Osteoporosis is a systemic skeletal disease characterized by decreased bone mass and deterioration of bone microarchitecture, with a core diagnostic criterion of bone mineral density (BMD) T-value ≤ −2.5 (Kanis, 1990; Rosen, 2018). Osteopenia is a transitional state between normal and osteoporotic BMD, with a T-value of −1.0 to −2.5 (Karaguzel and Holick, 2010). Osteopenia is often considered a precursor of osteoporosis, and may signal a further loss of BMD (Karaguzel and Holick, 2010). Aging and feminization are associated with osteoporosis, and women have a significantly increased risk of osteoporosis after menopause (Aspray and Hill, 2019; Fan et al., 2024). One study showed that the number of new cases of osteoporosis is expected to reach 41.5 million globally in 2019, and is expected to increase to 263.2 million cases between 2030 and 2034 (Zhu et al., 2023). Osteoporosis is a huge medical and economic burden in all regions of the world (Hopkins et al., 2016; Aziziyeh et al., 2019; Tatangelo et al., 2019). Currently in osteoporosis, medication reduces the risk of fracture and stimulates bone formation, increasing BMD (Reid and Billington, 2022). However, medication also has some side effects, which need to be treated with caution (Khan et al., 2017). Therefore, there is a need to develop alternative therapies that are safe, accessible and have a high level of participation.

In addition to pharmacological interventions, various nonpharmacological therapies have been shown to improve balance and mobility in patients with osteoporosis or osteopenia. For example, traditional physical therapy programs focusing on strength training, balance exercises, and aerobic exercise have been shown to have positive effects on physical function and quality of life in patients with osteoporosis and osteopenia (Chen et al., 2019). Similarly, exercises such as Tai Chi have gained recognition for their potential to enhance balance and reduce the risk of falls in older adults. These traditional interventions play a vital role in the management of osteoporosis and osteopenia (Li et al., 2004). However, they can face challenges in terms of patient engagement and compliance, especially in those who find the exercises monotonous or lack motivation.

Virtual Reality (VR) is a technology that provides multi-sensory interactive experiences through computer simulation of three-dimensional environments, and its core classifications include immersive and non-immersive (Prinz et al., 2023). In recent years, the application of VR in medicine has expanded from surgical training to rehabilitation, and has demonstrated unique advantages in neurorehabilitation and chronic pain management (Pourmand et al., 2017). VR-based rehabilitation is more conducive to the development of physical health than conventional rehabilitation, positively affecting recovery of aerobic function, balance, pain levels, psychological and motor function, in addition to improving patient motivation (Howard, 2017; de Araújo et al., 2019). However, as an emerging treatment modality, VR initially faced implementation barriers, including large financial investments, technical challenges, and operator training (Glegg and Levac, 2018; Chung et al., 2021; Sarkar et al., 2021). Based on the development of VR in rehabilitation, researchers have begun to explore its use in patients with osteoporosis or osteopenia, but the dispersed nature of the available evidence and the lack of systematic summarization have hindered the clinical translation process.

Preliminary clinical trials suggest that VR interventions are effective in improving balance function in patients with osteoporosis (Yilmaz and Kösehasanoğulları, 2024). A study of patients with postmenopausal osteoporosis showed that VR was effective in improving physical performance and quality of life (QOL) (Riaz et al., 2024b). In addition, Meta-analyses for other musculoskeletal disorders further support the efficacy of VR. Both non-immersive and immersive VR-assisted active training are effective in reducing back and neck pain symptoms (Lo et al., 2024). VR-based rehabilitation improves pain, motor function, and anxiety in total knee replacement patients within 1 month after surgery. However, no study has comprehensively evaluated the effects of VR on functional outcomes in patients with osteoporosis or osteopenia.

To fill this knowledge gap, this study aimed to integrate the existing evidence through systematic evaluation and Meta-analysis to provide an evidence-based basis for the clinical application of VR in the management of osteoporosis and osteopenia. These findings specifically focus on BMD, the effects of balance, mobility and QOL.

