Virtual and augmented reality technologies in Human Performance : a review

Abstract Introduction: Today's society is influenced by Information and Communication Technologies. Toys that were once built by hand have been reinterpreted and have become highly commercialized products. In this context, games using Augmented Reality (AR) and Virtual Reality (VR) technologies are present in the everyday lives of children, youth and adults. Objective: To investigate how Physical Education professionals in Brazil have been making use of AR and VR games to benefit their work. Materials and methods: We only included studies that addressed exercise or physical activity using AR or VR games. We searched the databases of Virtual Health Library (VHL) and Scientific Electronic Library Online (SciELO), using the words augmented reality, virtual reality, exergames, Wii and serious games. Results: Nineteen articles were included in the systematic review. The most frequently used device was the Nintendo® Wii, with over 25 different


Introduction
Every story is a construction of humanity, which involves social, cultural and economic factors.Thus, the story of games started early in labor relations history, with the process of the creation and use of tools for this purpose.Play activity, understood as a free activity or using rules, has a symbolic and functional role.Throughout the game, children come into contact with signs produced by the culture to which they belong, because the play activity is structured according to the cultural meaning systems of their group.Language, as a mediator of culture, makes it possible for us to understand play from a historical-cultural point of view: Language allows children to operate in the absence of objects, to generalize and categorize the objects with which they come into contact, and communication ensures the conservation and transmission of information and experiences (1).
In Brazil, Kishimoto (2)(3)(4) and João Batista Freire (5) stand out in the research of games, toys and play activity, evidencing historical aspects, gender relations, and their use as a resource in teaching and learning processes.They also try to elucidate these activities in the educational context.
Physical Education has widened its area of expertise, both in the formal context (schools) and in various perspectives of the informal context (training) (6).This area of expertise is recognized as a promoter of health, and the available technological resources can aid in the creation of strategies to promote the adoption of an active lifestyle (7).In this sense, computer science becomes a versatile tool that can be used to improve human performance by assisting in the implementation of intervention routines in physical education, from assessment to prescription.Thus, technological advances exert a profound modifying effect on the organizational processes of contemporary society (8).
Toys once built by hand -any pieces of wood, cloth or paper that were transformed into toys -have been reinterpreted and have become highly commercialized products.In this context, computers and video games have started to be used as toys (9, 10).Kings and Cavichiolli (11) assert that the video game industry is considered the world's biggest entertainment industry.The authors report that, in 2001, the gaming industry earned US$21 billion, three times more than the Hollywood film industry, and it has a projected growth of 20.1% per annum in the next five years.
Games and toys have changed in structure, time and space.They have been transferred to other environments using the Internet and information and communication technology (ICT) tools.They can be explored through a virtual system in real time, and players can interact with people located in different places.A web of virtual personal relationships is formed, and in this context, people communicate, get informed, play and have fun (12).
Computerized products, which appeared as video games in the 80s and were controlled by joysticks, mouse pads, gamepads or computer keys, have now gained new forms: They are controlled by player movements and make use of innovative peripherals, such as electronic dance pads, motion platforms, exercise bikes, haptic devices and motion-tracking cameras (13).
Video game players (of dance or sports games) are motivated to produce larger movements and abandon a sitting position in front of the television or computer in order to be able to play these interactive games, which are activated through body movements.
These interaction techniques, which have been made available by Virtual Reality (VR) and Augmented Reality (AR) technologies, allow the simulation of everyday situations in real life, as well as safe involvement in behaviors and challenges (14); in addition, they are interesting and motivating to the participant (15).
VR (three-dimensionally) simulates the real world by using computer graphics concepts.It thus allows an intuitive interaction using devices such as Head Mounted Displays (HMDs), data gloves or the user's own body (14).In terms of its functionality, VR is a simulation that uses the computer to create a vision of the real world and respond instantly when user motion is detected (16).Therefore, in a VR game, the environment is predominantly "virtual", and the user feels "inserted" into this context.
In the case of AR, the real world environment is used to visualize and interact with virtual objects, giving the illusion that the virtual world and the real world coexist.Unlike Virtual Reality, which "transports" users into a virtual environment, Augmented Reality keeps users in their physical environment and transports the virtual environment into the users' space by means of a technological device such as a video camera that captures users' movements and a multimedia projector that presents the virtual objects (or a video monitor screen).Thus, AR is expected to allow users to interact with virtual content in a natural and intuitive manner with no need for adaptation or training (14).
The evolution of these two knowledge areas -Physical Education and Information and Communication Technology (ICT) -provides us with facts that lead us to investigate how Physical Education professionals in Brazil have been making use of AR and VR games (designed with the purpose of entertaining through exercise, sports and dance) and Information and Communication Technology to benefit their work.We also investigated their attitudes toward these technological tools, their use in daily work, and future possibilities for the profession in the use of new entertainment technologies.

