CYBERPSYCHOLOGY, BEHAVIOR, AND SOCIAL NETWORKING

Volume 23, Number 3, 2020 ORIGINAL ARTICLES

ª Mary Ann Liebert, Inc.
DOI: 10.1089/cyber.2019.0269

Exergaming Executive Functions:

An Immersive Virtual Reality-Based Cognitive Training
for Adults Aged 50 and Older

Kuo-Ting Huang, PhD

Abstract
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Prior research suggests that both exergaming and virtual reality (VR)-based training programs could improve
executive functions in older adults. However, few studies investigated whether combining exergaming with VR
would be more effective. This study seeks to (a) investigate whether playing exergames in an immersive virtual
environment (IVE) would yield differential outcomes in selected executive functions, including inhibition, task
switching, and working, and (b) examine the role of feeling of presence as a potential mediator between
immersive exergaming and cognitive improvement in specific domains. Thirty-three participants over 50 years
of age (mean age = 62) participated in a 4-week training program and were randomly assigned into an IVE and
non-IVE to play an exergame (Fruit Ninja) for eight sessions within 4 weeks. The results revealed a significant
effect of the IVE on the Stroop Test and Trail Making Test after the 4-week training. Furthermore, the impacts
of the IVE exergaming on these two tasks were mediated by the feeling of presence. These findings suggested
that the immersive experience of exergaming would elicit the feeling of presence, which later contributes to
improved cognitive performances in inhibition and task switching. For the theoretical implications, this study
extends previous research by showing that (a) feeling of presence could contribute to older adults’ cognitive
improvement, and (b) the impacts of immersive exergame training on executive functions vary across individual
domains. Additionally, this study provides practical implications such that the design of exergames could
emphasize the game features requiring mental simulation, which can serve as a novel strategy for preventing
cognitive decline in midlife and old age.

Keywords: virtual reality, presence, older adults, exergame, executive functions

Introduction ecutive functions.5 Specifically, researchers have also found

that exergames could improve specific domains of cognitive

T he older population, which has grown dramatically

since the beginning of the 21st century, is at a consid-
erably higher risk of problems related to the aging of the
brain.1 Research shows that the economic costs associated
with dementia and other cognitive impairments in the United
States ranged from $159 billion to $215 billion in 2010 and
will increase to $511 billion by 2040.2 To protect against
cognitive aging, the World Health Organization has listed
physical activity as one of the treatments for the prevention of
cognitive decline and dementia.3
Prior studies suggest that exergaming, which refers to
combining the benefits of physical activity and the attrac-
tiveness of video games,4 could improve older adults’ ex-
functions in older adults, such as cognitive inhibition, task
switching/flexibility, and working memory.6 However, it is
still not fully explored how exergames would improve cog-
nitive functions in older adults.7 Furthermore, the positive
impacts of exergaming on individual cognitive domains are
inconsistent across studies,6 which may be a result of varying
forms and definitions of physical and cognitive demands.
Recently, scholars found that simply doing physical ex-
ercise without additional cognitive demands in the virtual
environment improved selected executive functions among
healthy older adults, such as inhibition, task switching, and
working memory. This may be due to the fact that players
require the use of their cognitive abilities to immerse

Department of Journalism, Center for Emerging Media Design and Development, Ball State University, Muncie, Indiana.

