Postural Sway Assessment in Virtual Reality and Technology-Assisted Rehabilitation: A Systematic Review

Postural sway, quantified through center of pressure (COP)-based measures, is a critical indicator of postural stability and fall risk. Despite growing interest in virtual reality (VR) and technology-assisted rehabilitation, a comprehensive synthesis of how interventions and experimental conditions affect postural sway across adults and older adults is lacking. This review aimed to systematically synthesize the effects of exercise-based interventions and experimental physiological, visual, and sensory conditions on COP-based postural sway in adults and older adults, with an emphasis on acute and short-term effects relevant to VR- and technology-assisted rehabilitation. A systematic search of PubMed, Scopus, Web of Science, and the Cochrane Library was conducted from database inception to 31 March 2025. Studies reporting COP-based postural sway outcomes with extractable quantitative data were included. Narrative synthesis was performed due to substantial clinical and methodological heterogeneity. Ten studies were included (2 RCTs, 6 pre–post, 1 crossover, 1 cross-sectional). Exercise-based interventions—including balance training and visual feedback training—generally reduced postural sway. Acute physical perturbations (fatigue, immobilization, cryotherapy, proprioceptive vibration) consistently worsened stability. Destabilizing visual stimulation increased sway, whereas stabilizing visual feedback reduced it. Exercise-based interventions and sensory-stabilizing conditions show promise for improving postural stability. Fatigue, immobilization, and sensory perturbations represent important modifiable risk factors. IMU-based wearable assessment may serve as a clinically scalable alternative to force plate systems in VR-based and rehabilitation settings.