This systematic review and meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines (Moher et al., 2009). Comprehensive methodological details are outlined in Supplementary Table 1. The study protocol has been registered with International Prospective Register of Systematic Reviews (PROSPERO) under the identifier CRD420251023178.

This study is the first meta-analysis to assess the effectiveness of a VR intervention on functional outcomes in patients with osteoporosis or osteopenia. The results showed that VR improved femoral neck BMD but had no significant effect on lumbar spine BMD. In terms of balance function and mobility, the VR intervention group was better than the control group, but the improvement in QOL did not reach statistical significance. Regarding the quality of the literature, four of the five included papers were of high quality. Sensitivity analyses further confirmed the robustness of the results for balance function, but heterogeneity in mobility remained high. GRADE scores for all evidence ranged from low to very low. This stems from risk of bias and imprecision, mainly because the evidence includes studies that are at risk of bias. In addition, the total sample size for each piece of evidence was low. Therefore, results need to be interpreted with caution.

The results of this study correlate with previous trends in the use of VR in rehabilitation medicine. VR highlights the importance of integrating games into rehabilitation programs as they allow observation of movement and control of activity levels. Games using Kinect technology have been shown to be highly effective in treating chronic diseases (Tarakci et al., 2016). The improvement of balance function and mobility in osteoporosis and osteopenia by VR echoes research in the field of neurorehabilitation, which may involve enhanced proprioceptive input and motor learning efficiency (Cano Porras et al., 2018; Zhang et al., 2021). BMD can be used as an indicator to define the severity of osteoporosis and the effectiveness of treatment (Löffler et al., 2020). A study has shown that VR biofeedback systems greatly enhance tissue regeneration, exercise efficacy and participation in training (Wang, 2024). Improvements in femoral neck BMD suggest that VR may stimulate local bone remodeling in the lower limb through mechanical loading. However, lumbar spine BMD did not significantly improve. This may be due to the fact that the VR rehabilitation programs focused on lower limb training and less on trunk training, which could be validated by adjusting the protocol in the future. On the other hand, nonsignificant lumbar BMD results may reflect inadequate statistical power rather than true biological invalidity. Small sample sizes are prone to Type II errors, resulting in false negatives (Mittendorf et al., 1995). In addition, negative QOL results may be influenced by multidimensional factors, such as psychological state and sociability, and existing studies have not targeted interventions in these areas (Gilani et al., 2023; Zhao et al., 2023).

Confounding factors can increase the heterogeneity of results, which may also be responsible for biased results. In the balanced results, subgroup analyses, meta-regression, and sensitivity analyses showed that VR showed better efficacy and decreased outcome heterogeneity in passive controls. The significant advantage of VR in passive controls may stem from the low intensity of the control measures, while the effectiveness of the active controls themselves may have diluted the effect of VR. Notably, the dominance of VR in the passive control group may reflect its potential as a stand-alone intervention, particularly in scenarios where structured rehabilitation resources are lacking. In addition, Mobility showed less effect of control group type on heterogeneity in all tests. The high heterogeneity in mobility and QOL may be related to differences in assessment tools and small sample sizes. Heterogeneity may also come from VR type. However, the types of VRs included in the study were all non-immersive VRs, and it was not possible to identify the effect of VR type on the results from the nature of the VRs. On the other hand, it is also possible that the heterogeneity originated from the systems of different non-immersive VRs, due to differences in the design of each system (Tarakci et al., 2016; Kumar et al., 2017). It is also possible that the heterogeneity was influenced by the duration of the intervention, which ranged from a minimum of 6 weeks to a maximum of 12 months for the included studies using VR. Subgroup analyses were not possible due to the small number of studies with the same factors. Future studies need to standardize outcome assessment methods and expand sample sizes to reduce confounding bias.