143
 144
themselves in the games.8 During exergaming, players have
to mentally simulate the virtual environment of the ex-
ergames, such as the scenery and virtual objects in the
games, so they can cognitively and mentally engage in the
game. Therefore, it is important to examine the impacts of
immersive experience on executive functions in a context of
exergaming. However, to date, only a few studies investi-
gated the impacts of immersive experiences during ex-
ergaming on cognitive improvement in older adults.
Built upon on previous work, the current study further
investigates the impact of immersive experience during ex-
ergaming on individual executive functions and specifically
focuses on the mediating role of presence, a subjective ex-
perience of feeling immersed in a mediated environment.
The current study proposes a 4-week exergaming training to
examine whether exergaming in a more immersive envi-
ronment, which leads to a stronger feeling of presence,
would yield differential outcomes in specific executive
functions. This study first discusses the cognitive mecha-
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nisms underlying the impacts of exergaming on executive
functions and then investigated the potential roles of im-
mersive experience (i.e., presence) in the relationship be-
tween exergaming and cognitive improvement.
Exergaming and executive functions
According to previous research, cognitive functions de-
cline during aging.9,10 Moreover, the concept of reserve11,12
states that two types of reserves account for age-related
cognitive loss: brain and cognitive. Specifically, brain re-
serve emphasizes the hardware characteristics such as brain
volume and neuronal structural integrity, while cognitive
reserve highlights the software aspects such as the cognitive
functioning and plasticity of neural circuits.13 In other words,
the theoretical framework of cognitive reserve explains how
to preserve cognitive functions from a hardware/software
perspective.
Similar to the concept of cognitive reserve, exergaming
scholars have identified two main mechanisms underlying
the effects of exergaming on cognitive functions: (a) physical
exercise—moving, jumping, or running—which enlarge
people’s attentional pool by increasing physiological arousal
and motor control skills; (b) mental exercise—memorizing
the rules and movements of an exercise—which involves
higher-order cognition and prime players to use their cog-
nitive functions.5,14
Systematic reviews and meta-analyses on the cognitive
benefits of exergaming in older adults further show positive
effects of exergaming were found on multiple cognitive
domains, including executive functions, processing speed,
visuospatial skill, short-term and long-term memory, verbal
fluency, and measure of cognitive state.6,7,15 Consistent
with previous research, the current research focuses on
executive functions, which is important for older adults to
maintain competence and independence, as the main out-
comes.5,14,16,17
Executive functions are multi-dimensional and have been
discussed based on three domains: inhibitory control, task
switching, and working memory. A meta-analysis of ran-
domized controlled trials on the effects of exergames on
executive function found positive effects of exergames on
inhibitory control and task switching across studies using a
HUANG
different intervention length.15 Moreover, two studies im-
plementing 8-week interventions found that exergames im-
proved participants’ working memory.18,19 These results
suggest that exergaming would influence prefrontal brain
activity, which has a direct impact on executive functions.
In addition, recent studies suggest that interacting with
virtual environments requires users to mentally stimulate the
environment of the exergames (e.g., imagining the 3D en-
vironments), which may also activate neurobiological
mechanisms associated with executive functions.20 For ex-
ample, cycling within a virtual environment leads to greater
improvement in executive functions, such as inhibitory
control and task switching, than riding a traditional sta-
tionary bike.21
Furthermore, clinical findings and neuroscientific evi-
dence indicate that virtual reality (VR)-based training and
interventions, such as virtual simulations of daily tasks and
navigational training, are effective tools for different exec-
utive functions (e.g., inhibition, task switching, and working
memory) among older adults.22–24 These studies also suggest
that VR-based training can enhance neuroplasticity, which
later improves older adults’ executive functions.22 Based on
these findings, exergaming in a more immersive virtual en-
vironment (IVE) should lead to greater improvement in ex-
ecutive functions than exergaming in a less immersive
environment. Therefore, the first hypothesis of the current
research is proposed as follows:
H1: Individuals who play an exergame in an IVE will have
better improvement in selected executive functions as in-
dicated in (a) inhibitory control, (b) task switching, and (c)
working memory than those in a nonimmersive virtual
environment.
Presence as a potential mediator
Previous research hypothesizes that feeling of presence
may be positively associated with cognitive improvement
and suggests that future research should directly measure the
impact of cognitive simulation during exergame interven-
tions.8 According to spatial presence theories,25 presence is a
psychological process that media users allocate their atten-
tions to the mediated/virtual environment, which enables
them to establish a better mental model of the mediat-
ed/virtual environment. Immersive technologies, which al-
low users to be isolated from the physical world, explore the
virtual environment, and create mental representations of the
virtual environment, which would lead to the experience of
spatial presence.26
Neurological evidence further indicates that spatial pres-
ence experiences elicited by immersive media would lead to
increased activities of the brain regions associated with
cognitive functions.27 In addition, research using functional
neuroimaging found that executive functions (selective at-
tention and task switching) activate the dorsolateral pre-
frontal cortex,28 which was also found to play an important
role in the control of the experience of spatial presence.24 A
recent study further showed that the neuropsychological
performance of older adults in VR cognitive training im-
