum of immersion. A fundamental level of virtual experience is akin to traditional video gaming, where users engage with graphics on standard flat-screen displays (Rizzo et al., 2011 ). More immersive virtual experiences encompass three-dimensional computer-generated simulations, allowing users to feel present in another place and interact and engage with the environment using full-body movements (Turoń-Skrzypińska et al., 2023 ; Runswick, 2023 ; Qian et al., 2020 ). These more immersive technologies naturally facilitate exergames, games that require the user to produce body movements to interact with the technology, and may be more enjoyable than less immersive options (Bird et al., 2024 ). Young users have identified gamification elements such as rewards, novelty and enjoyment, multiplayer options, and continued updates as important to engaging with sustained exercise behaviours (Farič et al., 2019 ). A range of evidence has shown the potential for VR exercise interventions to enhance physical activity, physical health, and mental health outcomes in young people (Maden et al., 2022 ; Ng., et al., 2019; Qian et al., 2020 , Xu et al., 2024 ). Work on existing users has suggested that using VR to exercise at home could be beneficial for health (Peng et al., 2022 ). However, despite positive responses to controlled interventions, there is limited understanding of how inactive young people can practically integrate exercise in VR into their lives as a tool for changing physical activity behaviours. The COM-B model of behaviour change (Michie et al., 2011 ) posits that consistent behaviour change is contingent upon three key components: Capability, Opportunity, and Motivation. “Capability” refers to an individual's psychological and physical capacity to engage in a behaviour. For example, physical discomfort and various psychosocial factors hinder individuals’ capability to engage in exercise (Baillot et al., 2021 ; Herazo-Beltrán et al., 2017 ). VR can enhance capability by allowing users to exercise at higher workloads with more enjoyment while maintaining the same levels of perceived effort (Barbour et al., 2024 ; Finnegan et al., 2023 ; Ochi et al., 2022 ; Runswick et al., 2023 ; Rutkowski et al., 2021 ; Stewart et al., 2022 ; Zeng et al., 2021 ). “Opportunity” encompasses the external factors that facilitate or hinder behaviour, such as time constraints, transportation issues, safety concerns in outdoor environments, and lack of equipment (King et al., 2000 ; Jack et al., 2010 ; Schättin et al., 2022 ). Many different forms of VR exercise can be undertaken in small spaces, without the need for other equipment, and in one’s own home (Riches et al., 2024 ). However, much of the research on VR exercise to date has focused on either group-based or supervised interventions; there is limited understanding of the facilitators and barriers of engaging in VR exercise at home. Finally, “Motivation” reflects the cognitive processes that drive and inspire behaviour, and, alongside enjoyment, is a key predictor in the initial adoption of exercise (Gardner & Lally, 2012 ; Teixeira et al., 2012 ). VR exergames have exhibited heightened levels of motivation, engagement, and enjoyment compared to less immersive forms of exercise (Barbour et al., 2024 ; Bird et al., 2024 ; Mologne et al., 2022 ; Mouatt et al., 2020 Ochi et al., 2022 ; Teixeira et al., 2024 ). While promising, these findings have primarily derived from acute responses, and there is a need to establish if VR can support exercise behaviour change over time. The need for further work on delivering VR interventions stems from estimates of attrition rates for exercise interventions, which range from anywhere between 10–80% in the existing literature (Pirotta et al., 2019 ; Linke et al., 2011 ), often witnessing short-term successes before dissipating back to baseline (Marcus et al., 2006 ). Much of the longitudinal work has so far only assessed the use of VR in controlled trials and in specific clinical populations, such as those living with mobility issues, rather than in changing exercise behaviour (Cho et al., 2014 ; Darekar et al., 2015 ; Dockx et al., 2016 ; Lei et al., 2019 ; 2022; Tobaiqi et al., 2023 ; Zhang et al., 2021 ). While a wide range of studies have also shown potential benefits using controlled trials for young people (Maden et al., 2022 ; Ng., et al., 2019; Qian et al., 2020 , Xu et al., 2024 ), these studies do not address an inactive younger population aiming to engage with exercise autonomously and have rarely used gold standard measures of physical fitness, such as VO2 max testing. Three studies have begun to address this need. Both Barbour et al. ( 2024 ) and Texiera et al. (2024) used the commercially available VR exercise app FitXR™ to investigate physical workload and emotional responses to VR compared to screen-based workouts. They found participants chose to work harder and displayed more positive psychological benefits in VR. Improved emotional responses to exercise were considered a proxy measure for an enhanced likelihood of engaging with exercise in the future. Xu et al. ( 2021 ) conducted a feasibility and usability study and measured impacts on university students’ mental health over a period of six weeks. However, all these studies were supervised interventions in organised sessions, meaning the advantage of allowing participants to engage in their own homes at flexible times was not part of the work. There is, therefore, a need to understand the realistic integration of affordable and accessible VR exercise into the lives of young people aiming to enhance their levels of physical activity (Mocco et al., 2024 ). Here, we used a mixed methods approach, combining home and organised sessions of the FitXR™ VR exercise app in a crossover design over eight weeks. To understand initial impacts on physical activity, exercise self-efficacy, and health, measures of psychological and physical wellbeing were taken before, at the mid-point, and post VR exercise. To assess acceptability and feasibility, adherence was measured throughout, and ten participants completed follow-up interviews about their experiences. Methods Study Design An exercise programme that consisted of four 15-minute workouts was undertaken by all participants in two different structures. Ten participants (Fig. 1 , red group) completed their first four weeks by completing two workouts twice per week in 30-minute supervised sessions, and their second four weeks at home, completing 15-minute sessions (one workout) 4 times per week. The other ten participants (Fig. 1 , blue group) completed the home sessions in the first four weeks and the supervised sessions in the second four weeks. All participants completed a pre-test, a mid-test after 4 weeks to assess changes in measures from the first half of the crossover, and a post-test after the full eight weeks. We captured acceptability and feasibility with engagement data and qualitative interviews of the participants' experience, including why they did or did not find a VR acceptable for use and how it could be integrated into day-to-day living. Initial efficacy, the opportunity to measure efficacy with the context of a small trial with no requirement for a control group (Birkhead et al., 2019), was captured using measures of physical and mental health at pre, mid, and post-tests. Participants Due to the focus on acceptability and feasibility in this mixed-methods study we did not power this study to find a specific effect (Birkhead et al., 2019). Twenty-eight participants from the university population (F = 15, M = 13) aged between 19 and 34 years old at start of intervention (22 ± 4 years) were recruited through volunteer sampling. Participants did not report any physical or mental health condition that prevented them from exercising or using immersive virtual reality. If the participant dropped out before the midpoint of the study, they were excluded from analysis. 20 participants (71%) completed the study sufficiently to be included in analysis (F = 10, M = 10; Age = 22 ± 3 years; BMI = 24 ± 5). A total of 10 participants (F = 7, M = 3; Age = 23 ± 3) volunteered to participate in additional follow-up interviews after the completion of the post-test. All interviews were conducted within one month of post-test completion to allow participants to provide insights based on their recent experience. The study was approved by the University research ethics committee (approval number: LRS/DP-22/23-38283). All participants were informed of the procedures prior to the first visit and given an opportunity to ask questions before signing informed consent. Immersive VR Exercise For this study, the Meta Quest 2 VR headset was used, each with a copy of FitXR [v.3.24.59] installed. During their first visit, participants were shown how to use the headset, including setting up a Wi-Fi connection, drawing a boundary, and charging the headset. They were then guided into the FitXR app, where they were shown how to navigate the menus. Participants were then able to complete three tutorial classes built into the app (Boxing, Dance, and HIIT). These tutorials took two minutes each to complete. To allow some personal preference and more accurately capture real behaviour while using the headset, while also controlling for the intensity and duration of exercise completed, participants were asked to choose an exercise plan they wished to complete based on the familiarisation. Each exercise plan was matched for workout time and intensity but consisted of 75% their preferred exercise style (boxing, dance, or HIIT) and 12.5% of each other style. This was to give participants the flexibility to choose their preferred style, whilst also still providing a comprehensive use of multiple class styles available in the app. Fourteen participants chose boxing, three chose dance, and three chose HIIT. Measures Initial efficacy measures taken at pre-, mid-, and post-testing Physical Activity. The General Practice Physical Activity Questionnaire (GPPAQ; Department for Health) was used to capture the physical activity levels of our participants. The questionnaire provides a 4-level physical activity index (PAI), categorising participants as inactive (1), moderately inactive (2), moderately active (3), or active (4). The Leisure Time Physical Activity Questionnaire (LTPAQ, Godin, 2011 ) was used to measure participants' leisure-time physical activity – physical activity undertaken in an individual’s free time. This scale categorises individuals as insufficiently active (1), moderately active (2), or active (3). Attitudes and Self-Efficacy. The Attitudes towards Exercise questionnaire (AtE, Kwan & Bryan, 2010 ) was used to capture participants' views towards doing physical activity. The questionnaire consists of 5 items; each marked on a 7-point Likert scale (strongly disagree – strongly agree). An average score is then computed from these responses, giving everyone an AtE score, with lower scores corresponding to lower enjoyment of exercise. The Exercise Self-Efficacy scale (ESE, Kwan & Bryan, 2010 ) was used to capture participants' beliefs in their capability to perform exercise, even when facing obstacles such as a lack of time. An average score is computed from the 7-item questionnaire, with lower numbers meaning low self-efficacy (0), and higher numbers meaning high self-efficacy (7). Physical Fitness. Participants completed a cardiopulmonary exercise test on a treadmill (Bowflex, BXT56) using a Modified Balke protocol (Balke & Ware, 1959 ). Following measurement of height and body mass, participants would either walk at 3mph (females) or 3.4mph (males), and the incline would increase 2%/min until 20%, at which point speed would then increase by 0.2mph/min until volitional exhaustion. All participants were instructed and verbally encouraged to continue until exhaustion. Heart rate (Polar H10) and respiratory variables (Metamax 3B) were continually recorded throughout the test. The metabolic cart system (Metamax 3B) was calibrated prior to use, as per manufacturer instructions, and connected to each participant via an oronasal mask (Hans Rudolf). VO 2 max was measured as the highest average VO 2 recorded over a 20 second period during the protocol. Ventilatory threshold 1 (VT1) was assessed using V-slope method and supported by the ventilatory equivalent for oxygen and respiratory exchange ratio (as described by Beaver et al 1986). VO 2 max % pred was established by using standard prediction equations (Wasserman et al 2012). Psychological Wellbeing. The Depression, Anxiety and Stress Scale (DASS21, Lovibond & Lovibond, 1995 ) was used to understand participants' psychological well-being. This 21-item scale has 3 subscales (Depression, Anxiety, Stress), each with 7 items. A score can be calculated for each subscale by summing all relevant items and multiplying the score by 2. Participants can then be categorised as Normal, Mild, Moderate, Severe, or Extremely Severe, for each subscale. Acceptability measures after each exercise session Affective Reponses. A 40-item abbreviated version of the Profile of Mood States Questionnaire (POMS, McNair, et al., 1971 /1992; POMS40, Grove & Prapavessis, 1992 ) was used to assess participants' mood after each exercise session. The scale consists of 40 items, scored on a 5-point Likert scale. 7 subscales can be derived from these items (Tension, Anger, Fatigue, Depression, Esteem-related Affect, Vigour, and Confusion), which can then be used to calculate a score for Total Mood Disturbance (TMD), with lower scores equating to better mood. Enjoyment. An 8-item abbreviated version of the Physical Activity Enjoyment Scale (PACES, Kendzierski & DeCarlo, 1991 ; PACES8, Mullen et al., 2011 ) was used to help us understand participants' enjoyment of each exercise session. This 8-item questionnaire asked participants to rate each item related to exercise enjoyment on a 7-point Likert scale. An average of these scores is then calculated to give a final score of enjoyment, with higher scores translating to higher enjoyment. Table 1 Measures GPPAQ = General Practice Physical Activity Questionnaire. LTPAQ = The Leisure Time Physical Activity Questionnaire. AtE = Attitudes toward exercise. ESE = Exercise self-efficacy. VO2max = maximal exercise test. DASS = Depression, Anxiety, and Stress Scale. POMS = Profile of Mood States. PACES = Physical Activity Enjoyment Scale. Time Point Pre-Test Post Session Weeks 1–4 Mid-Test Post Session Weeks 5–8 Post-Test GPPAQ ✓ ✓ ✓ LTPAQ ✓ ✓ ✓ AtE ✓ ✓ ✓ ESE ✓ ✓ ✓ VO 2 Max ✓ ✓ ✓ DASS21 ✓ ✓ ✓ POMS ✓ ✓ PACES ✓ ✓ Procedure Pre-Test Table 1 summarises measures taken at each time point. Upon arrival at the lab, participants completed a pre-test survey, which captured their physical activity and current attitudes to exercise (GPPAQ, LTPAQ, AtE, and ESES) and their psychological well-being (DASS21). Participants then completed the cardiopulmonary exercise test outlined above. Following recovery, participants were introduced to a VR headset and chose their preferred exercise type. The exercise schedule was explained and shared via access to a cloud-based drive where participants could record their workout completions and find links to questionnaires. Initial 4 Weeks of Exercise Participants were counterbalanced to exercise in one of two structures: (i) either twice per week supervised sessions in the lab for 30 minutes each, or (ii) 4 times per week independent sessions at home for 15 minutes each, with both structures lasting 4 weeks. For the supervised sessions in the lab, participants were asked to provide availability for their sessions (Monday-Friday between the hours of 9am and 5pm) in advance and encouraged to stick to the times organised. For the home sessions, participants were encouraged to exercise at any time that suited them and were left to complete the sessions autonomously. Mid-Test and Second 4 Weeks of Exercise After the initial 4 weeks of exercise, participants were once again invited into the lab to carry out their mid-test. This looked identical to the procedure for the pre-test outlined above (except for the VR introduction). Participants then completed another 4 weeks of exercise in the other structure. Post-Test and Follow Up Participants were then invited into the lab again for their final visit. The post-test looked identical to the procedure of the mid-test, with the addition of a debrief of the study. Follow-up Interviews to Investigate Acceptability and Feasibility Participants who volunteered were interviewed within one month of the post-test. The semi-structured interviews lasted approximately 30–40 minutes and were conducted remotely using Microsoft Teams. The formulation of the interview guide involved the application of the COM-B model and Birkhead et al’s (2019) approach to developing VR interventions, ensuring coherence with the study's overarching objectives. Secondly, insights from quantitative research on virtual reality within sports and exercise (Qian et al., 2020 ; Peng et al., 2022 ) were incorporated to enhance the guide's content. Thirdly, valuable perspectives from previous qualitative studies and interview guides (Bradwell et al., 2023 , Farič et al., 2019 ) were reviewed to inform the development of relevant questions. (See supplement for complete interview guide). Data Analysis Data Cleaning and Imputation Missing data primarily occurred due to occasional missed exercise sessions across the 24 measurement points (16 at home, and 8 in the lab). These missing values mainly affected session-level measures (PACES and TMD). Crucially, the missingness did not result from systematic dropout of participants, and all remained enrolled in the study. The missing sessions occurred sporadically and were typically due to external factors such as scheduling conflicts, illness, or unavailability. We deemed these missing sessions not due to participants’ psychological states, intervention engagement, or responses to prior sessions. Therefore, we determined that the probability of a data point being missing was related to external factors (such as scheduling conflicts) and not related to the values of PACES or TMD themselves, which is consistent with the Missing at Random (MAR) assumption (Rubin, 1987 ). This also aligns with recommendations by Graham ( 2009 ) and Enders ( 2010 ), who suggest that MAR