Case report

Ai Michibata,1 Miyoko Haraguchi,1 Yuichiro Murakawa,2 Hideo Ishikawa3
1

Rehabilitation Center, Eishinkai
Kishiwada Rehabilitation
Hospital, Kishiwada, Osaka,Japan
2
Department of Medical Device
Development, mediVR Inc,
Toyonaka, Japan
3
Hemoptysis and Pulmonary-­
Circulation Center, Eishinkai
Kishiwada Rehabilitation
Hospital, Kishiwada, Osaka,Japan
Correspondence to
Ms Ai Michibata;​michibata@​japanscr.o​ rg
Accepted 20 December 2021

SUMMARYA 41-­year-­old woman presented with spinal cord
infarction and paraplegia after acute thoracoabdominal
aortic dissection. Clinical evaluation revealed theAmerican Spinal Injury Association (ASIA) lower
limb exercise score of 0 points and the Functional
Assessment for Control of Trunk (FACT) score of 0
points. Conventional physical therapy for 60 days did
not significantly improve the paraplegia or FACT score;
therefore, belt electrode skeletal muscle electricalstimulation (B-­SES) and virtual reality (VR)-­guided
sitting balance training were introduced for 30 days.
She developed independence for all basic movements
and her gait was restored using short leg braces and
Lofstrand crutches. At discharge, her ASIA lower limb
exercise score was 24 and FACT score was 7, with afunctional impedance measure motor item of 57, andshe could continuously walk for a distance of 150 m. The
combination of B-­SES and VR-­guided balance training
may be a feasible therapeutic option after spinal cord
infarction.

BACKGROUND© BMJ Publishing Group
Limited 2022. Re-­use
permitted under CC BY-­NC. No
commercial re-­use. See rights
and permissions. Publishedby BMJ.
To cite: Michibata A,
Haraguchi M, Murakawa Y,
et al. BMJ Case Rep
2022;15:e244091.
doi:10.1136/bcr-2021244091

Spinal cord infarction is an acute type of myelopathy caused by spinal artery ischaemia.1 2 Its incidence is estimated in the range of 5000–8000 cases
per year in the USA, given that spinal cord infarction accounts for approximately 1% of all strokecases.3 4 Symptoms include paraplegia, sensory
loss and bladder and rectal dysfunction that varydepending on the infarction site.5 Several studies
with follow-­up periods of ≥3 years reported some
improvement in the paraplegia symptoms andassociated walking disability.6 7 Meanwhile, severe
paralysis at onset has been associated with poor
physical function prognosis.7 However, owing to
the low frequency of occurrence, reports on the
rehabilitation of patients with spinal cord infarction are scarce. Therefore, additional evidence isrequired on the outcomes of patients with severe
paraplegia and poor physical prognosis.
A recent systematic review of virtual reality(VR)-­
guided training suggested its usefulness in
improving balance and functional mobility inpatients with spinal cord injury.8 A longitudinalcase study revealed that neuromuscular electricalstimulation increased dynamic postural stability ina patient with spinal cord injury.9 Improved trunk
function and balance are essential for regaining
walking ability after stroke.10 Studies withpatients recovering from spinal cord infarction

using a combination of electrical stimulation andVR-­guided training may improve future outcomesin this patient group.10
This case report presents a patient with spinal
cord infarction that failed to achieve desired
improvement with conventional physical therapy
but did improve using supplementary lower limb
transcutaneous electrical stimulation and VR-­guided
balance training for paraplegia and trunk function,
respectively.