proved more than those in the traditional cognitive training
condition, suggesting that mentally engaging in the VR plays
an important role in cognitive improvement.29 Therefore, the
 EXERGAMING COGNITIVE FUNCTIONS
second hypothesis focuses on the mediating role of feeling of
presence and is proposed as follows:
H2: Feeling of presence will mediate the relationship be-
tween VR exergaming and selected executive functions as
indicated in (a) inhibitory control, (b) task switching, and
(c) working memory.
Materials and Methods
Participants
The current research uses people of ages 50 and older as
inclusion criteria for two reasons: First, peoples’ cognitive
ability may start declining at around 50 years of age30 or after
midlife.31 Second, adults 50–64 years of age are one of the
target populations for preventive care services, but 28% of
them are physically inactive.32 Therefore, those of the age 50
and above are ideal for preventive health care.
This study employed a two-condition-between-subjects
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design to test the proposed hypotheses. A total of 33 par-
ticipants (mean age = 61.93, standard deviation = 8.21; fe-
male = 24), recruited from a community research subject
pool administered by a large university in the United States,
were randomly assigned into each condition (immersive
VR = 16). Thirty-two participants finished all training ses-
sions within 4 weeks. Participants received up to $150 U.S.
dollars for their participation (depending on the numbers of
sessions they attended). There were no significant differ-
ences in gender, age, and race between participants across
the conditions. The study was approved by the University’s
Review Board.
Stimuli
The exergame for the study was Fruit Ninja, which has
both immersive VR (i.e., Fruit Ninja VR) and nonimmersive
(Fruit Ninja Kinect) versions. Fruit Ninja is an exergame in
which players use arm and hand movements to swing virtual
swords to slice fruit. Previous research also used a similar
VR exergame, which required players’ movements to match
the programmed gestures or movements, to improve older
adults’ cognitive reaction.33 In the immersive VR condition,
participants used a head-mounted display (Oculus Rift) to
play the exergame. In the nonimmersive condition, partici-
pants used a 27-inch LCD monitor to play the exergame.
When playing Fruit Ninja Kinect, participants were in-
structed to stand in front of the television (1.5–2 m away) and
use the motion-tracking Kinect controller to play the game.
Procedure
Upon arrival at the laboratory, participants were asked to
complete a survey of demographic information and a series
of executive function tasks (Stroop Test, Trail Making Test,
and Digit Span) before starting the first exergaming session.
As part of a larger study, participants were randomly as-
signed to immersive VR and nonimmersive environments
with different types of instructions during exergaming. This
manipulation was not found to influence this study’s out-
comes and thus is not reported in our results.
Afterward, participants were asked to complete a 20-
minute exergaming session. After exergaming, they were
145
asked to do three executive function tasks as well as answer
questions about their spatial presence experiences. After they
finished their first visit, they were encouraged to participate
in seven more visits in the next 4 weeks (two per week, eight
in total). Participants were asked to complete the cognitive
tasks and surveys at baseline (before the first session), after a
single bout (the first session), and after the 4-week training
(the last session).
Measures
Two outcome measures were included in the study: spatial
presence experiences and cognitive assessments. The 16-item
scale of spatial presence experiences (Cronbach’s a = 0.97),
which was adopted from the MEC Spatial Presence Ques-
tionnaires,34 has been empirically tested across diverse media
settings.35 All of the items were rated on a seven-point Likert-
like scale (1 = strongly disagree and 7 = strongly agree).
This study used the Stroop Test (for inhibitory control),
Trail Making Test (for task-switching/flexibility), and Digit
Span (for working memory) to assess different domains of
executive functions, which were widely used in previous
studies.5 An 88-item Stroop Test was administered, which
included congruent color words and incongruent color
words. The results were calculated using ratio scores
(congruent/incongruent) and standardized with higher scores
representing better performances.
For the Trail Making Test, participants were asked to draw
lines to connect 25 numbered circles (1–25) in ascending order
(Part A), and then draw lines to connect 25 circles, including
both numbers (1–13) and letters (A–L) in consecutive order
while also alternating between the numbers and letters (i.e.,
1-A-2-B.-13-L, etc.). The time to complete Part B subtracted
by time to complete Part A was calculated and standardized
with lower scores indicating more positive outcomes.
For the Digit Span, participants were asked to do two
memory tasks, one requiring them to recall numbers in a
forward order first and then the other one in backward
order. The results were calculated using the sum of correct
trails in backward order, with higher scores suggesting
favorable outcomes. All assessments were performed by
using Inquisit 5.0.
Results
The first hypothesis investigated the impact of exergaming
in an IVE on selected executive functions. A series of two-
way repeated-measures analyses of covariance (ANCOVAs)
were conducted to examine whether there were differences in
cognitive improvement between two conditions across two
posttests. Regarding the first posttest (right after a single bout
of training), two participants for Stroop and four for Trail
Making were identified as outliers or did not follow the in-
structions, and were therefore not included in the analyses.
There was no significant difference in all three cognitive
tasks between IVE and nonimmersive conditions immedi-
ately after the first training session. In other words, there was
no immediate effect after VR exergaming.
After participants finished all training sessions, partici-
pants were asked to complete the second posttest. Two par-
ticipants for Stroop and three for the Trail Making Test did
not complete the tests or were identified as outliers and
therefore were excluded from the analyses. The results
 146 HUANG