is a reasonable and practical assumption when missingness is due to external/logistical factors. They also recommend that auxiliary variables are included to inform the imputation model when data is MAR, which was carried out in the analysis. Given the assumption that the data was MAR, we used multiple imputations to account for missingness and reduce potential bias (Rubin, 1987 ). We conducted our multiple imputations using the ‘mice’ package in ‘R’, generating 5 imputed datasets (Graham et al., 2007 ). The imputation model used predictive mean matching (PMM) for continuous variables to ensure imputed variables were within the range of observed data, and logistic regression was applied to categorical variables. To ensure the accuracy of the imputed datasets, comparisons were made between complete data and imputed data. No significant differences were observed between the imputed and complete data cases. Analysis was performed on each of the five imputed datasets, and results were pooled according to Rubin’s rules (Rubin, 1987 ) to obtain final statistics. Quantitative Analysis To analyse acceptability and feasibility, a two-condition (home-organised or organised-home) by eight time point (weeks of intervention) repeated measures ANOVA was performed to evaluate the within-subject effects of time (week) and condition order on the percentage of the exercise plan that was completed. Bonferroni corrections were used in all post hoc analyses. The counterbalanced crossover design accounted for any order effects, so for further efficacy analysis, we treat participants as a single group. Partial eta squared (ηp 2 ) was used to measure effect sizes for ANOVAs (F tests), with Cohen’s d used for pairwise comparisons. We set an alpha level (p) of .05. Due to the desire to account for individual variability in our analysis, we used linear mixed-effects (LMM) models to analyse all dependent variables for physical activity, enjoyment, affective responses, and psychological and physical wellbeing. Our focus was on the effects of the intervention on physical and psychological variables over time; therefore, we included random intercepts for participants, age, and BMI. Modelling age and BMI as random intercepts provide a parsimonious way to account for minor between-subject heterogeneity without overfitting the model or drawing attention to secondary variables. Assumption checks across all primary LMMs were conducted using diagnostic plots (e.g., residual vs. fitted values, Q-Q plots) and collinearity diagnostics (Variance Inflation Factors) for fixed effects. These checks indicate that model residuals were approximately normally distributed with no substantial heteroscedasticity. A small degree of heteroscedasticity was observed at the upper range of fitted values for some LMMs. Still, given the limited number of data points in this range and the general robustness of LMMs to such violations, the model was retained. Multicollinearity was not a concern, with all VIF values well below commonly accepted thresholds. To analyse changes in enjoyment and affective responses to workouts over time, two LMMs were fitted to assess the relationship between the predictor variables of time and total sessions completed on enjoyment (PACES) and Total Mood Disturbance (TMD). To analyse initial efficacy of VR exercise on physical activity, psychological wellbeing, and physical fitness, we used LMMs with separately considered dependent variables of PAI (Physical activity index), LTE (Leisure time activity), AtE (Attitudes toward exercise), ESE (Exercise self-efficacy), D (DASS depression subscale), A (DASS anxiety subscale), S (DASS stress subscale), VO2 (maximum oxygen consumption), and VT1 (ventilatory threshold). The mixed-effects models included fixed effects for time point (pre-, mid-, or post-test), and total completion percentage. They also included random intercepts for participant, age, and BMI to account for between-subject variability. All LMM’s were computed using the ‘lme4’ package in ‘R’. The models were estimated using restricted maximum likelihood, which is commonly used when estimating variance. Cohen’s d with 95% confidence intervals was used to calculate post-hoc effect size estimates of differences between pre-, mid-, and post-tests. Interview Analysis The follow-up interviews were transcribed through Microsoft Teams, with any grammatical changes made as necessary. A two-stage reflexive analysis approach was used (Braun & Clarke 2006 , 2019 ), allowing for themes to be identified from the raw data. It is a common assumption that one needs to choose an inductive or deductive approach, but it is rarely possible for an analysis to neatly fall into one approach (Braun & Clarke, 2019 ; Byrne, 2022 ). Here we have used a predominantly inductive approach, but a degree of deductive analysis was employed to ensure the open-coding contributed themes that are meaningful to the research question (Byrne 2022 ; Rasheed & Runswick., 2024). The combination of approaches allows for the data to drive new themes, but ensures themes are relevant to the research question (Fereday & Muir-Cochrane, 2006 ). Results Acceptability & Feasibility of VR Exercise Programme Completion of Exercise Sessions Of the 28 people who volunteered to take part, eight dropped out during the first half of the programme and 20 completed testing at each time point. One participant dropped out due to a perceived negative response to the repeated use of VR, potentially interacting with an existing problem with migraines. The other participants dropped out for a range of practical reasons. Figure 2 shows completion rates of participants on each arm of the crossover. There was a significant main effect of week on completion of exercise sessions ( F (7, 126) = 8.262, p < .001, η p 2 = 0.315). Post-hoc analysis showed there was significantly less sessions were completed in week 6 ( p = .002, d = 1.273), week 7 ( p = .001, d = 1.304), and week 8 ( p < .001, d = 1.335) compared to week 1. This was driven by a week-by-crossover order interaction effect (F(7, 126) = 2.853, p = .009, ηp2 = 0.137), where the arm that completed home exercise first and organised sessions for the second four weeks maintained higher engagement than the arm that completed supervised sessions first. However, there was no significant overall between-subject effect of crossover order ( F (1, 18) = 3.695, p = .071, η p 2 = 0.170). Exploratory Analysis for Completion Rates During the study, we observed that participants with the lowest levels of exercise self-efficacy and the lowest starting physical fitness levels seemed to be more engaged in the intervention. To investigate this further, we conducted some exploratory analysis using Pearson’s correlations between pre-test measures of exercise self-efficacy and physical fitness (VO2 max) and total number of sessions completed (Fig. 3 ). Results showed that exercise self-efficacy negatively correlated with session completion (r = -0.616, p = 0.002). Participants with lower confidence in their ability to exercise completed more sessions than those with higher confidence. Similarly, we found that VO2max at pre-test negatively correlated with total session completion (r = -0.502, p < 0.001). Those with lower physical fitness at the pre-test completed more total exercise sessions. Enjoyment of Individual Exercise Sessions Figure 4 (left) shows the enjoyment of exercise sessions over time. The model indicates that the intercept is significantly different from zero (estimate = 4.98, p < 0.001), indicating a baseline PACES score of 4.98 when other predictors are zero. The effect of time (estimate = 0.055, p = 0.083) suggests non-significant trend toward enjoyment increasing over time. The effect of total session completion (estimate = 0.0049, p = 0.621) was non-significant. Affective Responses to Individual Exercise Sessions Figure 4 (right) shows TMD scores over time (high scores are a more positive mood after exercise). The model indicated that while the intercept reveals a significant baseline TMD score of 95.72, neither the effect of time nor the total sessions completed has a statistically significant impact on TMD scores ( p = 0.382 and p = 0.802, respectively). Initial Efficacy of VR Exercise Programme Table 2 presents the estimated means ± SE for all the dependent variables and fixed effects of time and competition percentage. Figure 5 shows the effect sizes of change between each measurement point across physical activity, psychological well-being, and physical health measures. The full descriptive statistics for all variables and full reports of effect sizes can be found in the supplementary materials. From pre- to mid-test, we found medium positive effects for both LTE (d = 0.596, 95% CI [0.113, 1.066]) and VO2 (d = 0.569, 95% CI [0.089, 1.036]). In the second four weeks, when engagement was lower, there were no significant changes. Figure 5 C demonstrates effects across the full eight weeks from pre- to post-test. These show a medium positive effect for increased leisure time activity (d = 0.656, 95% CI [0.122, 1.174]) and a medium negative effect for anxiety (d = -0.532, 95% CI [-1.034, -0.016]). This suggests that over the course of the 8-week intervention, participants engaged in more physical activity and experienced reduced levels of anxiety compared to the pre-test. Overall effect size trends suggest possible reductions in anxiety, depression, and stress and possible increases in exercise self-efficacy, physical activity, and physical fitness. Table 2 Estimated means ± SE for activity, psychological and physical health variables. PAI = Physical activity index calculated from GPPAQ. LTE = Leisure time activity. AtE = Attitudes toward exercise. ESE = Exercise self-efficacy. D = DASS depression subscale. A = DASS anxiety subscale. S = DASS stress subscale. VO2 = VO2max. VT1 = ventilatory threshold. Variable Time Estimate (SE) Completion Estimate (SE) Pre-Mid-Post PAI -0.05 (0.09) -0.01 (0.01) LTE 0.24 (0.07) 0.01 (0.01) AtE -0.02 (0.09) -0.01 (0.01) ESE 0.17 (0.11) -0.02 (0.01) Depression -1.46 (0.64) 0.04 (0.07) Anxiety -1.17 (0.72) 0.03 (0.07) Stress -0.76 (0.73) 0.07 (0.09) VO 2 4.43 (1.90) 0.14 (0.30) VT1 -0.63 (0.91) 0.23 (0.07) Pre-Mid PAI 0.05 (0.15) -0.02 (0.01) LTE 0.35 (0.13) 0.00 (0.01) AtE -0.12 (0.15) -0.01 (0.01) ESE 0.24 (0.18) -0.03 (0.01) Depression -1.70 (1.09) 0.03 (0.08) Anxiety -0.30 (1.45) 0.02 (0.07) Stress -1.90 (1.19) 0.07 (0.08) VO 2 10.15 (3.84) 0.18 (0.31) VT1 -1.47 (1.59) 0.22 (0.07) Mid-Post PAI -0.16 (0.17) -0.01 (0.01) LTE 0.12 (0.08) 0.01 (0.00) AtE 0.08 (0.20) -0.01 (0.01) ESE 0.05 (0.21) -0.01 (0.01) Depression -1.35 (1.18) 0.08 (0.06) Anxiety -1.67 (1.41) -0.04 (0.08) Stress 0.59 (1.47) 0.06 (0.09) VO 2 -2.58 (2.94) 0.14 (0.26) VT1 -0.04 (2.00) 0.24 (0.07) Pre-Post PAI -0.04 (0.10) -0.01 (0.01) LTE 0.24 (0.09) 0.00 (0.01) AtE -0.02 (0.10) -0.00 (0.01) ESE 0.19 (0.11) -0.03 (0.01) Depression -1.55 (0.79) 0.03 (0.07) Anxiety -1.47 (0.64) 0.11 (0.07) Stress -1.01 (0.85) 0.10 (0.09) VO 2 4.16 (1.75) 0.10 (0.35) VT1 -0.38 (0.82) 0.21 (0.08) Weekly TMD -0.26 (0.34) -0.09 (0.17) PACES 0.04 (0.03) 0.01 (0.01) Interview Analysis Table 3 displays the participant characteristics of those who volunteered to complete follow up interviews. Figure 6 shows the results of the thematic analysis where eight themes were identified, five relating to the acceptability of VR exercise, and one for each of feasibility, tolerability, and initial efficacy. Table 3 Participant characteristics for interviews PPT_ID Gender Age BMI Workouts completed (%) 1 Female 29 23.59 56.25 2 Female 21 26.06 87.5 7 Female 21 33.3 90.63 9 Male 21 23.14 71.88 16 Male 21 25.56 75 18 Female 34 36.51 96.88 22 Male 24 30.49 56.25 23 Female 19 21.21 68.75 24 Female 22 26.67 75 26 Female 20 20.11 65.63 Acceptability Participants discussed five key factors relating to their willingness to use FitXR for exercise: gamification, novelty, features of the app, presence and immersion, and the social elements of exercise. While generally positive in their acceptance of using VR for exercise, a number of these sub-themes feature both positive and negative opinions from participants. Gamification Gamification refers to using game-design elements to motivate individuals to engage in a behaviour in another setting. In this case, FitXR offers gamified exercise through several features, including animations, a leaderboard, and score multipliers. For example, when discussing their enjoyment of receiving feedback and higher scores for putting in more effort, participant 23 said: Also, for the boxing, they have that little fire for every punch if you do it like harder, like a full hotter punch. And I really enjoyed that it was satisfying. And like the harder you punch the higher you score. Overall, the gamification approach was positively received because participants found it “fun because you're not thinking that you're doing exercise, you're just thinking you're playing a game” (P26). The use of scoring was popular with participants motivated by maintaining and beating their personal high scores and streaks: “I think the biggest motivator is the sort of streaks and beating your score in streak and coming back to try and be better … there's something very, very, very satisfying about long streaks” (P18). App Features Alongside gamification elements, participants discussed other app features that affected their acceptability of using FitXR. These ranged from fundamental features like the instructions, music, and haptic feedback. For example, participant 16 discussed the benefits of feedback, stating, “I did the boxing plan like hitting the targets and then like they have the like vibration thing so that it feels like you're actually hitting something” (P16). The presence of a virtual trainer added to this sense of engagement “I feel more engaged with the VR too, because it felt like the trainer was actually going through things with me directly” (P23). The relatability of the instructors was also proposed to impact perceptions of FitXR, as evidenced by participant 18, who said, “I really like that the app includes a disabled trainer”. This was reiterated when other participants highlighted that their participation was negatively impacted because the instructor “just felt very corny and American in all honesty, maybe if they had a British accent, it would be less annoying” (P26). One element where participants did have autonomy in the programme was the virtual location in which they completed their workout. Participants liked that FitXR allowed them to complete a specific workout in a range of locations (e.g., a virtual gym, rooftop, beach). This was highlighted by participant 24 who stated, “ I like that you could choose like where you're doing the class like... on like this... The rooftop and then like on the ice rink or something.” Participants also identified reasons why the choice of location impacted positively on their engagement in FitXR, with some highlighting that it gave them the feeling of being outdoors despite physically being indoors: “I find myself going more towards the open spaces” (P18). However, not all elements of the app received positive feedback. Some participants struggled to follow auditory instructions without visual demonstrations or specific feedback on their own efforts. Participant 23 illustrated this, stating they “need to see the first movement from the trainer first. I got a bit disconnected with the verbal command and the actual movement I have to do.” Other participants experienced technical issues with the app that negatively affected their experience of using VR for exercise. For instance, for participant 3 “the VR wasn’t picking up...even if I was doing the correct movement...my timing was off." Presence and immersion Aligned with the importance of location discussed in the previous theme, participants identified immersion and presence (i.e., the feeling of being physically present in another place) as central to their engagement with FitXR. In this vein, participant 18 reported experiencing a sense of “being in a different place [...] There was something about the vastness of some of these environments.” Several participants highlighted how VR was more beneficial than other at-home workout formats (e.g., video-guided workouts) because they were “fully engaged with it compared to when I have done like yoga videos for example, I get distracted sometimes” (P23). Social elements The lack of interaction with others while using FitXR was considered as both positive and negative. For those who were uncomfortable exercising around others, lack of interaction was positive with participant 22 stating they were “very self-conscious… And so I'm always thinking are they looking at me, are they watching? I think that definitely did help”. Additionally, participant 23 described having tried the gym and how they “feel pressured when I go to the gym. There's lot of people watching. But VR was completely different.” In contrast, the lack of social interaction during workouts left some participants feeling isolated. For example, participant 1” missed that human contact and connection [during exercise]. For me really like sport is a social thing because most of the activities I do I do with friends”. As such, some participants felt that social interaction should be built into VR designs. This was illustrated by participant 18 who said, “I think it would be amazing if you could actually do it with someone [...] to have like scheduled times where the same people show up.” This does exist in many applications but is something we chose to control here just including the trainer and virtual avatars which for participant 23 reduced their sense of isolation because “you have a lot of like different players around you, so it isn’t an isolated environment.” Novelty Novelty was also perceived as central to participants' experiences of FitXR. This was evidenced by participant 26, who explained, “I think 'cause it's [FitXR] quite novel and something that you don't get to do that often, that it was like quite exciting to do it.” However, for some participants, motivation decreased as the novelty wore off. For example, participant 1 “found it really enjoyable the first week because it was something new [...] and I think then my motivation slowly decreased over time.” However, the app did offer ways for participants to maintain novelty within the prescribed workouts due to choices (discussed in the ‘App feature’ sub-theme) provided by the app. Indeed, for participant 26 their motivation was maintained because they “got to pick the background every time. So it kind of made it not get too boring because you could shake things up each time.” Feasibility As well as the factors that impacted the acceptability of FitXR, the ability to effectively integrate VR exercise into their everyday lives was deemed important to participants’ engagement. Specifically, participants discussed the convenience of being able to integrate VR exercise into their routines and the ability to exercise at home was perceived as important. Convenience The convenience of being able to workout from home was deemed important to participants’ adherence to the programme. Participant 22 found the ability to workout from home helped them adhere to the programme “because I was just doing it literally 2 feet away from my bed”. Other benefits of working out from home included the ability to exercise without the need for equipment and being able to try different things without needing to attend organised sessions. This was evidenced by participant 1: you have the variety of things and exercises that you can do, like you don't have to depend on if this class is on and if you be able to make it there on time, you can just choose and do whatever you want, which is I think big advantage. Many participants enjoyed the brevity of the exercise sessions compared to other options for exercise like the gym, with participant 7 saying they “more looked forward to doing the short 15-minute exercises, than I would like to get up and get the motivation to go to the gym.”