Data sources and search strategies
We searched the databases of Virtual Health Library (VHL) and Scientific Electronic Library Online (SciELO) using the words augmented reality, virtual reality, exergames, Wii and serious games (Figure 1).
We only selected empirical articles addressing the use of virtual reality (VR) or augmented reality (AR) in physical activity or exercise.All of the studies found were assessed by their titles and abstracts, and the relevant articles were read in full.
Duplicate articles were excluded, and all articles that met the inclusion and exclusion criteria described in Table 1 were included in the systematic review.Access to the full text of articles allowed us to identify where the papers had been published.We only selected the studies that had been conducted in Brazil.When information on the country where the study had been conducted could not be abstracted from the description of the subjects, the authors' affiliation was used to determine the country to which a publication was to be attributed.
The decision to investigate only studies conducted in Brazil was due to the fact that the stateof-the-art research on the use of technology to promote health and physical activity has been reported in systematic reviews worldwide conducted in the main databases, such as Cochrane Library, PsychInfo, PubMed, Web of Science, and SPORTDiscus (17); and PsycInfo, Medline, and PsycArticles (18).Thus, an updated view of the topic is already available for other countries.In addition, Nunes et al. (19) allege that there are several Brazilian research groups that are developing applications with VR and conducting research on a wide range of topics.We tried to find these studies conducted in Brazil.
The studies were first assessed by title and then by abstract.All of those which addressed body movements with the use of interactive games were included in the first sample.We selected all of the articles that addressed the use of AR or VR technologies in physical activity or exercise training.When the title or abstract did not contain enough information to make a decision to include the article in the sample, the full text was analyzed.We paid special attention to the identification of the method used, the study site (in Brazil or abroad) and the proposed activity using AR or VR.