Table 1. Cognitive Assessment and Presence at the Baseline, After Single Bout, and After 4 Weeks
Mean difference
Immersive VR Non-immersive VR
Mean (SE) Mean (SE) F (df)c p Partial eta2
Baseline measuresa
Trail Making 0.056 (0.176) -0.036 (0.171) 0.738 (1, 38) 0.396 0.022
Stroop -0.066 (0.243) 0.051 (0.235) 0.111 (1, 38) 0.741 0.003
Digit Span 5.663 (0.379) 5.440 (0.368) 0.166 (1, 38) 0.686 0.005
After a single-bout trainingb
Trail Making 0.005 (0.101) 0.001 (0.101) 0.555 (1, 31) 0.881 0.001
Stroop -0.044 (0.194) 0.040 (0.188) 0.023 (1, 33) 0.462 0.018
Digit Span 5.828 (0.253) 5.562 (0.247) 0.147 (1, 35) 0.704 0.004
Presence 6.164 (0.276) 4.684 (0.262) 21.241 (1, 35) 0.000*** 0.378
After a 4-week trainingb
Trail Making -0.069 (0.133) 0.070 (0.141) 5.065 (1, 23) 0.033* 0.163
Stroop 0.104 (0.192) -0.005 (0.232) 4.876 (1, 22) 0.038* 0.197
Digit Span 5.982 (0.338) 6.114 (0.388) 0.804 (1, 26) 0.380 0.035
Presence 6.07 (0.343) 4.774 (0.366) 6.383 (1, 26) 0.018* 0.197
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a
Marginal mean difference reported was based on ANCOVA controlling for age and sex.
b
Marginal mean difference reported was based on repeated measures ANCOVA controlling for age, sex, and the other manipulation not
included in the current study.
c
The first df refers to the effect (group · time) and the second df refers to the error term.
*p < 0.05, ***p < 0.001.
ANCOVA, analyses of covariance; SE, standard error; VR, virtual reality.