. However, some participants found the short workouts inconvenient because it meant they needed to fit more sessions into their schedule. For example, participant 1 commented, “I just didn't find the right way to maybe put it into my schedule four times a week.” Some participants also struggled to complete sessions at home due to the lack of an appropriate space, which reduced their comfort level to engage in exercises and increased safety concerns. For example, discussing this issue participant 22 said, “I had to be careful with furniture, I had to make sure not to punch the TV or whatever by accident.” However, some participants got used to this over time, as participant 7 described “the first week I was more trying to think about my surroundings and stuff like that, afterwards it was just easier to focus on the exercise and VR.” Additionally, factors such as internet connection impacted engagement with participant 23, saying “because I live in a student accommodation, obviously there would be Wi-Fi disruption.” Tolerability As well as the pragmatics of fitting VR exercise into their everyday lives, participants also identified the hardware as something that negatively impacted their engagement with the workouts. While no participants reported simulation sickness during their familiarisation sessions, certain factors related to the HMD negatively impacted their experience. Hardware discomfort Participants discussed some negative aspects of exercising while wearing the Meta Quest 2 headset. Specifically, participants experienced discomfort due to the sweat created by the headset and the headset moving too much. For example, participant 24 suggested that “if you're really going for it [during exercise], then, like, the sweat like drips down. It's not very nice.” Another issue with the hardware was maintaining a clear picture, as illustrated by participant 26, who stated, “There are a few times where I think the headset looked a bit blurry and it felt a bit clumpy and that makes it a little bit awkward at times.” Screen issues led some participants to experience simulation sickness when working out at home. This was illustrated by participant 1 who “found it quite hard to have all the screen time, I found sometimes I was almost like getting dizzy”. Initial Efficacy Alongside speaking to the pragmatic and practical factors that impacted their engagement in VR exercise, participants also discussed potential psychological benefits of using FitXR. Psychological benefits Participants discussed a range of psychological benefits of taking part in virtual exercise. For example, participant 23 discussed how the exercise helped them with “ the burdens of the day kind of got taken out from my brain and my body and I'm just immersed in this exercise. ” Additionally, engagement in VR exercise was also perceived to have an impact on participants’ mood post exercise, with participant 1 outlining that “when I finished, I really feel like, you know, happy and good and positive… I found that it had really good like immediate effect.” These positive responses were often attributed to the distraction or escapism element of VR exercise: it's kind of acts like a bit of escapism…it's a nice rest, a nice break from what you're doing, nice stress reliever, just to think about something different for 15 minutes…I think it helped in exam season actually because it was like something to distract me from being stressed about my tests (P26). While some participants identified only these acute benefits, others discussed longer-term benefits (e.g., reduced stress, increased confidence and motivation). Indeed, participant 23 “found it helped me manage my stress. And yeah, I think I've become quite like a happier person.” Participants also discussed how the benefits extended to motivation in other areas of their lives. For example, participant 7 experienced University-associated improvements, especially from organised sessions because “it kind of gives me more motivation to because it was on campus as well, I felt like, it gave me more motivation to, like, complete more tasks afterwards.” Participants also perceived engagement in the programme to impact their exercise behaviour. For example, participant 7 discussed paying more attention to their physical activity levels outside of Fit XR, stating, “before the study, I wasn't really thinking about how active I was, but after the FitXR exercises, I also started thinking about how many steps I've taken.” Discussion This study evaluated the acceptability and feasibility for young adults to change their exercise behaviour using the FitXR™ VR exercise app, and the initial impacts this had on physical activity, exercise self-efficacy, and health, using a mixed methods approach. We captured acceptability and feasibility through completion rates of the exercise programme, enjoyment and mood responses for every organised session and use at home. For initial efficacy, we measured exercise self-efficacy, physical activity, physical fitness and psychological well-being pre-intervention, at four weeks, and eight weeks. A subset of participants completed follow-up interviews to offer an in-depth understanding of their experiences. When engaging with the intervention, individuals expressed an overall positive range of opinions about engaging in exercise using VR. Participants showed VR exercise was acceptable and feasible to fit into their lives, either at home or in supervised sessions. It was particularly beneficial to give participants autonomy to work out at home first and then integrate organised sessions later. Data supported initial efficacy and a range of previous research by showing early improvements in both physical fitness and psychological well-being (Maden et al., 2022 ; Ng et al., 2019 ; Qian et al., 2020 ; Xu et al., 2024 ). However, these effects were primarily shown early in the study and began to reduce over time. The participants' acceptability of and willingness to use VR, and the feasibility with which participants could integrate the intervention into their day-to-day living were captured by completion of sessions, enjoyment of sessions, affective responses to exercise, and qualitative responses (Birckhead et al., 2019 ; Fig. 2 ). Overall, 71% of participants who started completed the study, with an average rate of 66% of prescribed exercise sessions completed. Engagement in the exercise sessions did decrease over time, particularly for the group that received four weeks of supervised sessions followed by four weeks at home unsupervised. This mirrors existing literature that finds dropout rates for supervised exercise interventions for mental health sit at 18–25% (Stubbs et al., 2016 ; Vancampfort et al., 2021 ), but around at around 50% of users aiming to take up exercise independently will have dropped out after the equivalent of eight weeks. These rates can be higher when participants have lower previous levels of physical activity and higher BMI (Sperandei et al., 2016 ). However, exploratory analysis (Fig. 3 ) here suggested participants with the lowest exercise self-efficacy and lowest physical fitness at the start of the intervention completed more of exercise sessions. A more in-depth understanding of how individual differences affect responses to VR interventions is warranted in future work. While completion rates are helpful to understand the acceptability and feasibility over eight weeks, the affective attitude and enjoyment are key elements for future engagement in exercise and the likelihood of purchasing VR (Gardner & Lally, 2012 ; Lee et al., 2019 ; Sekhon et al., 2017 ). When participants did engage in sessions, they maintained high levels of enjoyment and reported positive affective responses to each session (Fig. 4 ). These findings support a wide range of literature that has reported enhanced levels of enjoyment and positive affect when engaging in acute bouts of exercise in immersive settings (Bird et al., 2024 ; Barbour et al., 2024 ; Runswick et al., 2023 a; Teixeira et al., 2024 ) but also exemplify the need for long-term studies. Here, it was not the enjoyment of the exercise itself that was driving engagement, but the opportunity or motivation to start the session in the first place. Findings suggest that previous work on more structured interventions may not fully reflect the realities of engaging in exercise outside the lab (Maden et al., 2022 ; Ng et al., 2019 ; Riches et al., 2024 ; Xu et al., 2024 ). In interviews, the participants reported that the gamification, presence in sessions that enhanced engagement and concentration, and the ability to fit exercise into the routine using short sessions and sessions at home had a positive impact on motivation and opportunity to exercise, but for the young people we studied here, many had barriers around sufficient space to exercise at home. The findings support previous work in exergames (Farič et al., 2019 ) but extend to include specific issues related to the use of HMDs and working out at home. Here, we captured participants perceived outcomes in qualitative data and initial evidence for efficacy in quantitative data (see Fig. 5 ). Despite the relatively low intensity and frequency of exercise associated with this intervention (see Barbour et al., 2024 ), the initial quantitative analysis did suggest a likely increase in physical health and therefore offered evidence for the initial efficacy of a VR exercise intervention. However, this positive effect was heavily focused in the first half of the intervention (pre to mid tests) where engagement was the highest. Few previous studies investigating the physiological effects of exercising with VR have used the gold standard of cardiovascular fitness, and these data offer a promising starting point for understanding the use of gamified VR exercise to improve physical health. As well as positive trends in physical fitness, data also suggested a likely decrease in scores for anxiety and an increase in exercise self-efficacy and leisure time activity. These findings extend the work of Xu et al ( 2021 ), who found a structured XR exercise intervention to be effective for reducing depression and anxiety. Unlike the physiological data, these effects were most prevalent over the whole course of the intervention. The positive effects of engaging in exercise on anxiety and depression are well documented (Kandola et al., 2019 ; Stathopoulou et al., 2006 ; Schuch et al., 2016 ), and the findings here offer initial suggestion at the VR exercise could be a new option for engaging with exercise for young people and could serve as a gateway to potentially engaging in other forms of activity. The findings presented here should be considered in light of the limitations of the work. While we did explicitly aim to create a more naturalistic exploration of participant engagement with VR exercise, this meant we had limited control over the frequency and intensity of the exercise being conducted. This is realistic of real-world applications; however, it means we cannot draw complete conclusions on the relationship between frequency and intensity of VR exercise and variables relating to physical and psychological health benefits. We did, however, control the workouts that were conducted, including the trainer and music, meaning that we removed some of the autonomy. The desire to control the amount of exercise participants completed in each side of the crossover in this study removed some of the novelty for participants, so this may not be reflective of more autonomous use of VR. In the interviews, participants discussed the novelty of VR wearing off, and novelty is required to maintain motivation for exercise plans, even amongst active individuals (Grave et al., 2011; Lakicevic et al., 2020 ). Future work should investigate the autonomy of choice in music, trainers, workout locations and other features and how they influence engagement and exercise intensity. Due to the timing and budget of this work, we did not use the most up-to-date hardware and software, meaning that many issues relating to tolerability of the headset and feasibility of space in the home may be addressed by the lighter weight and passthrough features on newer products. In summary, the findings suggest that exercising using a commercially available VR fitness app may serve as a feasible and acceptable alternative for young adults looking to engage in exercise. A combination of autonomous exercise at home and organised sessions will likely lead to the best engagement, and future development of exercise apps should continue to leverage gamification elements, options to maintain novelty, and choice about the engagement with others during exercise. VR exercise shows benefits for health, particularly acute psychological responses, with potential for longer term benefits to symptoms of anxiety (Maden et al., 2022 ; Ng et al., 2019 ; Riches et al., 2024 ; Xu et al., 2024 ), but future research should seek to understand how these interventions can be practically implemented to enhance adherence to new exercise behaviours. Declarations Competing Interests Dr Runswick received research funding from FitXR Ltd who are a virtual reality fitness company, and the app used in this paper. Dr Stubbs has received honorarium from a co-edited book on exercise and mental illness (Elsevier), and unrelated advisory work from ASICS, in addition to honorarium from FitXR Ltd. Author Contribution Oliver Runswick: Conceptualization, Methodology, Formal analysis, Resources, Writing-Original Draft, Project administration, Funding acquisition. Megan Smith: Investigation, Formal analysis, Data curation, Writing-Review & Editing, Project administration. Harry Rowland: Investigation, Formal analysis, Data curation, Writing-Review & Editing, Project administration. Lakshmi Mahendru: Investigation, Data curation, Writing-Review & Editing. Simran Chahal: Investigation, Formal analysis, Data curation, Writing-Review & Editing. Lucia Valmaggia: Conceptualization, Methodology, Writing-Review & Editing, Funding acquisition. Brendon Stubbs: Conceptualization, Methodology, Writing-Review & Editing. Sean Figgins: Methodology, Writing-Review & Editing. Richard Bruce: Conceptualization, Methodology, Resources, Writing-Review & Editing Data Availability Data associated with this manuscript is available at https://osf.io/snrv5/?view_only=370b7584024b4af494181a7715b20353 References Baillot A, Chenail S, Barros Polita N, Simoneau M, Libourel M, Nazon E, Riesco E, Bond DS, Romain AJ (2021) Physical activity motives, barriers, and preferences in people with obesity: A systematic review. 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Ann Behav Med 36(2):186–194. https://doi.org/10.1007/s12160-008-9054-7 Xu W, Liang H-N, Baghaei N, Ma X, Yu K, Meng X, Wen S (2021) Effect of Immersive Virtual Reality Exergaming on University Students’ Anxiety, Depression, and Perceived Stress: A Pilot Study (Preprint). JMIR Serious Games 9(4). https://doi.org/10.2196/29330 Zeng N, Liu W, Pope ZC, McDonough DJ, Gao Z (2021) Acute Effects of Virtual Reality Exercise Biking on College Students’ Physical Responses. Res Q Exerc Sport 1–7. https://doi.org/10.1080/02701367.2021.1891188 Zhang B, Li D, Liu Y, Wang J, Xiao Q (2021) Virtual reality for limb motor function, balance, gait, cognition and daily function of stroke patients: A systematic review and meta-analysis. J Adv Nurs 77(8). https://doi.org/10.1111/jan.14800 Additional Declarations Competing interest reported. Dr Runswick received research funding from FitXR Ltd who are a virtual reality fitness company, and the app used in this paper. Dr Stubbs has received honorarium from a co-edited book on exercise and mental illness (Elsevier), and unrelated advisory work from ASICS, in addition to honorarium from FitXR Ltd. Supplementary Files SupplementaryMaterials.docx Cite Share Download PDF Status: Published Journal Publication published 08 Dec, 2025 Read the published version in Virtual Reality → Version 1 posted You are reading this latest preprint version Research Square lets you share your work early, gain feedback from the community, and start making changes to your manuscript prior to peer review in a journal. As a division of Research Square Company, we’re committed to making research communication faster, fairer, and more useful. We do this by developing innovative software and high quality services for the global research community. Our growing team is made up of researchers and industry professionals working together to solve the most critical problems facing scientific publishing. 