The mechanism of action of VR in osteoporosis management may involve multi-pathway synergies. Firstly, VR training optimizes neuromuscular coordination by inducing motor control and learning in an immersive virtual environment where patients combine visual, motor and haptic signals to perform high-quality exercises (Maden et al., 2025). Secondly, the real-time visual feedback provided by VR may improve proprioceptive integration, reduce the risk of falls and indirectly protect the bone microstructure (Raffegeau et al., 2023). In addition, unlike the repetitive nature of traditional training, VR training is full of motivation and fun, which can significantly improve patient compliance (Riaz et al., 2024a). VR can guide patients to make postural changes during training, thereby increasing localized loads on the body. However, the negative results of lumbar spine BMD suggest that the intensity of mechanical stimulation of the spine by VR may be insufficient and further optimization of the exercise programs design is required.

When considering incorporating VR interventions into routine clinical practice, it is important to weigh these costs against the potential benefits of VR interventions. Although the initial investment in VR technology is substantial, the long-term cost-effectiveness may be greater because reduced healthcare costs are associated with improved patient outcomes (e.g., fewer fractures and hospitalizations). In addition, as VR technology becomes more popular and market competition increases, the costs of VR interventions may decrease (Geraets et al., 2021). The feasibility of implementing VR interventions in a clinical setting is another key consideration. VR requires specialized equipment and trained personnel to operate and maintain the system. However, as technology advances, VR systems are becoming more user-friendly and accessible (Ciccone et al., 2023). Furthermore, it is also important to consider whether healthcare providers have access to technical support and training to ensure smooth implementation of VR interventions (Hood et al., 2021; Iqbal et al., 2024). Patient compliance is a key factor in the success of any intervention, and VR is no exception. The engaging and interactive nature of VR can enhance patient motivation and compliance. One study has shown that patients are more likely to complete VR exercises than traditional rehabilitation exercises due to the fun and immersive experience VR provides (Cano Porras et al., 2018). It is also critical to select appropriate VR content and adjust the length and intensity of VR sessions to minimize these side effects (Mao et al., 2021).

There are some limitations to this study. Firstly, the small number of included studies and limited sample size may reduce statistical validity. The small number of included studies also resulted in an inability to detect publication bias. Second, the high heterogeneity of the intervention protocols, such as differences in the type of VR equipment and training duration, limits the generalizability of the findings. Finally, there was a lack of long-term follow-up data to assess the persistence effect of the results. Future multicenter large-sample RCTs and in-depth investigation of the mechanisms of VR in osteoporosis and bone loss are needed. In addition, VR combined with artificial intelligence to adjust the intensity or in combination with anti-bone resorption drugs may be a new direction to optimize the efficacy. Despite the positive effects of VR on osteoporosis and bone loss, certain uncertainties remain and further research is needed. The results of the meta-analyses showed only effectiveness. However, the adverse effects and safety of VR remain unknown. More comprehensive studies of VR therapy are necessary in the future to more fully understand its effects. In addition, future research also needs to verify different VR types and different VR training parameters. In addition to verifying the effectiveness of VR, it is also possible to compare several commonly used treatment parameters in previous studies and establish standards for VR treatment of osteoporosis and osteopenia.

VR-based rehabilitation is a novel and promising treatment modality that is increasingly being implemented in clinical settings. This study is the first to assess the impact of VR intervention on functional outcomes in patients with osteoporosis or bone loss through systematic evaluation and meta-analysis. Given the overall low and very low level of evidence, the results need to be treated with caution. While these results suggest that VR has potential as an adjunctive therapy, its clinical application is still in the research phase. In addition, no study has conclusively demonstrated the clinical safety of virtual reality interventions for individuals with osteoporosis or osteopenia. The sustained effects, safety and potential side effects of VR still need to be further evaluated. Future RCTs need to focus on extending follow-up, exploring bone remodeling effects and stratifying the baseline population.