showed a difference in the Stroop Test [F(1,23) = 5.166;
p = 0.034; gp2 = 0.197] and the Trail Making Task [F(1,
22) = 4.876; p = 0.038; gp2 = 0.181] between IVE and non-
immersive conditions, which suggests that exergaming in an
IVE led to more cognitive improvement than nonimmersive
exergaming. Regarding the backward Digit Span (n = 30), the
findings suggested that there was no significant difference
between the IVE and nonimmersive conditions. Therefore,
H1a and H1b were supported, but H1c was not (Table 1 and
Figs. 1 and 2).
To provide a more conservative way to interpret the data,
another series of repeated ANCOVAs were conducted to
address the issues of dropping-out cases and missing re-
sponses by using intention-to-treat (ITT) analysis. ITT
analysis has been widely used to deal with noncompliance
and missing outcomes in research using randomized con-
trolled trials.36 Previous studies (e.g., Peng37) suggested
three different approaches to analyze missing values: (a)
mean substitution, (b) pretest value carried forward, and (c)
posttest value carried forward. Therefore, the current study
also provided results using these three approaches. The IIT
results showed that the impact of exergaming in an IVE was
still significant even using stricter, conservative approaches
to analyze the data (Table 2).

FIG. 1. Estimated marginal means for scores on the Stroop Test.