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13:57:10","extension":"png","order_by":17,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":23340,"visible":true,"origin":"","legend":"","description":"","filename":"Onlinefloatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/b74e19c6c37bc5686f1a9dfd.png"},{"id":94397605,"identity":"9c877d73-f1a2-4659-bbb8-32cb6f5d8994","added_by":"auto","created_at":"2025-10-27 13:56:43","extension":"xml","order_by":18,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":236507,"visible":true,"origin":"","legend":"","description":"","filename":"70316719193f423abdeca575b3d2ad351structuring.xml","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/2c7648a2a49c1685ec46c7fd.xml"},{"id":94397187,"identity":"4151f26d-e8fb-4ce5-a3ec-950f716ca25c","added_by":"auto","created_at":"2025-10-27 13:56:31","extension":"html","order_by":19,"title":"","display":"","copyAsset":false,"role":"acdc-reference","size":251740,"visible":true,"origin":"","legend":"","description":"","filename":"earlyproof.html","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/e3891f053e5a70bb044e5f53.html"},{"id":94398290,"identity":"5af02402-3271-4f3d-8106-126d36b7c4b0","added_by":"auto","created_at":"2025-10-27 13:57:02","extension":"png","order_by":1,"title":"Figure 1","display":"","copyAsset":false,"role":"figure","size":140675,"visible":true,"origin":"","legend":"\u003cp\u003eThe cross-over design and testing points for the eight-week exercise intervention.\u003c/p\u003e","description":"","filename":"floatimage1.png","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/b211a3b5526a471dbb51e5c4.png"},{"id":94395905,"identity":"674b14dd-e1b3-4ca1-b1f3-c90ba727db91","added_by":"auto","created_at":"2025-10-27 13:55:44","extension":"jpeg","order_by":2,"title":"Figure 2","display":"","copyAsset":false,"role":"figure","size":152175,"visible":true,"origin":"","legend":"\u003cp\u003eThe % of total 15-minute sessions completed over the course of the eight-week intervention (mean per week ±SE). The left-hand figure is participants who completed the home sessions first, followed by the supervised workouts. The right-hand figure represents participants who completed the supervised element followed by the home sessions.\u003c/p\u003e","description":"","filename":"floatimage2.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/e0eb77f5814be8c92f61168c.jpeg"},{"id":94398941,"identity":"40f70dca-d3fb-456b-b260-6c64af66508a","added_by":"auto","created_at":"2025-10-27 13:57:17","extension":"jpeg","order_by":3,"title":"Figure 3","display":"","copyAsset":false,"role":"figure","size":208764,"visible":true,"origin":"","legend":"\u003cp\u003eCorrelations between exercise self-efficacy (left) and VO2 max (right) at pre-test with the number of sessions completed during the intervention.\u003c/p\u003e","description":"","filename":"floatimage3.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/7154a69b647ad116f8af2eb8.jpeg"},{"id":94397753,"identity":"a90333c1-a8a1-4315-a385-8deaacd52411","added_by":"auto","created_at":"2025-10-27 13:56:47","extension":"jpeg","order_by":4,"title":"Figure 4","display":"","copyAsset":false,"role":"figure","size":150222,"visible":true,"origin":"","legend":"\u003cp\u003eMean (SE) of individual session reports of enjoyment (left) and the total mood disturbance variable from POMS (right). High scores show more enjoyment or better mood.\u003c/p\u003e","description":"","filename":"floatimage4.jpeg","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/9c461ed3d9cd0af04736c1a2.jpeg"},{"id":94489272,"identity":"99898243-b0bc-4b47-af3c-f9dd23db3501","added_by":"auto","created_at":"2025-10-27 17:04:03","extension":"png","order_by":5,"title":"Figure 5","display":"","copyAsset":false,"role":"figure","size":108019,"visible":true,"origin":"","legend":"\u003cp\u003eEffect sizes of change in each variable between pre- and mid-test (A), mid- and post-test (B), and pre- and post-test (C). PAI = Physical activity index from GPPAQ. LTE = Leisure time activity. AtE = Attitudes toward exercise. ESE = Exercise self-efficacy. D = DASS depression subscale. A = DASS anxiety subscale. S = DASS stress subscale. VO2 = maximum oxygen consumption. VT1 = ventilatory threshold.\u003c/p\u003e","description":"","filename":"floatimage5.png","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/d57975a08f22d06f51165c13.png"},{"id":94396045,"identity":"3c39c9cd-cc4b-47bd-8333-6e5d31091e38","added_by":"auto","created_at":"2025-10-27 13:55:48","extension":"png","order_by":6,"title":"Figure 6","display":"","copyAsset":false,"role":"figure","size":64108,"visible":true,"origin":"","legend":"\u003cp\u003eThemes discussed by participants relating to their experiences and engagement with FitXR.\u003c/p\u003e","description":"","filename":"floatimage7.png","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/a918166650a9a956acf5d957.png"},{"id":98243496,"identity":"1f809763-0c0e-4b2f-a073-e428d043d861","added_by":"auto","created_at":"2025-12-15 16:06:58","extension":"pdf","order_by":0,"title":"","display":"","copyAsset":false,"role":"manuscript-pdf","size":2039167,"visible":true,"origin":"","legend":"","description":"","filename":"manuscript.pdf","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/e4c511fd-cb16-441a-b99c-d6633f57317c.pdf"},{"id":94398100,"identity":"0a2acc36-4fa2-4cf5-af3f-3cda16665530","added_by":"auto","created_at":"2025-10-27 13:56:59","extension":"docx","order_by":0,"title":"","display":"","copyAsset":false,"role":"supplement","size":42829,"visible":true,"origin":"","legend":"","description":"","filename":"SupplementaryMaterials.docx","url":"https://assets-eu.researchsquare.com/files/rs-5486191/v1/9431f14ded318045348f17ab.docx"}],"financialInterests":"Competing interest reported. Dr Runswick received research funding from FitXR Ltd who are a virtual reality fitness company, and the app used in this paper. Dr Stubbs has received honorarium from a co-edited book on exercise and mental illness (Elsevier), and unrelated advisory work from ASICS, in addition to honorarium from FitXR Ltd.","formattedTitle":"Acceptability, Feasibility, and Initial Efficacy of Virtual Reality as a Home-Based Exercise Modality for Young Adults","fulltext":[{"header":"Introduction","content":"\u003cp\u003eExercise has numerous positive effects on physical and mental health, including the prevention and alleviation of symptoms in various chronic conditions (Warburton et al., \u003cspan citationid=\"CR81\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Warburton \u0026amp; Bredin, \u003cspan citationid=\"CR80\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). The World Health Organization (WHO) recommends that adults get 150\u0026ndash;300 minutes of moderate aerobic activity per week and that children and adolescents average 60 minutes per day (420 minutes per week) for optimal health and wellbeing (Bull et al., 2022). Despite the known benefits of exercise, relatively few individuals engage with recommended levels (Garber et al., \u003cspan citationid=\"CR23\" class=\"CitationRef\"\u003e2011\u003c/span\u003e; Haskell et al., \u003cspan citationid=\"CR29\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). There is emerging evidence that life expectancy is plateauing, long-term conditions develop at younger ages, and younger people are less active than previous generations (DuGoff et al., \u003cspan citationid=\"CR18\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Kandola et al., \u003cspan citationid=\"CR34\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Vancampfort et al. \u003cspan citationid=\"CR79\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). There is, therefore, a continuing need to develop strategies to support sustained commitment to exercise and physical activity across the lifespan. New technological developments, such as exergames in virtual reality (VR), can offer new ways to address this need (Ng et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), but research is required to understand the practical implementation of these new technologies.\u003c/p\u003e\u003cp\u003eVR is a versatile technology providing diverse user experiences that exist across a spectrum of immersion. A fundamental level of virtual experience is akin to traditional video gaming, where users engage with graphics on standard flat-screen displays (Rizzo et al., \u003cspan citationid=\"CR61\" class=\"CitationRef\"\u003e2011\u003c/span\u003e). More immersive virtual experiences encompass three-dimensional computer-generated simulations, allowing users to feel present in another place and interact and engage with the environment using full-body movements (Turoń-Skrzypińska et al., \u003cspan citationid=\"CR77\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Runswick, \u003cspan citationid=\"CR64\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Qian et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). These more immersive technologies naturally facilitate exergames, games that require the user to produce body movements to interact with the technology, and may be more enjoyable than less immersive options (Bird et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e).\u003c/p\u003e\u003cp\u003eYoung users have identified gamification elements such as rewards, novelty and enjoyment, multiplayer options, and continued updates as important to engaging with sustained exercise behaviours (Farič et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2019\u003c/span\u003e). A range of evidence has shown the potential for VR exercise interventions to enhance physical activity, physical health, and mental health outcomes in young people (Maden et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ng., et al., 2019; Qian et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2020\u003c/span\u003e, Xu et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Work on existing users has suggested that using VR to exercise at home could be beneficial for health (Peng et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). However, despite positive responses to controlled interventions, there is limited understanding of how inactive young people can practically integrate exercise in VR into their lives as a tool for changing physical activity behaviours.\u003c/p\u003e\u003cp\u003eThe COM-B model of behaviour change (Michie et al., \u003cspan citationid=\"CR48\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) posits that consistent behaviour change is contingent upon three key components: Capability, Opportunity, and Motivation. \u0026ldquo;Capability\u0026rdquo; refers to an individual's psychological and physical capacity to engage in a behaviour. For example, physical discomfort and various psychosocial factors hinder individuals\u0026rsquo; capability to engage in exercise (Baillot et al., \u003cspan citationid=\"CR1\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Herazo-Beltr\u0026aacute;n et al., \u003cspan citationid=\"CR30\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). VR can enhance capability by allowing users to exercise at higher workloads with more enjoyment while maintaining the same levels of perceived effort (Barbour et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Finnegan et al., \u003cspan citationid=\"CR22\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Ochi et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Runswick et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Rutkowski et al., \u003cspan citationid=\"CR66\" class=\"CitationRef\"\u003e2021\u003c/span\u003e; Stewart et al., \u003cspan citationid=\"CR72\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Zeng et al., \u003cspan citationid=\"CR84\" class=\"CitationRef\"\u003e2021\u003c/span\u003e).\u003c/p\u003e\u003cp\u003e\u0026ldquo;Opportunity\u0026rdquo; encompasses the external factors that facilitate or hinder behaviour, such as time constraints, transportation issues, safety concerns in outdoor environments, and lack of equipment (King et al., \u003cspan citationid=\"CR36\" class=\"CitationRef\"\u003e2000\u003c/span\u003e; Jack et al., \u003cspan citationid=\"CR31\" class=\"CitationRef\"\u003e2010\u003c/span\u003e; Sch\u0026auml;ttin et al., \u003cspan citationid=\"CR67\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Many different forms of VR exercise can be undertaken in small spaces, without the need for other equipment, and in one\u0026rsquo;s own home (Riches et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, much of the research on VR exercise to date has focused on either group-based or supervised interventions; there is limited understanding of the facilitators and barriers of engaging in VR exercise at home.\u003c/p\u003e\u003cp\u003eFinally, \u0026ldquo;Motivation\u0026rdquo; reflects the cognitive processes that drive and inspire behaviour, and, alongside enjoyment, is a key predictor in the initial adoption of exercise (Gardner \u0026amp; Lally, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Teixeira et al., \u003cspan citationid=\"CR74\" class=\"CitationRef\"\u003e2012\u003c/span\u003e). VR exergames have exhibited heightened levels of motivation, engagement, and enjoyment compared to less immersive forms of exercise (Barbour et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Bird et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Mologne et al., \u003cspan citationid=\"CR50\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Mouatt et al., \u003cspan citationid=\"CR52\" class=\"CitationRef\"\u003e2020\u003c/span\u003e Ochi et al., \u003cspan citationid=\"CR55\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Teixeira et al., \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). While promising, these findings have primarily derived from acute responses, and there is a need to establish if VR can support exercise behaviour change over time.\u003c/p\u003e\u003cp\u003eThe need for further work on delivering VR interventions stems from estimates of attrition rates for exercise interventions, which range from anywhere between 10\u0026ndash;80% in the existing literature (Pirotta et al., \u003cspan citationid=\"CR57\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Linke et al., \u003cspan citationid=\"CR41\" class=\"CitationRef\"\u003e2011\u003c/span\u003e), often witnessing short-term successes before dissipating back to baseline (Marcus et al., \u003cspan citationid=\"CR45\" class=\"CitationRef\"\u003e2006\u003c/span\u003e). Much of the longitudinal work has so far only assessed the use of VR in controlled trials and in specific clinical populations, such as those living with mobility issues, rather than in changing exercise behaviour (Cho et al., \u003cspan citationid=\"CR13\" class=\"CitationRef\"\u003e2014\u003c/span\u003e; Darekar et al., \u003cspan citationid=\"CR15\" class=\"CitationRef\"\u003e2015\u003c/span\u003e; Dockx et al., \u003cspan citationid=\"CR17\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Lei et al., \u003cspan citationid=\"CR40\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; 2022; Tobaiqi et al., \u003cspan citationid=\"CR76\" class=\"CitationRef\"\u003e2023\u003c/span\u003e; Zhang et al., \u003cspan citationid=\"CR85\" class=\"CitationRef\"\u003e2021\u003c/span\u003e). While a wide range of studies have also shown potential benefits using controlled trials for young people (Maden et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ng., et al., 2019; Qian et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2020\u003c/span\u003e, Xu et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), these studies do not address an inactive younger population aiming to engage with exercise autonomously and have rarely used gold standard measures of physical fitness, such as VO2 max testing.\u003c/p\u003e\u003cp\u003eThree studies have begun to address this need. Both Barbour et al. (\u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) and Texiera et al. (2024) used the commercially available VR exercise app FitXR\u0026trade; to investigate physical workload and emotional responses to VR compared to screen-based workouts. They found participants chose to work harder and displayed more positive psychological benefits in VR. Improved emotional responses to exercise were considered a proxy measure for an enhanced likelihood of engaging with exercise in the future. Xu et al. (\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e2021\u003c/span\u003e) conducted a feasibility and usability study and measured impacts on university students\u0026rsquo; mental health over a period of six weeks. However, all these studies were supervised interventions in organised sessions, meaning the advantage of allowing participants to engage in their own homes at flexible times was not part of the work.\u003c/p\u003e\u003cp\u003eThere is, therefore, a need to understand the realistic integration of affordable and accessible VR exercise into the lives of young people aiming to enhance their levels of physical activity (Mocco et al., \u003cspan citationid=\"CR49\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). Here, we used a mixed methods approach, combining home and organised sessions of the FitXR\u0026trade; VR exercise app in a crossover design over eight weeks. To understand initial impacts on physical activity, exercise self-efficacy, and health, measures of psychological and physical wellbeing were taken before, at the mid-point, and post VR exercise. To assess acceptability and feasibility, adherence was measured throughout, and ten participants completed follow-up interviews about their experiences.\u003c/p\u003e"},{"header":"Methods","content":"\u003cdiv id=\"Sec3\" class=\"Section2\"\u003e\u003ch2\u003eStudy Design\u003c/h2\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eAn exercise programme that consisted of four 15-minute workouts was undertaken by all participants in two different structures. Ten participants (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, red group) completed their first four weeks by completing two workouts twice per week in 30-minute supervised sessions, and their second four weeks at home, completing 15-minute sessions (one workout) 4 times per week. The other ten participants (Fig.