CASE PRESENTATION

A 41-­year-­old woman was diagnosed with an acutethoracoabdominal aortic dissection (Stanford TypeB, DeBakey III b) based on contrast-­enhanced CT
findings (figure 1A). The patient presented without
any signs of vital organ blood supply loss caused bybranch arterial obstruction secondary to the dissection and, thus, received conservative treatment.
The following day, the patient presented with theparalysis of both lower limbs and the trunk, sensory
impairment below the ninth thoracic vertebra,
increased tendon reflexes in bilateral lower extremities and bowel and bladder dysfunction. She wasdiagnosed with spinal cord infarction due to insufficient blood flow in the spinal arteries. Spinal cord
MRI was not performed, at the attending surgeon’s
discretion, and the diagnosis was made according
to the criteria proposed by Zalewski et al.11 The
criteria for probable periprocedural spinal cord
infarction include acute non-­traumatic myelopathy and severe acute antigravity muscle deficits, occurring within 12 hours after the onset ofthoracoabdominal aortic dissection, in the absenceof any plausible alternative diagnoses.11 Bilateral
neurological deficits, increased tendon reflex andbowel and bladder dysfunction further supported
the diagnosis of spinal cord infarction. The patientunderwent emergent endovascular aortic stentgrafting to prevent aortic dissection progression(figure 1B). After about 2 months of acute treatment, the patient was transferred to our hospitalfor rehabilitation.

INVESTIGATIONSAt the time of her transfer, no limited range of
motion or spasticity was observed in the limbs ortrunk; however, the American Spinal Injury Association (ASIA) lower extremity motor score was0, indicating severe flaccid paralysis (table 1).
Functional indices are presented in tables 1 and 2.
Light touch and pin prick responses were severely

Michibata A, et al. BMJ Case Rep 2022;15:e244091. doi:10.1136/bcr-2021-244091

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Electrical stimulation and virtual reality-­guided
balance training for managing paraplegia and trunkdysfunction due to spinal cord infarction

Case report

impaired below the ninth thoracic vertebra level and absent
below the second lumbar vertebra level, without signs of sacral
sparing (table 2). Additionally, the trunk function was 0 points
on the functional assessment for control of trunk (FACT), while
the manual muscle test score of the rectus abdominis was 2. The
patient required assistance for all movements, such as getting
up and maintaining a sitting position without support, and an
indwelling urinary catheter was used for bladder management.
From the beginning, the patient strongly desired to walk home
without using a wheelchair at discharge.

TREATMENT

Details of the conventional physical therapy protocol used in thiscase are presented in table 3. Changes to the ASIA lower limb
total motor score and FACT scores over time are presented infigure 2. To regain independence in basic movements, training
for transferring and sitting up movements was provided. In
addition, since the patient had a desire to reacquire the ability
to walk, walking training was conducted using bilateral knee–
ankle–foot orthoses and a load relief type rehabilitation liftSP-­1000 (Moritoh, Aichi, Japan). The rehabilitation lift used inTable 1

Progress in total score (points) of various functional indices
cPT

After
B-­SESAfter
VR

At admission

cPT

cPT

At dischargeDays after admission (hospital day)

0

30

60

90

120

150

180

ASIA impairment scale

A

A

A

C

C

C

C

ASIA Motor Score (upper limbs)

50

50

50

50

50

50

50

ASIA Motor Score (lower limbs)

0

0

2

17

20

24

24

ASIA Sensory Score (light touch)

72

72

74

78

76

77

70

ASIA Sensory Score (pin prick)

72

72

74

72

77

77

78

ASIA neurological level of injury

T9

T9

T9

T8

T8

T8

T8

FACT

0

1

2

2

5

5

7

FIM motor item

23

40

40

41

45

53

57

Total walking distance per day (mean)

0m

40 m

100 m

120 m

120 m

600 m

600 m

Walkable distance

0m

10 m

20 m

60 m

100 m

150 m

150 m

ASIA, American Spinal Injury Association; B-­SES, belt electrode skeletal muscle electrical stimulation; cPT, conventional physical therapy; FACT, functional assessment for control of trunk; FIM,
functional independence measure; T8, eighth thoracic vertebra; T9, ninth thoracic vertebra; VR, virtual reality.