Results
We selected 19 articles from a total of 465 papers found in the databases Virtual Health Library (VHL) and Scientific Electronic Library Online (SciELO).We accessed the databases to identify the content, title, and publication data of each of the articles.The articles that met the inclusion criteria described in Table 1 were selected for this review.
Only articles addressing physical activity and associated with the use of augmented reality (AR) or virtual reality (VR) were selected.The final sample was constituted of 19 studies (Table 2).
The most frequently used device was the Nintendo ® Wii Fit (n=13), which offers several different kinds of games, followed by the Balance Rehabilitation Unit -BRU™ (n = 4).Cacau et al. (20) did not mention what device was used in their study and Damasceno, Lamounier Junior and Cardoso (28) used the MoCap interface, which organizes the data produced and presents the user with a variation of the motion disability measured at the beginning and end of each therapy session.Other types of information offered by the interface include average strength, speed and exercise time.Nintendo ® Wii Fit VR exposure therapy provided better results in improving stiffness and balance in elderly women with osteoarthritis than conventional physical therapy.
(to be continued) Nintendo ® Wii Fit The implementation of VR in rehabilitation allowed expansion and improvement in the use of the support base, and is an interesting resource to be added to conventional therapy.
(to be continued) interactive device that was used motivated individuals to participate in the physical therapy sessions.Three studies investigated the use of several Nintendo Wii games in patients with Parkinson's disease (29)(30)(31).The postural and balance changes presented by patients with this disease are important parameters used by physical therapists in choosing the best therapies for these patients (29).All of the studies showed results that support the use of VR as a new therapeutic tool, because it increases motivation and adherence to long-term rehabilitation processes.
Nascimento et al. (22) and Sposito et al. (24) used the Nintendo Wii software in elderly women.They found improvements in different psychological factors and asserted that it is a device that can be used during leisure time and encourages the practice of physical exercise.
Souza et al. (23) considered the exercises performed with the Nintendo Wii Sports Resort basketball game to be of mild to moderate intensity.According to the authors, virtual games could help improve and maintain cardiorespiratory fitness in healthy university students, and they should be seen as an auxiliary tool to reduce monotony and increase entertainment and adherence to physical activity, always with the guidance of a professional instructor.Baracho, Gripp and Lima (38) compared the perceptions of students from a public school when playing a baseball game in a virtual and in a real environment.The authors concluded that VR games contributed in a direct way to the practice of physical education in schools, because it increased students' motivation and participation during classes.However, they say that physical education teachers should not consider virtual games as an immediate substitute for real games, but rather as a challenge that involves the assimilation of a new language, which expands and re-creates the possibilities of corporal practices in cyberspace.
The other studies used the Nintendo Wii during physical therapy sessions conducted with women with knee osteoarthritis (25), patients with spinocerebellar ataxias (26), as well as patients with brain damage due to stroke (32), patients diagnosed with high injury of the median and ulnar nerves (35) and patients diagnosed with Early Cerebellar Ataxia (16).All of these studies reported positive results with the use of VR games.
The Balance Rehabilitation Unit (BRU™) is a device that uses the transmission of virtual imagesseen through 3D glasses -to recreate situations that cause dizziness.It comprises a computer with the test software, a safety metal structure, a security holder with handles and a belt, a strength platform measuring 40 cm × 40 cm, virtual reality glasses, an accelerometer and a foam cushion.Three modules are included: posturography, body balance rehabilitation and postural training games (21).This system makes it possible to train the different movements and oculomotor reflexes involved in the maintenance of body-balance in a controlled manner, by using a variety of visual stimuli modified according to frequency, depth perception, direction and movement speed (37).
Barcala et al. (34) performed a comparative analysis of balance in 12 hemiparetic patients by conducting 30-minute sessions of conventional physical therapy and 30-minute sessions of balance exercises using the Wii Fit software, which offers a visual biofeedback resource.The sessions were conducted twice weekly.The authors explained that the Nintendo ® Wii Balance Board requires individuals to constantly change their standing posture and assesses their ability to control environmental stimuli.The results that were found were significant, and the vestibular rehabilitation sessions resulted in clinical improvement, better functional body balance, reduced risk of falls, greater integration of sensory information, and improved the functional capacity and quality of life of an elderly woman with chronic peripheral vestibular disease of metabolic origin and multisensory syndrome.
Ghiringhelli and Ganança (36) found relevant results in posturography with VR stimuli using the BRU™ platform in young adults with balance disorders.Data collection was conducted with 50 healthy young adults presenting no otoneurological complaints, according to parameters such as center-of-pressure, stability limit and speed of oscillation resulting from different visual stimuli associated with the male and female genders.
The BRU™ platform was also used by Garcia et al. (21) to assess and rehabilitate patients with dizziness and associated symptoms.When compared to the control group, the experimental group, which participated in the rehabilitation program with VR, showed improvements in dizziness and quality of life, as well as an increase in stability limit areas and an improved ability to move their bodies and maintain balance without altering the support base.Yamamoto and Ganança (33) concluded that the BRU TM is an effective method to assess the stability limit area, ellipse area and speed of oscillation in patients with vestibular dysfunction.