\u0026nbsp;\u003cspan refid=\"Fig1\" class=\"InternalRef\"\u003e1\u003c/span\u003e, blue group) completed the home sessions in the first four weeks and the supervised sessions in the second four weeks. All participants completed a pre-test, a mid-test after 4 weeks to assess changes in measures from the first half of the crossover, and a post-test after the full eight weeks. We captured acceptability and feasibility with engagement data and qualitative interviews of the participants' experience, including why they did or did not find a VR acceptable for use and how it could be integrated into day-to-day living. Initial efficacy, the opportunity to measure efficacy with the context of a small trial with no requirement for a control group (Birkhead et al., 2019), was captured using measures of physical and mental health at pre, mid, and post-tests.\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eParticipants\u003c/h3\u003e\n\u003cp\u003eDue to the focus on acceptability and feasibility in this mixed-methods study we did not power this study to find a specific effect (Birkhead et al., 2019). Twenty-eight participants from the university population (F\u0026thinsp;=\u0026thinsp;15, M\u0026thinsp;=\u0026thinsp;13) aged between 19 and 34 years old at start of intervention (22\u0026thinsp;\u0026plusmn;\u0026thinsp;4 years) were recruited through volunteer sampling. Participants did not report any physical or mental health condition that prevented them from exercising or using immersive virtual reality. If the participant dropped out before the midpoint of the study, they were excluded from analysis. 20 participants (71%) completed the study sufficiently to be included in analysis (F\u0026thinsp;=\u0026thinsp;10, M\u0026thinsp;=\u0026thinsp;10; Age\u0026thinsp;=\u0026thinsp;22\u0026thinsp;\u0026plusmn;\u0026thinsp;3 years; BMI\u0026thinsp;=\u0026thinsp;24\u0026thinsp;\u0026plusmn;\u0026thinsp;5). A total of 10 participants (F\u0026thinsp;=\u0026thinsp;7, M\u0026thinsp;=\u0026thinsp;3; Age\u0026thinsp;=\u0026thinsp;23\u0026thinsp;\u0026plusmn;\u0026thinsp;3) volunteered to participate in additional follow-up interviews after the completion of the post-test. All interviews were conducted within one month of post-test completion to allow participants to provide insights based on their recent experience. The study was approved by the University research ethics committee (approval number: LRS/DP-22/23-38283). All participants were informed of the procedures prior to the first visit and given an opportunity to ask questions before signing informed consent.\u003c/p\u003e\n\u003ch3\u003eImmersive VR Exercise\u003c/h3\u003e\n\u003cp\u003eFor this study, the Meta Quest 2 VR headset was used, each with a copy of FitXR [v.3.24.59] installed. During their first visit, participants were shown how to use the headset, including setting up a Wi-Fi connection, drawing a boundary, and charging the headset. They were then guided into the FitXR app, where they were shown how to navigate the menus. Participants were then able to complete three tutorial classes built into the app (Boxing, Dance, and HIIT). These tutorials took two minutes each to complete. To allow some personal preference and more accurately capture real behaviour while using the headset, while also controlling for the intensity and duration of exercise completed, participants were asked to choose an exercise plan they wished to complete based on the familiarisation. Each exercise plan was matched for workout time and intensity but consisted of 75% their preferred exercise style (boxing, dance, or HIIT) and 12.5% of each other style. This was to give participants the flexibility to choose their preferred style, whilst also still providing a comprehensive use of multiple class styles available in the app. Fourteen participants chose boxing, three chose dance, and three chose HIIT.\u003c/p\u003e\n\u003ch3\u003eMeasures\u003c/h3\u003e\n\u003cdiv id=\"Sec7\" class=\"Section2\"\u003e\u003ch2\u003eInitial efficacy measures taken at pre-, mid-, and post-testing\u003c/h2\u003e\u003cp\u003e\u003cb\u003ePhysical Activity.\u003c/b\u003e The General Practice Physical Activity Questionnaire (GPPAQ; Department for Health) was used to capture the physical activity levels of our participants. The questionnaire provides a 4-level physical activity index (PAI), categorising participants as inactive (1), moderately inactive (2), moderately active (3), or active (4). The Leisure Time Physical Activity Questionnaire (LTPAQ, Godin, \u003cspan citationid=\"CR25\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) was used to measure participants' leisure-time physical activity \u0026ndash; physical activity undertaken in an individual\u0026rsquo;s free time. This scale categorises individuals as insufficiently active (1), moderately active (2), or active (3).\u003c/p\u003e\u003cp\u003e\u003cb\u003eAttitudes and Self-Efficacy.\u003c/b\u003e The Attitudes towards Exercise questionnaire (AtE, Kwan \u0026amp; Bryan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) was used to capture participants' views towards doing physical activity. The questionnaire consists of 5 items; each marked on a 7-point Likert scale (strongly disagree \u0026ndash; strongly agree). An average score is then computed from these responses, giving everyone an AtE score, with lower scores corresponding to lower enjoyment of exercise. The Exercise Self-Efficacy scale (ESE, Kwan \u0026amp; Bryan, \u003cspan citationid=\"CR37\" class=\"CitationRef\"\u003e2010\u003c/span\u003e) was used to capture participants' beliefs in their capability to perform exercise, even when facing obstacles such as a lack of time. An average score is computed from the 7-item questionnaire, with lower numbers meaning low self-efficacy (0), and higher numbers meaning high self-efficacy (7).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePhysical Fitness.\u003c/b\u003e Participants completed a cardiopulmonary exercise test on a treadmill (Bowflex, BXT56) using a Modified Balke protocol (Balke \u0026amp; Ware, \u003cspan citationid=\"CR2\" class=\"CitationRef\"\u003e1959\u003c/span\u003e). Following measurement of height and body mass, participants would either walk at 3mph (females) or 3.4mph (males), and the incline would increase 2%/min until 20%, at which point speed would then increase by 0.2mph/min until volitional exhaustion. All participants were instructed and verbally encouraged to continue until exhaustion. Heart rate (Polar H10) and respiratory variables (Metamax 3B) were continually recorded throughout the test. The metabolic cart system (Metamax 3B) was calibrated prior to use, as per manufacturer instructions, and connected to each participant via an oronasal mask (Hans Rudolf). VO\u003csub\u003e2\u003c/sub\u003e max was measured as the highest average VO\u003csub\u003e2\u003c/sub\u003e recorded over a 20 second period during the protocol. Ventilatory threshold 1 (VT1) was assessed using V-slope method and supported by the ventilatory equivalent for oxygen and respiratory exchange ratio (as described by Beaver et al 1986). VO\u003csub\u003e2\u003c/sub\u003e max % pred was established by using standard prediction equations (Wasserman et al 2012).\u003c/p\u003e\u003cp\u003e\u003cb\u003ePsychological Wellbeing.\u003c/b\u003e The Depression, Anxiety and Stress Scale (DASS21, Lovibond \u0026amp; Lovibond, \u003cspan citationid=\"CR43\" class=\"CitationRef\"\u003e1995\u003c/span\u003e) was used to understand participants' psychological well-being. This 21-item scale has 3 subscales (Depression, Anxiety, Stress), each with 7 items. A score can be calculated for each subscale by summing all relevant items and multiplying the score by 2. Participants can then be categorised as Normal, Mild, Moderate, Severe, or Extremely Severe, for each subscale.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec8\" class=\"Section2\"\u003e\u003ch2\u003eAcceptability measures after each exercise session\u003c/h2\u003e\u003cp\u003e\u003cb\u003eAffective Reponses.\u003c/b\u003e A 40-item abbreviated version of the Profile of Mood States Questionnaire (POMS, McNair, et al., \u003cspan citationid=\"CR47\" class=\"CitationRef\"\u003e1971\u003c/span\u003e/1992; POMS40, Grove \u0026amp; Prapavessis, \u003cspan citationid=\"CR28\" class=\"CitationRef\"\u003e1992\u003c/span\u003e) was used to assess participants' mood after each exercise session. The scale consists of 40 items, scored on a 5-point Likert scale. 7 subscales can be derived from these items (Tension, Anger, Fatigue, Depression, Esteem-related Affect, Vigour, and Confusion), which can then be used to calculate a score for Total Mood Disturbance (TMD), with lower scores equating to better mood.\u003c/p\u003e\u003cp\u003e\u003cb\u003eEnjoyment.\u003c/b\u003e An 8-item abbreviated version of the Physical Activity Enjoyment Scale (PACES, Kendzierski \u0026amp; DeCarlo, \u003cspan citationid=\"CR35\" class=\"CitationRef\"\u003e1991\u003c/span\u003e; PACES8, Mullen et al., \u003cspan citationid=\"CR53\" class=\"CitationRef\"\u003e2011\u003c/span\u003e) was used to help us understand participants' enjoyment of each exercise session. This 8-item questionnaire asked participants to rate each item related to exercise enjoyment on a 7-point Likert scale. An average of these scores is then calculated to give a final score of enjoyment, with higher scores translating to higher enjoyment.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab1\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 1\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eMeasures GPPAQ\u0026thinsp;=\u0026thinsp;General Practice Physical Activity Questionnaire. LTPAQ\u0026thinsp;=\u0026thinsp;The Leisure Time Physical Activity Questionnaire. AtE\u0026thinsp;=\u0026thinsp;Attitudes toward exercise. ESE\u0026thinsp;=\u0026thinsp;Exercise self-efficacy. VO2max\u0026thinsp;=\u0026thinsp;maximal exercise test. DASS\u0026thinsp;=\u0026thinsp;Depression, Anxiety, and Stress Scale. POMS\u0026thinsp;=\u0026thinsp;Profile of Mood States. PACES\u0026thinsp;=\u0026thinsp;Physical Activity Enjoyment Scale.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"6\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c6\" colnum=\"6\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/th\u003e\u003cth align=\"left\" colspan=\"5\" nameend=\"c6\" namest=\"c2\"\u003e\u003cp\u003eTime Point\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003ePre-Test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003ePost Session Weeks 1\u0026ndash;4\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003eMid-Test\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003ePost Session Weeks 5\u0026ndash;8\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003ePost-Test\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eGPPAQ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLTPAQ\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eESE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVO\u003csub\u003e2\u003c/sub\u003e Max\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDASS21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePOMS\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePACES\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c4\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e✓\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c6\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003eProcedure\u003c/h3\u003e\n\u003cdiv id=\"Sec10\" class=\"Section2\"\u003e\u003ch2\u003ePre-Test\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab1\" class=\"InternalRef\"\u003e1\u003c/span\u003e summarises measures taken at each time point. Upon arrival at the lab, participants completed a pre-test survey, which captured their physical activity and current attitudes to exercise (GPPAQ, LTPAQ, AtE, and ESES) and their psychological well-being (DASS21). Participants then completed the cardiopulmonary exercise test outlined above. Following recovery, participants were introduced to a VR headset and chose their preferred exercise type. The exercise schedule was explained and shared via access to a cloud-based drive where participants could record their workout completions and find links to questionnaires.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec11\" class=\"Section2\"\u003e\u003ch2\u003eInitial 4 Weeks of Exercise\u003c/h2\u003e\u003cp\u003eParticipants were counterbalanced to exercise in one of two structures: (i) either twice per week supervised sessions in the lab for 30 minutes each, or (ii) 4 times per week independent sessions at home for 15 minutes each, with both structures lasting 4 weeks. For the supervised sessions in the lab, participants were asked to provide availability for their sessions (Monday-Friday between the hours of 9am and 5pm) in advance and encouraged to stick to the times organised. For the home sessions, participants were encouraged to exercise at any time that suited them and were left to complete the sessions autonomously.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec12\" class=\"Section2\"\u003e\u003ch2\u003eMid-Test and Second 4 Weeks of Exercise\u003c/h2\u003e\u003cp\u003eAfter the initial 4 weeks of exercise, participants were once again invited into the lab to carry out their mid-test. This looked identical to the procedure for the pre-test outlined above (except for the VR introduction). Participants then completed another 4 weeks of exercise in the other structure.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec13\" class=\"Section2\"\u003e\u003ch2\u003ePost-Test and Follow Up\u003c/h2\u003e\u003cp\u003eParticipants were then invited into the lab again for their final visit. The post-test looked identical to the procedure of the mid-test, with the addition of a debrief of the study.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec14\" class=\"Section2\"\u003e\u003ch2\u003eFollow-up Interviews to Investigate Acceptability and Feasibility\u003c/h2\u003e\u003cp\u003eParticipants who volunteered were interviewed within one month of the post-test. The semi-structured interviews lasted approximately 30\u0026ndash;40 minutes and were conducted remotely using Microsoft Teams. The formulation of the interview guide involved the application of the COM-B model and Birkhead et al\u0026rsquo;s (2019) approach to developing VR interventions, ensuring coherence with the study's overarching objectives. Secondly, insights from quantitative research on virtual reality within sports and exercise (Qian et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Peng et al., \u003cspan citationid=\"CR56\" class=\"CitationRef\"\u003e2022\u003c/span\u003e) were incorporated to enhance the guide's content. Thirdly, valuable perspectives from previous qualitative studies and interview guides (Bradwell et al., \u003cspan citationid=\"CR7\" class=\"CitationRef\"\u003e2023\u003c/span\u003e, Farič et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) were reviewed to inform the development of relevant questions. (See supplement for complete interview guide).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec15\" class=\"Section2\"\u003e\u003ch2\u003eData Analysis\u003c/h2\u003e\u003cdiv id=\"Sec16\" class=\"Section3\"\u003e\u003ch2\u003eData Cleaning and Imputation\u003c/h2\u003e\u003cp\u003eMissing data primarily occurred due to occasional missed exercise sessions across the 24 measurement points (16 at home, and 8 in the lab). These missing values mainly affected session-level measures (PACES and TMD). Crucially, the missingness did not result from systematic dropout of participants, and all remained enrolled in the study. The missing sessions occurred sporadically and were typically due to external factors such as scheduling conflicts, illness, or unavailability. We deemed these missing sessions not due to participants\u0026rsquo; psychological states, intervention engagement, or responses to prior sessions. Therefore, we determined that the probability of a data point being missing was related to external factors (such as scheduling conflicts) and not related to the values of PACES or TMD themselves, which is consistent with the Missing at Random (MAR) assumption (Rubin, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e1987\u003c/span\u003e). This also aligns with recommendations by Graham (\u003cspan citationid=\"CR26\" class=\"CitationRef\"\u003e2009\u003c/span\u003e) and Enders (\u003cspan citationid=\"CR19\" class=\"CitationRef\"\u003e2010\u003c/span\u003e), who suggest that MAR is a reasonable and practical assumption when missingness is due to external/logistical factors. They also recommend that auxiliary variables are included to inform the imputation model when data is MAR, which was carried out in the analysis.\u003c/p\u003e\u003cp\u003eGiven the assumption that the data was MAR, we used multiple imputations to account for missingness and reduce potential bias (Rubin, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e1987\u003c/span\u003e). We conducted our multiple imputations using the \u0026lsquo;mice\u0026rsquo; package in \u0026lsquo;R\u0026rsquo;, generating 5 imputed datasets (Graham et al., \u003cspan citationid=\"CR27\" class=\"CitationRef\"\u003e2007\u003c/span\u003e). The imputation model used predictive mean matching (PMM) for continuous variables to ensure imputed variables were within the range of observed data, and logistic regression was applied to categorical variables. To ensure the accuracy of the imputed datasets, comparisons were made between complete data and imputed data. No significant differences were observed between the imputed and complete data cases. Analysis was performed on each of the five imputed datasets, and results were pooled according to Rubin\u0026rsquo;s rules (Rubin, \u003cspan citationid=\"CR63\" class=\"CitationRef\"\u003e1987\u003c/span\u003e) to obtain final statistics.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec17\" class=\"Section2\"\u003e\u003ch2\u003eQuantitative Analysis\u003c/h2\u003e\u003cp\u003eTo analyse acceptability and feasibility, a two-condition (home-organised or organised-home) by eight time point (weeks of intervention) repeated measures ANOVA was performed to evaluate the within-subject effects of time (week) and condition order on the percentage of the exercise plan that was completed. Bonferroni corrections were used in all post hoc analyses. The counterbalanced crossover design accounted for any order effects, so for further efficacy analysis, we treat participants as a single group. Partial eta squared (ηp\u003csup\u003e2\u003c/sup\u003e) was used to measure effect sizes for ANOVAs (F tests), with Cohen\u0026rsquo;s d used for pairwise comparisons. We set an alpha level (p) of .05.