Understanding visual attention in balance rehabilitation

After neurological decline or in the presence of cognitive impairment, recovery is rarely just about regaining strength. Many older adults also experience changes in attention, visual processing, and coordination — factors that directly influence balance, mobility, and independence. 

At Clínica Alemana in Chile, a rehabilitation research team explored how eye tracking technology, combined with non-immersive virtual reality (VR) balance training, could help them better understand how patients visually engage with rehabilitation tasks. Their objective was not to test a therapeutic intervention, but to explore how visual attention behaves during motor training. 

The challenge 

In neurorehabilitation, clinicians routinely assess balance, gait, and functional mobility. What is far more difficult to quantify is how patients visually explore their environment while moving. 

Subtle attentional patterns, such as inefficient scanning, delayed anticipation, or inconsistent focus, often go undetected in traditional clinical assessments. Observation alone does not allow therapists to measure how long attention is sustained, when it drifts, or how gaze patterns evolve during repeated task exposure. 

The team sought a way to objectively measure these attentional behaviors during dynamic balance tasks. 

The approach: Combining VR and eye tracking 

To explore this question, the research team designed a pilot study pairing non-immersive VR balance training with wearable eye tracking. 

• Participants performed stepping and obstacle-based tasks in a virtual environment designed to challenge coordination and balance. 

• Tobii Pro Glasses were used to capture gaze behavior during these exercises. 

• Eye tracking served strictly as an exploratory measurement tool, enabling researchers to analyze fixation patterns, gaze plots, areas of interest (AOIs), and pupil diameter changes during task execution. 

Because the VR system was non-immersive, participants could move naturally and safely. This is an important consideration when working with older adults with cognitive impairment. 

Study design and participants 

This exploratory pilot study included seven older adults (median age 77) with mild to moderate cognitive impairment, including Parkinson’s disease, balance disorders, and frontotemporal dementia. 

Participants completed 10 non-immersive VR balance sessions, with eye tracking data collected early and late in the training period. Clinical measures of balance, walking speed, endurance, and cognition were recorded pre- and post-training. 

The study was designed to assess feasibility and characterize visual attention patterns during balance tasks. It was not intended to establish clinical efficacy. 

What the eye tracking data revealed 

Although the study was not powered to demonstrate clinical effectiveness, several meaningful observational patterns emerged: 

• Participants progressed through increasing task difficulty levels during training. 

• Small numerical changes were observed in certain balance and gait variables, though these did not reach statistical significance. 

• Gaze data showed a shift from rapid scanning toward longer, more stable fixations over time. 

• Pupil diameter trends suggested potential changes in cognitive effort as tasks became more familiar. 

Importantly, the eye tracking system enabled researchers to objectively observe attentional behavior during full-body movement, something not easily measurable through clinical observation alone. 

The value of the study lies in demonstrating that attention patterns during motor tasks can be captured and analyzed in real rehabilitation environments. 

Why this matters for rehabilitation research 

This exploratory study highlights how eye tracking can make visual attention measurable during dynamic balance training, an area traditionally assessed through observation alone. 

While the study was not designed to establish clinical efficacy, it demonstrates the feasibility of integrating wearable eye tracking into real-world rehabilitation environments. 

By objectively capturing gaze behavior during movement, researchers can begin to explore how cognitive and motor processes interact in older adults with cognitive impairment. These insights may help inform the design of future controlled studies and more data-driven rehabilitation research. 

As the field moves toward increasingly personalized and evidence-based care models, tools that enable precise measurement of attention during movement offer meaningful opportunities to advance research in neurorehabilitation. 

Reference 

Maldonado-Díaz Marcos, Jara-Vargas Gonzalo, González-Seguel Felipe (2025). Visual attention during non-immersive virtual reality balance training in older adults with mild to moderate cognitive impairment: an eye tracking study. Frontiers in Aging Neuroscience.