Discussion
The phenomenal growth of Information and Communication Technologies and the growing use of video games in the everyday lives of people from various age groups is noteworthy.According to the studies reviewed in this article, video games and software using virtual reality (VR) and augmented reality (AR) motivate physical activity and contribute to improving the health of patients who are participating in rehabilitation treatment programs.
Some studies also evidenced the use of video games with VR effects in physical education classes.This fact seems to indicate that health professionals are applying the resources and knowledge acquired from these technologies to their scientific studies, as well as in practice with their students and clients.These technologies allow the practice of physical activities through sports, sport fights and dance, and they are readily available on market shelves for popular consumption.
A review by Sousa (39) investigated the use of the Nintendo ® Wii software as a therapeutic tool and the risk factors associated with it.The author suggests the use of these devices in the rehabilitation of patients with obesity or motor or postural dysfunction.
These resources and technologies are in the market and should be tested and used by health professionals in their everyday work.This was evidenced by all of the studies reviewed, which investigated different kinds of video games.However, there is a need for further collective research involving a variety of health professionals in order to create and develop proposals for this market.This would probably aid in the acceptance and use of AR and VR technologies as health tools and increase their degree of reliability, because such technologies would be designed and monitored by experts who know the needs of patients.
The studies reviewed have shown that video games with AR and VR effects possess playful elements that motivate, encourage, and provide pleasant, as well as learning moments.However, in order for these games to be safely used in gyms, schools and clinics, further studies are needed to test their performance in a significant number of subjects, corroborate the results reported herein and provide other results that guide professional practices.
The training of professional physical educators can produce knowledge that enables the qualification of activities using AR and VR.In addition, it may find results suggesting that the combination of VR and AR and exercise may result in some psychological benefits, as well as in increased feelings of energy and pleasure, and reduced levels of perceived tiredness (23,40).Moreover, given the policy for the inclusion of people with disabilities in mainstream schools, these technologies could be used as an aid for physical education teachers, who often have difficulties in involving these students in the proposed activities (38).
There is a broad field for investigation.Nevertheless, it is necessary for health professionals to break their resistance to these technologies, to get to know these games and to apply them to their daily work, in order to benefit from their potential to motivate the practice of physical activities.
To think about the profession is to design the future.We live in a time when professionals must be hope that this study can provide useful guidance about this wide research field for educators, professionals and researchers in the fields of Physical Education and Physical Therapy, as well as for video game designers.creative, innovative and possess a deep knowledge of their field.Thus, we must envision and develop gyms, clinics, schools and leisure facilities that can use these resources in order to improve daily practice.In fact, going against the available technologies means not believing that it is possible to work smoothly with them.Professional physical educators have always had to deal with a multiplicity of tools and apparatuses, such as balls, timers, fitness equipment, etc. Video games with AR or VR effects should be seen as new equipment that is available on the market for use in their daily work.Therefore, it is necessary to expand and create new experiences.

Conclusion
One cannot deny that Information and Communication Technologies are constantly changing our way of being in the world.And this consequently changes our culture of body movements.We must stay vigilant to keep pace with these changes and to analyze them critically.
The studies reviewed have shown that video games using virtual reality (VR) and augmented reality (AR) effects are already being used as an everyday working tool by physical therapists and occupational therapists in the rehabilitation of patients.Further, studies conducted in physical education settings in Brazil have found positive results associated with the use of such technologies in exercise and physical activity practices.
The involvement of health professionals in the creation and testing of games with AR and VR in significant patient populations is an emerging need, which will enable scholars to improve the reliability of research findings.
We envisage the possibility of future changes in the attitudes of teachers as mediators of and experts in physical activity who are able to guide and motivate their students by using, researching and creating tools (together with other professionals) that give them support and speak the language of contemporaneity.This movement can be developed in research groups and through the possibility for this content to become a part of professional training.
This study indicates that video games are available and can be a tool that may contribute to the adoption of exercise as an enjoyable form of recreation.We

Figure 1 -
Figure1-Flow chart of the search in the databases Virtual Health Library (VHL) (http://www.bvsalud.org)and Scientific Electronic Library Online (SciELO)

Table 1 -
Inclusion and exclusion criteria used to select articles retrieved from the Virtual Health Library (http://www.bvsalud.org)and the Scientific Electronic Library Online (SciELO)

Table 2 -
Details of the articles that addressed a virtual reality or augmented reality feature and were selected from the databases of Virtual Health Library (VHL) and Scientific Electronic Library Online (SciELO)

Table 2 -
Details of the articles that addressed a virtual reality or augmented reality feature and were selected from the databases of Virtual Health Library (VHL) and Scientific Electronic Library Online (SciELO)