\u003c/p\u003e\u003cp\u003eDue to the desire to account for individual variability in our analysis, we used linear mixed-effects (LMM) models to analyse all dependent variables for physical activity, enjoyment, affective responses, and psychological and physical wellbeing. Our focus was on the effects of the intervention on physical and psychological variables over time; therefore, we included random intercepts for participants, age, and BMI. Modelling age and BMI as random intercepts provide a parsimonious way to account for minor between-subject heterogeneity without overfitting the model or drawing attention to secondary variables. Assumption checks across all primary LMMs were conducted using diagnostic plots (e.g., residual vs. fitted values, Q-Q plots) and collinearity diagnostics (Variance Inflation Factors) for fixed effects. These checks indicate that model residuals were approximately normally distributed with no substantial heteroscedasticity. A small degree of heteroscedasticity was observed at the upper range of fitted values for some LMMs. Still, given the limited number of data points in this range and the general robustness of LMMs to such violations, the model was retained. Multicollinearity was not a concern, with all VIF values well below commonly accepted thresholds.\u003c/p\u003e\u003cp\u003eTo analyse changes in enjoyment and affective responses to workouts over time, two LMMs were fitted to assess the relationship between the predictor variables of time and total sessions completed on enjoyment (PACES) and Total Mood Disturbance (TMD). To analyse initial efficacy of VR exercise on physical activity, psychological wellbeing, and physical fitness, we used LMMs with separately considered dependent variables of PAI (Physical activity index), LTE (Leisure time activity), AtE (Attitudes toward exercise), ESE (Exercise self-efficacy), D (DASS depression subscale), A (DASS anxiety subscale), S (DASS stress subscale), VO2 (maximum oxygen consumption), and VT1 (ventilatory threshold). The mixed-effects models included fixed effects for time point (pre-, mid-, or post-test), and total completion percentage. They also included random intercepts for participant, age, and BMI to account for between-subject variability. All LMM\u0026rsquo;s were computed using the \u0026lsquo;lme4\u0026rsquo; package in \u0026lsquo;R\u0026rsquo;. The models were estimated using restricted maximum likelihood, which is commonly used when estimating variance. Cohen\u0026rsquo;s d with 95% confidence intervals was used to calculate post-hoc effect size estimates of differences between pre-, mid-, and post-tests.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec18\" class=\"Section2\"\u003e\u003ch2\u003eInterview Analysis\u003c/h2\u003e\u003cp\u003eThe follow-up interviews were transcribed through Microsoft Teams, with any grammatical changes made as necessary. A two-stage reflexive analysis approach was used (Braun \u0026amp; Clarke \u003cspan citationid=\"CR8\" class=\"CitationRef\"\u003e2006\u003c/span\u003e, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e), allowing for themes to be identified from the raw data. It is a common assumption that one needs to choose an inductive or deductive approach, but it is rarely possible for an analysis to neatly fall into one approach (Braun \u0026amp; Clarke, \u003cspan citationid=\"CR9\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Byrne, \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e). Here we have used a predominantly inductive approach, but a degree of deductive analysis was employed to ensure the open-coding contributed themes that are meaningful to the research question (Byrne \u003cspan citationid=\"CR12\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Rasheed \u0026amp; Runswick., 2024). The combination of approaches allows for the data to drive new themes, but ensures themes are relevant to the research question (Fereday \u0026amp; Muir-Cochrane, \u003cspan citationid=\"CR21\" class=\"CitationRef\"\u003e2006\u003c/span\u003e).\u003c/p\u003e\u003c/div\u003e"},{"header":"Results","content":"\u003cdiv id=\"Sec20\" class=\"Section2\"\u003e\u003ch2\u003eAcceptability \u0026amp; Feasibility of VR Exercise Programme\u003c/h2\u003e\u003cdiv id=\"Sec21\" class=\"Section3\"\u003e\u003ch2\u003eCompletion of Exercise Sessions\u003c/h2\u003e\u003cp\u003eOf the 28 people who volunteered to take part, eight dropped out during the first half of the programme and 20 completed testing at each time point. One participant dropped out due to a perceived negative response to the repeated use of VR, potentially interacting with an existing problem with migraines. The other participants dropped out for a range of practical reasons.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e shows completion rates of participants on each arm of the crossover. There was a significant main effect of week on completion of exercise sessions (\u003cem\u003eF\u003c/em\u003e(7, 126)\u0026thinsp;=\u0026thinsp;8.262, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, \u003cem\u003eη\u003c/em\u003e\u003csub\u003e\u003cem\u003ep\u003c/em\u003e\u003c/sub\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.315). Post-hoc analysis showed there was significantly less sessions were completed in week 6 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.002, d\u0026thinsp;=\u0026thinsp;1.273), week 7 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.001, d\u0026thinsp;=\u0026thinsp;1.304), and week 8 (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;.001, d\u0026thinsp;=\u0026thinsp;1.335) compared to week 1. This was driven by a week-by-crossover order interaction effect (F(7, 126)\u0026thinsp;=\u0026thinsp;2.853, p\u0026thinsp;=\u0026thinsp;.009, ηp2\u0026thinsp;=\u0026thinsp;0.137), where the arm that completed home exercise first and organised sessions for the second four weeks maintained higher engagement than the arm that completed supervised sessions first. However, there was no significant overall between-subject effect of crossover order (\u003cem\u003eF\u003c/em\u003e(1, 18)\u0026thinsp;=\u0026thinsp;3.695, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;.071, \u003cem\u003eη\u003c/em\u003e\u003csub\u003e\u003cem\u003ep\u003c/em\u003e\u003c/sub\u003e\u003csup\u003e\u003cem\u003e2\u003c/em\u003e\u003c/sup\u003e\u0026thinsp;=\u0026thinsp;0.170).\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec22\" class=\"Section2\"\u003e\u003ch2\u003eExploratory Analysis for Completion Rates\u003c/h2\u003e\u003cp\u003eDuring the study, we observed that participants with the lowest levels of exercise self-efficacy and the lowest starting physical fitness levels seemed to be more engaged in the intervention. To investigate this further, we conducted some exploratory analysis using Pearson\u0026rsquo;s correlations between pre-test measures of exercise self-efficacy and physical fitness (VO2 max) and total number of sessions completed (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e). Results showed that exercise self-efficacy negatively correlated with session completion (r = -0.616, p\u0026thinsp;=\u0026thinsp;0.002). Participants with lower confidence in their ability to exercise completed more sessions than those with higher confidence. Similarly, we found that VO2max at pre-test negatively correlated with total session completion (r = -0.502, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001). Those with lower physical fitness at the pre-test completed more total exercise sessions.\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec23\" class=\"Section3\"\u003e\u003ch2\u003eEnjoyment of Individual Exercise Sessions\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e (left) shows the enjoyment of exercise sessions over time. The model indicates that the intercept is significantly different from zero (estimate\u0026thinsp;=\u0026thinsp;4.98, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;\u0026lt;\u0026thinsp;0.001), indicating a baseline PACES score of 4.98 when other predictors are zero. The effect of time (estimate\u0026thinsp;=\u0026thinsp;0.055, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.083) suggests non-significant trend toward enjoyment increasing over time. The effect of total session completion (estimate\u0026thinsp;=\u0026thinsp;0.0049, \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.621) was non-significant.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec24\" class=\"Section2\"\u003e\u003ch2\u003eAffective Responses to Individual Exercise Sessions\u003c/h2\u003e\u003cp\u003eFigure \u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e (right) shows TMD scores over time (high scores are a more positive mood after exercise). The model indicated that while the intercept reveals a significant baseline TMD score of 95.72, neither the effect of time nor the total sessions completed has a statistically significant impact on TMD scores (\u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.382 and \u003cem\u003ep\u003c/em\u003e\u0026thinsp;=\u0026thinsp;0.802, respectively).\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003cdiv id=\"Sec25\" class=\"Section3\"\u003e\u003ch2\u003eInitial Efficacy of VR Exercise Programme\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab2\" class=\"InternalRef\"\u003e2\u003c/span\u003e presents the estimated means\u0026thinsp;\u0026plusmn;\u0026thinsp;SE for all the dependent variables and fixed effects of time and competition percentage. Figure\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e shows the effect sizes of change between each measurement point across physical activity, psychological well-being, and physical health measures. The full descriptive statistics for all variables and full reports of effect sizes can be found in the supplementary materials. From pre- to mid-test, we found medium positive effects for both LTE (d\u0026thinsp;=\u0026thinsp;0.596, 95% CI [0.113, 1.066]) and VO2 (d\u0026thinsp;=\u0026thinsp;0.569, 95% CI [0.089, 1.036]). In the second four weeks, when engagement was lower, there were no significant changes. Figure\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003eC demonstrates effects across the full eight weeks from pre- to post-test. These show a medium positive effect for increased leisure time activity (d\u0026thinsp;=\u0026thinsp;0.656, 95% CI [0.122, 1.174]) and a medium negative effect for anxiety (d = -0.532, 95% CI [-1.034, -0.016]). This suggests that over the course of the 8-week intervention, participants engaged in more physical activity and experienced reduced levels of anxiety compared to the pre-test. Overall effect size trends suggest possible reductions in anxiety, depression, and stress and possible increases in exercise self-efficacy, physical activity, and physical fitness.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab2\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 2\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eEstimated means\u0026thinsp;\u0026plusmn;\u0026thinsp;SE for activity, psychological and physical health variables. PAI\u0026thinsp;=\u0026thinsp;Physical activity index calculated from GPPAQ. LTE\u0026thinsp;=\u0026thinsp;Leisure time activity. AtE\u0026thinsp;=\u0026thinsp;Attitudes toward exercise. ESE\u0026thinsp;=\u0026thinsp;Exercise self-efficacy. D\u0026thinsp;=\u0026thinsp;DASS depression subscale. A\u0026thinsp;=\u0026thinsp;DASS anxiety subscale. S\u0026thinsp;=\u0026thinsp;DASS stress subscale. VO2\u0026thinsp;=\u0026thinsp;VO2max. VT1\u0026thinsp;=\u0026thinsp;ventilatory threshold.\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"3\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVariable\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eTime Estimate (SE)\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eCompletion Estimate (SE)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePre-Mid-Post\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.05 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLTE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.24 (0.07)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.02 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eESE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.17 (0.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.02 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.46 (0.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.04 (0.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.17 (0.72)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.03 (0.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.76 (0.73)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.07 (0.09)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.43 (1.90)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.14 (0.30)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.63 (0.91)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.23 (0.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePre-Mid\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.05 (0.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.02 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLTE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.35 (0.13)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.00 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.12 (0.15)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eESE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.24 (0.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.03 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.70 (1.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.03 (0.08)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.30 (1.45)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.02 (0.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.90 (1.19)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.07 (0.08)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e10.15 (3.84)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.18 (0.31)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.47 (1.59)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.22 (0.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eMid-Post\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.16 (0.17)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLTE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.12 (0.08)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.01 (0.00)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.08 (0.20)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eESE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.05 (0.21)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.35 (1.18)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.08 (0.06)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.67 (1.41)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.04 (0.08)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.59 (1.47)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.06 (0.09)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-2.58 (2.94)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.14 (0.26)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.04 (2.00)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.24 (0.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003ePre-Post\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePAI\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.04 (0.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eLTE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.24 (0.09)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.00 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAtE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.02 (0.10)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.00 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eESE\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.19 (0.11)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.03 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eDepression\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.55 (0.79)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.03 (0.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eAnxiety\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.47 (0.64)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.11 (0.07)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eStress\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-1.01 (0.85)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.10 (0.09)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVO\u003csub\u003e2\u003c/sub\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e4.16 (1.75)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.10 (0.35)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eVT1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.38 (0.82)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.21 (0.08)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e\u003cb\u003eWeekly\u003c/b\u003e\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u0026nbsp;\u003c/td\u003e\u003ctd align=\"left\" colname=\"c3\"\u003e\u0026nbsp;\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003eTMD\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e-0.26 (0.34)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e-0.09 (0.17)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePACES\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c2\"\u003e\u003cp\u003e0.04 (0.03)\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e0.01 (0.01)\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec26\" class=\"Section3\"\u003e\u003ch2\u003eInterview Analysis\u003c/h2\u003e\u003cp\u003eTable\u0026nbsp;\u003cspan refid=\"Tab3\" class=\"InternalRef\"\u003e3\u003c/span\u003e displays the participant characteristics of those who volunteered to complete follow up interviews. Figure\u0026nbsp;\u003cspan refid=\"Fig6\" class=\"InternalRef\"\u003e6\u003c/span\u003e shows the results of the thematic analysis where eight themes were identified, five relating to the acceptability of VR exercise, and one for each of feasibility, tolerability, and initial efficacy.