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Figure 1 Three-­dimensional reconstructed CT angiography ofthoracoabdominal aorta at the onset (A). Chest X-­ray findings after
endovascular aortic stent-­grafting (B). (A) The aortic dissection extended
from the left subclavian artery to both renal arteries at the onset. (B)Endovascular aortic stent-­grafting was performed in the descending
aorta distal to the aortic arch.

this case enabled weight unloading by lifting the body with thearm placed on top of the lift. Meanwhile, the presence of wheels
supported walking practice by maintaining weight unloading.
The patient was instructed to push the lift forward using theirarms, and the physical therapist assisted from behind, helping
the patient swing forward the leg that was fixed with the longleg orthosis. Walking training was performed at approximately
100 m/day, depending on the patient’s vital signs and fatigue
level. The conventional physical therapy described in table 3 wasprovided 180 min on weekdays, as supported by medical insurance coverage. Several physical therapists provided patient care.
After the patient completed the aforementioned physical therapy
programme for approximately 60 days, grooming and dressing
both improved to 7 points on the functional independence
measure (FIM). Although no obvious change was noted in trunk
function FACT score, the patient was able to maintain a seatedposition in clinical situations without the use of a brace, andonly light assistance was required for transfer tasks to prevent
slips and falls. However, the transfer operation in the ward was
1 point on the FIM, as it sometimes required two caregivers
depending on the skill of the caregiver. Additionally, only a few
changes were observed in the lower limb function, and muscle
contraction was not observed in either of the lower limbs.
Based on these results, in addition to conventional physical therapy, B-­SES therapy using a general therapy electricalstimulator (Homerion Laboratory Tokyo, Japan) was initiated on hospital day 60. The entire belt of the B-­SES device
acts as an electrode that can induce contraction in the quadriceps, hamstrings, triceps surae and tibialis anterior muscles
when wrapped around the waist, thigh and distal lower limbs(figure 3). B-­
SES was performed as self-­training separatelyfrom physical therapy for 20 min a day, five times a week, ata frequency of 20 Hz, with the maximum intensity at which
the muscle contraction appeared and the pain could be tolerated. Several weeks after the initiation of B-­SES, slight muscle
contraction of the lower limbs was observed (table 1). From thestate where only reflective movements of the lower limbs wereobserved, intentional autonomous movements became gradually feasible, and the ASIA lower limb mobility score improved
to 17 points, 30 days after the initiation of B-­SES (figure 2).
The patient began walking with light assistance using a walker
without fixing the knee joints using a knee–ankle–foot orthosis.
Although the patient showed resistance to self-­catheterisation for
urination at the beginning of her hospitalisation, the indwellingCase report
Changes to ASIA and FACT score items
At
admission