 EXERGAMING COGNITIVE FUNCTIONS
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FIG. 2. Estimated marginal means for scores on the Trail Making Test.
Finally, to test the second hypothesis, a series of mediation
tests were conducted using the PROCESS path-analysis mac-
ro38 (model 4). The results based on the second posttest show
that being in the VR environment elicited a stronger feeling of
spatial presence, which later positively associated with par-
ticipants’ improvement in cognitive tasks. Specifically, the first
mediation model showed that exergaming in an IVE posi-
tively influenced participants’ spatial presence experiences
(b = 2.463, p = 0.01), which then led to better Stroop results
(b = 0.315, p = 0.007). The indirect effect from immersion to
spatial presence experiences and then to Stroop results was
significant (95% confidence interval [CI]: 0.08–0.55). The
second mediation relationship in the posttest of the final session
revealed that exergaming in an IVE positively influenced par-
ticipants’ spatial presence experiences (b = 3.30, p = 0.005),
which then led to a better performance in Trail Making
(b = -0.124, p = 0.04). The indirect effect from IVE to the Trail
Making Test through spatial presence was significant (95% CI:
-0.24 to -0.01). Therefore, H2a and H2b were supported. No
mediation effect was found based on the first posttest.
Discussion
Previous research suggests that exercise in virtual envi-
ronments (i.e., exergaming) would yield cognitive benefits,
particularly executive functions, even if the virtual envi-
ronments are not immersive.20 The current study further
investigated the impact of exergaming in an IVE on three
Table 2. Intention-to-Treat Analyses of Outcome Measures After the 4-Week Training
Mean substitution
2 2
Outcome measures F Partial eta
Stroop (n = 33) 4.70* 0.176
Trail Making (n = 33) 4.41* 0.140
Note: The results were based on repeated measures ANCOVA controlling for age, sex, and the other manipulation not included in the
current study.
*p < 0.05.
147
basic executive functions and the role of feeling of presence
elicited by IVE during exergaming. Preliminary evidence
gathered from 33 participants demonstrated significant im-
provement in inhibition and task switching from immersive
exergaming over nonimmersive exergaming after the 4-week
training despite no immediate effect after a single training
session. The findings showed that engaging in a more im-
mersive environment while exergaming may contribute to a
greater improvement of inhibitory control and task switching
in older adults, which is consistent with the previous research
on the comparison between nonimmersive exergaming and
traditional exercise.21,39
The findings revealed a mediating relationship suggesting
that the effects of immersive VR exergaming on selected ex-
ecutive functions (i.e., inhibition and task switching) were fully
mediated by spatial presence after the 4-week training. Speci-
fically, when players felt located within an IVE and perceived
the possibility of moving within the environment, they were
more likely to improve their inhibitory control and task
switching after experiencing presence. The underlying mech-
anism for cognitive improvement may be that the process of
feeling presence activated the brain areas associated with ex-
ecutive functions,8 especially for those associated with inhib-
itory control and task switching. However, no direct and
mediation effects were found immediately after the first train-
ing session, suggesting that the effects of presence require a
certain amount of time to have an impact on these individual
executive functions.
Pretest carried Posttest carried
F Partial eta F Partial eta2
5.07* 0.187 5.21* 0.192
5.20* 0.163 4.30* 0.137
 148
Regarding working memory, participants in the IVE con-
dition did not show significant improvement in Digit Span
results. There are two possible explanations for this nonsig-
nificant finding. First, as previous studies suggest, exergames
might require a longer intervention (e.g., 8 weeks) to affect
working memory,18,19 even when enhancing the level of im-
mersion. Additionally, Digit Span is a digital-related memory
instead of object-related memory, and the training of the cur-
rent study was not involved in the use of digital-related
working memory. Hence, future research could consider using
different types of measures for working memory, such as ob-
ject or verbal working memory performance.
One main strength of the current research is that this ex-
ergaming training used commercial off-the-shelf exergames
as the stimuli, which means that the training materials are
easily accessible. This study also contributes to the literature
by showing that the combination of immersive VR and ex-
ergames, which enhanced the feeling of presence during
exergaming, has the potential to further improve selected
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executive functions in midlife and older adults after a 4-week
exergame training. The findings, suggesting that immersive
exergaming may promote neuroplasticity and enhance
domain-specific cognitive reserves (i.e., inhibition and task
switching), also support the argument that the effects of
cognitive reserve on cognitive performance may vary across
individual cognitive domains.40,41
This study has both theoretical and practical implications.
Theoretically, this study adds to the literature that investigates
the characteristics of exergames and improvement of execu-
tive functions. The results of this study support the concept of
cognitive reserve12 and spatial presence theories and found
that the immersive experience of exergaming has the potential
to improve specific cognitive domains in older adults. Re-
garding practical implications, game designers could empha-
size the immersive features of exergames to create a stronger
feeling of presence, which can serve as a novel strategy for
preventing cognitive decline in midlife and older age.
Limitations and Future Research
Like previous studies of exergaming for cognitive im-
provement, this longitudinal study is not without limitations.
First of all, the majority of the participants were white
(90.2%) and most were females (73.2%). Also, the results of
this study may not be able to apply to all older adults since
the average of the participants was 62 years of age, which
were considered on the younger side of older adults. Thus,
the findings may not be able to be generalized to all popu-
lations. Second, small sample sizes and missing responses
may decrease statistical power. This limitation was common
in previous studies due to limited resources. Future studies
should consider implementing a large-scale longitudinal
exergaming intervention given that the researchers have
enough resources. Third, the current research found a sig-
nificant effect after the 4-week training. However, the current
study could not predict how long the impacts would last.
Future studies should further investigate the long-term im-
pact of interventions on executive functions.
Conclusion
As immersive virtual technologies become more popular
and affordable, individuals who want to ameliorate cognitive
HUANG
decline or avoid cognitive deficits may benefit from the use
of exergaming in IVEs. This study shows the possibilities of
applying the immersive VR technologies to exergaming,
which amplifies the advantages of exergames—having the
benefits of physical activity and attractiveness of video
games. Overall, the current research also demonstrates the
cognitive benefits of immersive VR exergaming for people
50 years of age and older.
Acknowledgments
Special thanks to Dr. Wei Peng and Courtney Tuchman for
their contributions.
Author Disclosure Statement
No competing financial interests exist.
Funding Information
This study was partially supported by the Pearl J. Aldrich
Endowment in Aging Related Research and Education at
Michigan State University.
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Address correspondence to:
Dr. Kuo-Ting Huang
Department of Journalism
Center for Emerging Media Design and Development
Ball State University
Muncie, IN 47306
E-mail: tim.kuoting.huang@gmail.com
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