\u003c/p\u003e\u003cp\u003e\u003cdiv class=\"gridtable\"\u003e\u003ctable float=\"Yes\" id=\"Tab3\" border=\"1\"\u003e\u003ccaption language=\"En\"\u003e\u003cdiv class=\"CaptionNumber\"\u003eTable 3\u003c/div\u003e\u003cdiv class=\"CaptionContent\"\u003e\u003cp\u003eParticipant characteristics for interviews\u003c/p\u003e\u003c/div\u003e\u003c/caption\u003e\u003ccolgroup cols=\"5\"\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c1\" colnum=\"1\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c2\" colnum=\"2\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c3\" colnum=\"3\"\u003e\u003c/div\u003e\u003cdiv align=\"char\" char=\".\" class=\"colspec\" colname=\"c4\" colnum=\"4\"\u003e\u003c/div\u003e\u003cdiv align=\"left\" class=\"colspec\" colname=\"c5\" colnum=\"5\"\u003e\u003c/div\u003e\u003cthead\u003e\u003ctr\u003e\u003cth align=\"left\" colname=\"c1\"\u003e\u003cp\u003ePPT_ID\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c2\"\u003e\u003cp\u003eGender\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c3\"\u003e\u003cp\u003eAge\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c4\"\u003e\u003cp\u003eBMI\u003c/p\u003e\u003c/th\u003e\u003cth align=\"left\" colname=\"c5\"\u003e\u003cp\u003eWorkouts completed (%)\u003c/p\u003e\u003c/th\u003e\u003c/tr\u003e\u003c/thead\u003e\u003ctbody\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e1\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e29\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.59\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e56.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e2\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.06\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e87.5\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e7\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e33.3\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e90.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e9\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e23.14\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e71.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e16\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e25.56\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e18\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e34\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e36.51\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e96.88\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eMale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e30.49\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e56.25\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e23\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e19\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e21.21\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e68.75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e24\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e22\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e26.67\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e75\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003ctr\u003e\u003ctd align=\"left\" colname=\"c1\"\u003e\u003cp\u003e26\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c2\"\u003e\u003cp\u003eFemale\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c3\"\u003e\u003cp\u003e20\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"char\" char=\".\" colname=\"c4\"\u003e\u003cp\u003e20.11\u003c/p\u003e\u003c/td\u003e\u003ctd align=\"left\" colname=\"c5\"\u003e\u003cp\u003e65.63\u003c/p\u003e\u003c/td\u003e\u003c/tr\u003e\u003c/tbody\u003e\u003c/colgroup\u003e\u003c/table\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003e\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec27\" class=\"Section3\"\u003e\u003ch2\u003eAcceptability\u003c/h2\u003e\u003cp\u003eParticipants discussed five key factors relating to their willingness to use FitXR for exercise: gamification, novelty, features of the app, presence and immersion, and the social elements of exercise. While generally positive in their acceptance of using VR for exercise, a number of these sub-themes feature both positive and negative opinions from participants.\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\u003cdiv id=\"Sec28\" class=\"Section2\"\u003e\u003ch2\u003eGamification\u003c/h2\u003e\u003cp\u003eGamification refers to using game-design elements to motivate individuals to engage in a behaviour in another setting. In this case, FitXR offers gamified exercise through several features, including animations, a leaderboard, and score multipliers. For example, when discussing their enjoyment of receiving feedback and higher scores for putting in more effort, participant 23 said:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eAlso, for the boxing, they have that little fire for every punch if you do it like harder, like a full hotter punch. And I really enjoyed that it was satisfying. And like the harder you punch the higher you score.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eOverall, the gamification approach was positively received because participants found it \u0026ldquo;fun because you're not thinking that you're doing exercise, you're just thinking you're playing a game\u0026rdquo; (P26). The use of scoring was popular with participants motivated by maintaining and beating their personal high scores and streaks: \u0026ldquo;I think the biggest motivator is the sort of streaks and beating your score in streak and coming back to try and be better \u0026hellip; there's something very, very, very satisfying about long streaks\u0026rdquo; (P18).\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec29\" class=\"Section2\"\u003e\u003ch2\u003eApp Features\u003c/h2\u003e\u003cp\u003eAlongside gamification elements, participants discussed other app features that affected their acceptability of using FitXR. These ranged from fundamental features like the instructions, music, and haptic feedback. For example, participant 16 discussed the benefits of feedback, stating, \u0026ldquo;I did the boxing plan like hitting the targets and then like they have the like vibration thing so that it feels like you're actually hitting something\u0026rdquo; (P16). The presence of a virtual trainer added to this sense of engagement \u0026ldquo;I feel more engaged with the VR too, because it felt like the trainer was actually going through things with me directly\u0026rdquo; (P23). The relatability of the instructors was also proposed to impact perceptions of FitXR, as evidenced by participant 18, who said, \u0026ldquo;I really like that the app includes a disabled trainer\u0026rdquo;. This was reiterated when other participants highlighted that their participation was negatively impacted because the instructor \u0026ldquo;just felt very corny and American in all honesty, maybe if they had a British accent, it would be less annoying\u0026rdquo; (P26).\u003c/p\u003e\u003cp\u003eOne element where participants did have autonomy in the programme was the virtual location in which they completed their workout. Participants liked that FitXR allowed them to complete a specific workout in a range of locations (e.g., a virtual gym, rooftop, beach). This was highlighted by participant 24 who stated, \u003cem\u003e\u0026ldquo;\u003c/em\u003eI like that you could choose like where you're doing the class like... on like this... The rooftop and then like on the ice rink or something.\u0026rdquo; Participants also identified reasons why the choice of location impacted positively on their engagement in FitXR, with some highlighting that it gave them the feeling of being outdoors despite physically being indoors: \u0026ldquo;I find myself going more towards the open spaces\u0026rdquo; (P18).\u003c/p\u003e\u003cp\u003eHowever, not all elements of the app received positive feedback. Some participants struggled to follow auditory instructions without visual demonstrations or specific feedback on their own efforts. Participant 23 illustrated this, stating they \u0026ldquo;need to see the first movement from the trainer first. I got a bit disconnected with the verbal command and the actual movement I have to do.\u0026rdquo; Other participants experienced technical issues with the app that negatively affected their experience of using VR for exercise. For instance, for participant 3 \u0026ldquo;the VR wasn\u0026rsquo;t picking up...even if I was doing the correct movement...my timing was off.\"\u003c/p\u003e\u003c/div\u003e\n\u003ch3\u003ePresence and immersion\u003c/h3\u003e\n\u003cp\u003e Aligned with the importance of location discussed in the previous theme, participants identified immersion and presence (i.e., the feeling of being physically present in another place) as central to their engagement with FitXR. In this vein, participant 18 reported experiencing a sense of \u0026ldquo;being in a different place [...] There was something about the vastness of some of these environments.\u0026rdquo; Several participants highlighted how VR was more beneficial than other at-home workout formats (e.g., video-guided workouts) because they were \u0026ldquo;fully engaged with it compared to when I have done like yoga videos for example, I get distracted sometimes\u0026rdquo; (P23).\u003c/p\u003e\u003cdiv id=\"Sec31\" class=\"Section2\"\u003e\u003ch2\u003eSocial elements\u003c/h2\u003e\u003cp\u003eThe lack of interaction with others while using FitXR was considered as both positive and negative. For those who were uncomfortable exercising around others, lack of interaction was positive with participant 22 stating they were \u0026ldquo;very self-conscious\u0026hellip; And so I'm always thinking are they looking at me, are they watching? I think that definitely did help\u0026rdquo;. Additionally, participant 23 described having tried the gym and how they \u0026ldquo;feel pressured when I go to the gym. There's lot of people watching. But VR was completely different.\u0026rdquo;\u003c/p\u003e\u003cp\u003eIn contrast, the lack of social interaction during workouts left some participants feeling isolated. For example, participant 1\u0026rdquo; missed that human contact and connection [during exercise]. For me really like sport is a social thing because most of the activities I do I do with friends\u0026rdquo;. As such, some participants felt that social interaction should be built into VR designs. This was illustrated by participant 18 who said, \u0026ldquo;I think it would be amazing if you could actually do it with someone [...] to have like scheduled times where the same people show up.\u0026rdquo; This does exist in many applications but is something we chose to control here just including the trainer and virtual avatars which for participant 23 reduced their sense of isolation because \u0026ldquo;you have a lot of like different players around you, so it isn\u0026rsquo;t an isolated environment.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec32\" class=\"Section2\"\u003e\u003ch2\u003eNovelty\u003c/h2\u003e\u003cp\u003eNovelty was also perceived as central to participants' experiences of FitXR. This was evidenced by participant 26, who explained, \u0026ldquo;I think 'cause it's [FitXR] quite novel and something that you don't get to do that often, that it was like quite exciting to do it.\u0026rdquo; However, for some participants, motivation decreased as the novelty wore off. For example, participant 1 \u0026ldquo;found it really enjoyable the first week because it was something new [...] and I think then my motivation slowly decreased over time.\u0026rdquo; However, the app did offer ways for participants to maintain novelty within the prescribed workouts due to choices (discussed in the \u0026lsquo;App feature\u0026rsquo; sub-theme) provided by the app. Indeed, for participant 26 their motivation was maintained because they \u0026ldquo;got to pick the background every time. So it kind of made it not get too boring because you could shake things up each time.\u0026rdquo;\u003c/p\u003e\u003cdiv id=\"Sec33\" class=\"Section3\"\u003e\u003ch2\u003eFeasibility\u003c/h2\u003e\u003cp\u003eAs well as the factors that impacted the acceptability of FitXR, the ability to effectively integrate VR exercise into their everyday lives was deemed important to participants\u0026rsquo; engagement. Specifically, participants discussed the convenience of being able to integrate VR exercise into their routines and the ability to exercise at home was perceived as important.\u003c/p\u003e\u003c/div\u003e\u003cdiv id=\"Sec34\" class=\"Section3\"\u003e\u003ch2\u003eConvenience\u003c/h2\u003e\u003cp\u003eThe convenience of being able to workout from home was deemed important to participants\u0026rsquo; adherence to the programme. Participant 22 found the ability to workout from home helped them adhere to the programme \u0026ldquo;because I was just doing it literally 2 feet away from my bed\u0026rdquo;. Other benefits of working out from home included the ability to exercise without the need for equipment and being able to try different things without needing to attend organised sessions. This was evidenced by participant 1:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eyou have the variety of things and exercises that you can do, like you don't have to depend on if this class is on and if you be able to make it there on time, you can just choose and do whatever you want, which is I think big advantage.\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eMany participants enjoyed the brevity of the exercise sessions compared to other options for exercise like the gym, with participant 7 saying they \u0026ldquo;more looked forward to doing the short 15-minute exercises, than I would like to get up and get the motivation to go to the gym.\u0026rdquo;. However, some participants found the short workouts inconvenient because it meant they needed to fit more sessions into their schedule. For example, participant 1 commented, \u0026ldquo;I just didn't find the right way to maybe put it into my schedule four times a week.\u0026rdquo;\u003c/p\u003e\u003cp\u003eSome participants also struggled to complete sessions at home due to the lack of an appropriate space, which reduced their comfort level to engage in exercises and increased safety concerns. For example, discussing this issue participant 22 said, \u0026ldquo;I had to be careful with furniture, I had to make sure not to punch the TV or whatever by accident.\u0026rdquo; However, some participants got used to this over time, as participant 7 described \u0026ldquo;the first week I was more trying to think about my surroundings and stuff like that, afterwards it was just easier to focus on the exercise and VR.\u0026rdquo; Additionally, factors such as internet connection impacted engagement with participant 23, saying \u0026ldquo;because I live in a student accommodation, obviously there would be Wi-Fi disruption.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e\n\u003ch3\u003eTolerability\u003c/h3\u003e\n\u003cp\u003eAs well as the pragmatics of fitting VR exercise into their everyday lives, participants also identified the hardware as something that negatively impacted their engagement with the workouts. While no participants reported simulation sickness during their familiarisation sessions, certain factors related to the HMD negatively impacted their experience.\u003c/p\u003e\n\u003ch3\u003eHardware discomfort\u003c/h3\u003e\n\u003cp\u003eParticipants discussed some negative aspects of exercising while wearing the Meta Quest 2 headset. Specifically, participants experienced discomfort due to the sweat created by the headset and the headset moving too much. For example, participant 24 suggested that \u0026ldquo;if you're really going for it [during exercise], then, like, the sweat like drips down. It's not very nice.\u0026rdquo;\u003c/p\u003e\u003cp\u003eAnother issue with the hardware was maintaining a clear picture, as illustrated by participant 26, who stated, \u0026ldquo;There are a few times where I think the headset looked a bit blurry and it felt a bit clumpy and that makes it a little bit awkward at times.\u0026rdquo; Screen issues led some participants to experience simulation sickness when working out at home. This was illustrated by participant 1 who \u0026ldquo;found it quite hard to have all the screen time, I found sometimes I was almost like getting dizzy\u0026rdquo;.\u003c/p\u003e\u003cdiv id=\"Sec37\" class=\"Section2\"\u003e\u003ch2\u003eInitial Efficacy\u003c/h2\u003e\u003cp\u003eAlongside speaking to the pragmatic and practical factors that impacted their engagement in VR exercise, participants also discussed potential psychological benefits of using FitXR.\u003c/p\u003e\u003cdiv id=\"Sec38\" class=\"Section3\"\u003e\u003ch2\u003ePsychological benefits\u003c/h2\u003e\u003cp\u003eParticipants discussed a range of psychological benefits of taking part in virtual exercise. For example, participant 23 discussed how the exercise helped them with \u003cem\u003e\u0026ldquo;\u003c/em\u003ethe burdens of the day kind of got taken out from my brain and my body and I'm just immersed in this exercise.\u003cem\u003e\u0026rdquo;\u003c/em\u003e Additionally, engagement in VR exercise was also perceived to have an impact on participants\u0026rsquo; mood post exercise, with participant 1 outlining that \u0026ldquo;when I finished, I really feel like, you know, happy and good and positive\u0026hellip; I found that it had really good like immediate effect.\u0026rdquo; These positive responses were often attributed to the distraction or escapism element of VR exercise:\u003cdiv class=\"BlockQuote\"\u003e\u003cp\u003eit's kind of acts like a bit of escapism\u0026hellip;it's a nice rest, a nice break from what you're doing, nice stress reliever, just to think about something different for 15 minutes\u0026hellip;I think it helped in exam season actually because it was like something to distract me from being stressed about my tests (P26).\u003c/p\u003e\u003c/div\u003e\u003c/p\u003e\u003cp\u003eWhile some participants identified only these acute benefits, others discussed longer-term benefits (e.g., reduced stress, increased confidence and motivation). Indeed, participant 23 \u0026ldquo;found it helped me manage my stress. And yeah, I think I've become quite like a happier person.\u0026rdquo; Participants also discussed how the benefits extended to motivation in other areas of their lives. For example, participant 7 experienced University-associated improvements, especially from organised sessions because \u0026ldquo;it kind of gives me more motivation to because it was on campus as well, I felt like, it gave me more motivation to, like, complete more tasks afterwards.\u0026rdquo; Participants also perceived engagement in the programme to impact their exercise behaviour. For example, participant 7 discussed paying more attention to their physical activity levels outside of Fit XR, stating, \u0026ldquo;before the study, I wasn't really thinking about how active I was, but after the FitXR exercises, I also started thinking about how many steps I've taken.\u0026rdquo;\u003c/p\u003e\u003c/div\u003e\u003c/div\u003e"},{"header":"Discussion","content":"\u003cp\u003eThis study evaluated the acceptability and feasibility for young adults to change their exercise behaviour using the FitXR\u0026trade; VR exercise app, and the initial impacts this had on physical activity, exercise self-efficacy, and health, using a mixed methods approach. We captured acceptability and feasibility through completion rates of the exercise programme, enjoyment and mood responses for every organised session and use at home. For initial efficacy, we measured exercise self-efficacy, physical activity, physical fitness and psychological well-being pre-intervention, at four weeks, and eight weeks. A subset of participants completed follow-up interviews to offer an in-depth understanding of their experiences.\u003c/p\u003e\u003cp\u003eWhen engaging with the intervention, individuals expressed an overall positive range of opinions about engaging in exercise using VR. Participants showed VR exercise was acceptable and feasible to fit into their lives, either at home or in supervised sessions. It was particularly beneficial to give participants autonomy to work out at home first and then integrate organised sessions later. Data supported initial efficacy and a range of previous research by showing early improvements in both physical fitness and psychological well-being (Maden et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ng et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Qian et al., \u003cspan citationid=\"CR58\" class=\"CitationRef\"\u003e2020\u003c/span\u003e; Xu et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). However, these effects were primarily shown early in the study and began to reduce over time.\u003c/p\u003e\u003cp\u003eThe participants' acceptability of and willingness to use VR, and the feasibility with which participants could integrate the intervention into their day-to-day living were captured by completion of sessions, enjoyment of sessions, affective responses to exercise, and qualitative responses (Birckhead et al., \u003cspan citationid=\"CR5\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Fig.\u0026nbsp;\u003cspan refid=\"Fig2\" class=\"InternalRef\"\u003e2\u003c/span\u003e). Overall, 71% of participants who started completed the study, with an average rate of 66% of prescribed exercise sessions completed. Engagement in the exercise sessions did decrease over time, particularly for the group that received four weeks of supervised sessions followed by four weeks at home unsupervised. This mirrors existing literature that finds dropout rates for supervised exercise interventions for mental health sit at 18\u0026ndash;25% (Stubbs et al., \u003cspan citationid=\"CR73\" class=\"CitationRef\"\u003e2016\u003c/span\u003e; Vancampfort et al., \u003cspan citationid=\"CR78\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), but around at around 50% of users aiming to take up exercise independently will have dropped out after the equivalent of eight weeks. These rates can be higher when participants have lower previous levels of physical activity and higher BMI (Sperandei et al., \u003cspan citationid=\"CR70\" class=\"CitationRef\"\u003e2016\u003c/span\u003e). However, exploratory analysis (Fig.\u0026nbsp;\u003cspan refid=\"Fig3\" class=\"InternalRef\"\u003e3\u003c/span\u003e) here suggested participants with the lowest exercise self-efficacy and lowest physical fitness at the start of the intervention completed more of exercise sessions. A more in-depth understanding of how individual differences affect responses to VR interventions is warranted in future work.\u003c/p\u003e\u003cp\u003eWhile completion rates are helpful to understand the acceptability and feasibility over eight weeks, the affective attitude and enjoyment are key elements for future engagement in exercise and the likelihood of purchasing VR (Gardner \u0026amp; Lally, \u003cspan citationid=\"CR24\" class=\"CitationRef\"\u003e2012\u003c/span\u003e; Lee et al., \u003cspan citationid=\"CR39\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Sekhon et al., \u003cspan citationid=\"CR69\" class=\"CitationRef\"\u003e2017\u003c/span\u003e). When participants did engage in sessions, they maintained high levels of enjoyment and reported positive affective responses to each session (Fig.\u0026nbsp;\u003cspan refid=\"Fig4\" class=\"InternalRef\"\u003e4\u003c/span\u003e). These findings support a wide range of literature that has reported enhanced levels of enjoyment and positive affect when engaging in acute bouts of exercise in immersive settings (Bird et al., \u003cspan citationid=\"CR6\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Barbour et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Runswick et al., \u003cspan citationid=\"CR65\" class=\"CitationRef\"\u003e2023\u003c/span\u003ea; Teixeira et al., \u003cspan citationid=\"CR75\" class=\"CitationRef\"\u003e2024\u003c/span\u003e) but also exemplify the need for long-term studies. Here, it was not the enjoyment of the exercise itself that was driving engagement, but the opportunity or motivation to start the session in the first place. Findings suggest that previous work on more structured interventions may not fully reflect the realities of engaging in exercise outside the lab (Maden et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ng et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Riches et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Xu et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e). In interviews, the participants reported that the gamification, presence in sessions that enhanced engagement and concentration, and the ability to fit exercise into the routine using short sessions and sessions at home had a positive impact on motivation and opportunity to exercise, but for the young people we studied here, many had barriers around sufficient space to exercise at home. The findings support previous work in exergames (Farič et al., \u003cspan citationid=\"CR20\" class=\"CitationRef\"\u003e2019\u003c/span\u003e) but extend to include specific issues related to the use of HMDs and working out at home.\u003c/p\u003e\u003cp\u003eHere, we captured participants perceived outcomes in qualitative data and initial evidence for efficacy in quantitative data (see Fig.\u0026nbsp;\u003cspan refid=\"Fig5\" class=\"InternalRef\"\u003e5\u003c/span\u003e). Despite the relatively low intensity and frequency of exercise associated with this intervention (see Barbour et al., \u003cspan citationid=\"CR3\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), the initial quantitative analysis did suggest a likely increase in physical health and therefore offered evidence for the initial efficacy of a VR exercise intervention. However, this positive effect was heavily focused in the first half of the intervention (pre to mid tests) where engagement was the highest. Few previous studies investigating the physiological effects of exercising with VR have used the gold standard of cardiovascular fitness, and these data offer a promising starting point for understanding the use of gamified VR exercise to improve physical health. As well as positive trends in physical fitness, data also suggested a likely decrease in scores for anxiety and an increase in exercise self-efficacy and leisure time activity. These findings extend the work of Xu et al (\u003cspan citationid=\"CR83\" class=\"CitationRef\"\u003e2021\u003c/span\u003e), who found a structured XR exercise intervention to be effective for reducing depression and anxiety. Unlike the physiological data, these effects were most prevalent over the whole course of the intervention. The positive effects of engaging in exercise on anxiety and depression are well documented (Kandola et al., \u003cspan citationid=\"CR33\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Stathopoulou et al., \u003cspan citationid=\"CR71\" class=\"CitationRef\"\u003e2006\u003c/span\u003e; Schuch et al., \u003cspan citationid=\"CR68\" class=\"CitationRef\"\u003e2016\u003c/span\u003e), and the findings here offer initial suggestion at the VR exercise could be a new option for engaging with exercise for young people and could serve as a gateway to potentially engaging in other forms of activity.\u003c/p\u003e\u003cp\u003eThe findings presented here should be considered in light of the limitations of the work. While we did explicitly aim to create a more naturalistic exploration of participant engagement with VR exercise, this meant we had limited control over the frequency and intensity of the exercise being conducted. This is realistic of real-world applications; however, it means we cannot draw complete conclusions on the relationship between frequency and intensity of VR exercise and variables relating to physical and psychological health benefits. We did, however, control the workouts that were conducted, including the trainer and music, meaning that we removed some of the autonomy. The desire to control the amount of exercise participants completed in each side of the crossover in this study removed some of the novelty for participants, so this may not be reflective of more autonomous use of VR. In the interviews, participants discussed the novelty of VR wearing off, and novelty is required to maintain motivation for exercise plans, even amongst active individuals (Grave et al., 2011; Lakicevic et al., \u003cspan citationid=\"CR38\" class=\"CitationRef\"\u003e2020\u003c/span\u003e). Future work should investigate the autonomy of choice in music, trainers, workout locations and other features and how they influence engagement and exercise intensity. Due to the timing and budget of this work, we did not use the most up-to-date hardware and software, meaning that many issues relating to tolerability of the headset and feasibility of space in the home may be addressed by the lighter weight and passthrough features on newer products.\u003c/p\u003e\u003cp\u003eIn summary, the findings suggest that exercising using a commercially available VR fitness app may serve as a feasible and acceptable alternative for young adults looking to engage in exercise. A combination of autonomous exercise at home and organised sessions will likely lead to the best engagement, and future development of exercise apps should continue to leverage gamification elements, options to maintain novelty, and choice about the engagement with others during exercise. VR exercise shows benefits for health, particularly acute psychological responses, with potential for longer term benefits to symptoms of anxiety (Maden et al., \u003cspan citationid=\"CR44\" class=\"CitationRef\"\u003e2022\u003c/span\u003e; Ng et al., \u003cspan citationid=\"CR54\" class=\"CitationRef\"\u003e2019\u003c/span\u003e; Riches et al., \u003cspan citationid=\"CR60\" class=\"CitationRef\"\u003e2024\u003c/span\u003e; Xu et al., \u003cspan citationid=\"CR32\" class=\"CitationRef\"\u003e2024\u003c/span\u003e), but future research should seek to understand how these interventions can be practically implemented to enhance adherence to new exercise behaviours.\u003c/p\u003e"},{"header":"Declarations","content":"\u003cp\u003e\u003ch2\u003eCompeting Interests\u003c/h2\u003e\u003cp\u003eDr Runswick received research funding from FitXR Ltd who are a virtual reality fitness company, and the app used in this paper. Dr Stubbs has received honorarium from a co-edited book on exercise and mental illness (Elsevier), and unrelated advisory work from ASICS, in addition to honorarium from FitXR Ltd.\u003c/p\u003e\u003c/p\u003e\u003ch2\u003eAuthor Contribution\u003c/h2\u003e\u003cp\u003eOliver Runswick: Conceptualization, Methodology, Formal analysis, Resources, Writing-Original Draft, Project administration, Funding acquisition. Megan Smith: Investigation, Formal analysis, Data curation, Writing-Review \u0026amp; Editing, Project administration. Harry Rowland: Investigation, Formal analysis, Data curation, Writing-Review \u0026amp; Editing, Project administration. Lakshmi Mahendru: Investigation, Data curation, Writing-Review \u0026amp; Editing. Simran Chahal: Investigation, Formal analysis, Data curation, Writing-Review \u0026amp; Editing. Lucia Valmaggia: Conceptualization, Methodology, Writing-Review \u0026amp; Editing, Funding acquisition. Brendon Stubbs: Conceptualization, Methodology, Writing-Review \u0026amp; Editing. Sean Figgins: Methodology, Writing-Review \u0026amp; Editing. Richard Bruce: Conceptualization, Methodology, Resources, Writing-Review \u0026amp; Editing\u003c/p\u003e\u003ch2\u003eData Availability\u003c/h2\u003e\u003cp\u003eData associated with this manuscript is available at https://osf.io/snrv5/?view_only=370b7584024b4af494181a7715b20353\u003c/p\u003e"},{"header":"References","content":"\u003col\u003e\u003cli\u003e\u003cspan\u003eBaillot A, Chenail S, Barros Polita N, Simoneau M, Libourel M, Nazon E, Riesco E, Bond DS, Romain AJ (2021) Physical activity motives, barriers, and preferences in people with obesity: A systematic review. 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J Adv Nurs 77(8). \u003cspan class=\"ExternalRef\"\u003e\u003cspan class=\"RefSource\"\u003ehttps://doi.org/10.1111/jan.14800\u003c/span\u003e\u003cspan address=\"10.1111/jan.14800\" targettype=\"DOI\" class=\"RefTarget\"\u003e\u003c/span\u003e\u003c/span\u003e\u003c/span\u003e\u003c/li\u003e\u003c/ol\u003e"}],"fulltextSource":"","fullText":"","funders":[],"hasAdminPriorityOnWorkflow":false,"hasManuscriptDocX":true,"hasOptedInToPreprint":true,"hasPassedJournalQc":"","hasAnyPriority":true,"hideJournal":true,"highlight":"","institution":"","isAcceptedByJournal":true,"isAuthorSuppliedPdf":false,"isDeskRejected":"","isHiddenFromSearch":false,"isInQc":false,"isInWorkflow":false,"isPdf":false,"isPdfUpToDate":true,"isWithdrawnOrRetracted":false,"journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true},"keywords":"Physical Activity, VR, XR, Gamification, Home Exercise, Mental Health","lastPublishedDoi":"10.21203/rs.3.rs-5486191/v1","lastPublishedDoiUrl":"https://doi.org/10.21203/rs.3.rs-5486191/v1","license":{"name":"CC BY 4.0","url":"https://creativecommons.org/licenses/by/4.0/"},"manuscriptAbstract":"\u003cp\u003eExercise is a powerful tool for supporting physical and mental health, yet many people do not meet recommended levels of engagement. Virtual reality (VR) offers an immersive platform to make enjoy able and interactive exercise available in the home. However, there is a need to understand the acceptability, feasibility, and initial efficacy of engaging in VR exercise across extended durations within different real-world settings. In this mixed-methods study, 20 young adult participants (male\u0026thinsp;=\u0026thinsp;10, female\u0026thinsp;=\u0026thinsp;10), completed an eight-week VR exercise programme that included four weeks of autonomous training at home and a matched four weeks of organized sessions in a counterbalanced crossover design. To establish initial efficacy, measures of psychological and physical well-being were taken before, at the mid-point, and post VR exercise. To assess acceptability and feasibility, adherence was measured throughout, and ten participants completed follow-up interviews about their experiences. Results showed higher session completion rates in organised sessions (79%) compared to at home (51%) and likely positive effects on physical fitness and psychological wellbeing early in the intervention. Gamification and immersion were discussed as key positives for engagement, with space identified as a key barrier for use at home. In conclusion, VR may offer an alternative gateway into exercise that is feasible and acceptable for use in the home and organised exercise settings.\u003c/p\u003e","manuscriptTitle":"Acceptability, Feasibility, and Initial Efficacy of Virtual Reality as a Home-Based Exercise Modality for Young Adults","msid":"","msnumber":"","nonDraftVersions":[{"code":1,"date":"2025-10-26 00:21:57","doi":"10.21203/rs.3.rs-5486191/v1","editorialEvents":[{"type":"communityComments","content":0}],"status":"published","journal":{"display":true,"email":"[email protected]","identity":"researchsquare","isNatureJournal":false,"hasQc":true,"allowDirectSubmit":true,"externalIdentity":"","sideBox":"","snPcode":"","submissionUrl":"/submission","title":"Research Square","twitterHandle":"researchsquare","acdcEnabled":true,"dfaEnabled":false,"editorialSystem":"","reportingPortfolio":"","inReviewEnabled":false,"inReviewRevisionsEnabled":true}}],"origin":"","ownerIdentity":"089bfae7-c132-40f9-b472-b3147053ff5d","owner":[],"postedDate":"October 26th, 2025","published":true,"recentEditorialEvents":[],"rejectedJournal":[],"revision":"","amendment":"","status":"posted","subjectAreas":[],"tags":[],"updatedAt":"2025-12-15T16:00:40+00:00","versionOfRecord":{"articleIdentity":"rs-5486191","link":"https://doi.org/10.1007/s10055-025-01270-6","journal":{"identity":"virtual-reality","isVorOnly":false,"title":"Virtual Reality"},"publishedOn":"2025-12-08 15:57:15","publishedOnDateReadable":"December 8th, 2025"},"versionCreatedAt":"2025-10-26 00:21:57","video":"","vorDoi":"10.1007/s10055-025-01270-6","vorDoiUrl":"https://doi.org/10.1007/s10055-025-01270-6","workflowStages":[]},"version":"v1","identity":"rs-5486191","journalConfig":"researchsquare"},"__N_SSP":true},"page":"/article/[identity]/[[...version]]","query":{"redirect":"/article/rs-5486191","identity":"rs-5486191","version":["v1"]},"buildId":"8U1c8b4HqxoKbykW_rLl7","isFallback":false,"isExperimentalCompile":false,"dynamicIds":[84888],"gssp":true,"scriptLoader":[]}