cPT

cPT

After
B-­SES

After
VR

cPT

At discharge

0

30

60

90

120

150

180

 Elbow flexors, right/left

5/5

5/5

5/5

5/5

5/5

5/5

5/5

 Wrist extensors, right/left

5/5

5/5

5/5

5/5

5/5

5/5

5/5

 Elbow extensors, right/left

5/5

5/5

5/5

5/5

5/5

5/5

5/5

 Finger flexors, right/left

5/5

5/5

5/5

5/5

5/5

5/5

5/5

 Finger abductors, right/left

5/5

5/5

5/5

5/5

5/5

5/5

5/5

 Hip flexors, right/left

0/0

0/0

0/0

1/2

2/2

2/2

2/2

 Knee extensors, right/left

0/0

0/0

1/1

2/2

2/2

4/4

4/4

 Ankle dorsiflexors, right/left

0/0

0/0

0/0

1/2

2/2

2/2

2/2

 Long toe extensors, right/left

0/0

0/0

0/0

1/2

2/2

2/2

2/2

 Ankle plantar flexors, right/left

0/0

0/0

0/0

2/2

2/2

2/2

2/2

 C2-­T8, right/left

2/2

2/2

2/2

2/2

2/2

2/2

2/2

 T9, right/left

2/2

2/2

2/2

1/1

1/1

1/1

1/1

 T10, right/left

1/1

1/1

1/1

1/1

1/1

1/1

1/1

 T11, right/left

1/1

1/1

1/1

1/1

1/1

1/1

1/1

 T12, right/left

1/1

1/1

1/1

1/1

1/1

1/1

1/1

 L1, right/left

1/1

1/1

1/1

1/1

1/1

1/1

1/1

 L2, right/left

0/0

0/0

1/1

1/1

1/1

1/1

0/0

 L3, right/left

0/0

0/0

0/0

1/1

1/1

1/1

0/0

 L4, right/left

0/0

0/0

0/0

1/1

1/1

1/1

0/0

 L5, right/left

0/0

0/0

0/0

1/1

0/0

1/0

0/0

 S1, right/left

0/0

0/0

0/0

0/0

0/0

0/0

0/0

 S2-S­ 5, right/left

0/0

0/0

0/0

0/0

0/0

0/0

0/0

 C2-­T8, right/left

2/2

2/2

2/2

2/2

2/2

2/2

2/2

 T9, right/left

2/2

2/2

2/2

1/1

1/1

1/1

1/1

 T10, right/left

1/1

1/1

1/1

1/1

1/1

1/1

1/1

 T11, right/left

1/1

1/1

1/1

1/1

1/1

1/1

1/1

 T12, right/left

1/1

1/1

1/1

1/1

1/1

1/1

1/1

 L1, right/left

1/0

1/1

1/1

1/1

1/1

1/1

1/1

 L2, right/left

1/0

0/0

1/1

1/1

1/1

1/1

1/1

 L3, right/left

0/0

0/0

0/0

0/0

1/1

1/1

1/1

 L4, right/left

0/0

0/0

0/0

0/0

1/1

1/1

1/1

 L5, right/left

0/0

0/0

0/0

0/0

1/0

1/0

1/0

 S1, right/left

0/0

0/0

0/0

0/0

0/0

0/0

1/0

 S2-S­ 5, right/left

0/0

0/0

0/0

0/0

0/0

0/0

0/0

1. Ability to sit upright for more than 10 s when grabbing a railing or seatsurface using the upper limbs.
Yes/no: 1/0 points

0

1

1

1

1

1

1

2. Ability to sit upright for more than 10 s without using the upper limbs.
Yes/no: 1/0 points

0

0

1

1

1

1

1

3. Ability to grab using either the left or right hand the ankle on the other sideand then return to the original position.
Yes/no: 1/0 points

0

0

0

0

0

0

0

4. Ability to move at least 10 cm to both the right and left side while lifting thebilateral buttocks.
Yes/no: 2/0 points

0

0

0

0

0

0

0

5. Ability to lift the unilateral buttock from the seat for at least 3 s (bilateral).
Bilateral/unilateral/unable: 2/1/0 points

0

0

0

0

0

0

2

6. Ability to lift right or left thigh and remain for at least 3 s with the sole of thefoot not touching the ground (bilateral).
Bilateral/unilateral/unable: 2/1/0 points

0

0

0

0

0

0

0

Days after admission (hospital day)
ASIA Motor Score (upper limbs)

ASIA Motor Score (lower limbs)

ASIA Sensory Score (light touch)

ASIA Sensory Score (pin prick)

FACTContinued

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Table 2

Case report
Continued
Atadmission

cPT

cPT

After
B-­SES

After
VR

cPT

7. Ability to lift both the right and left thighs with both feet not touching the
ground for at least 3 s.
Yes/no: 2/0 points

0

0

0

0

0

0

0

8. Ability to lift buttocks one side at a time and move both forward andbackward with the bottom.
Yes/no: 3/0 points

0

0

0

0

0

0

0

9. The examiner should touch the seat surface 20 cm posterior to the sacralbone. The examinee should look over their shoulder and say how many fingers
the examiner is showing, which should be changed three times at 1 s intervals.
Able/unable: 3/0 points

0

0

0

0

0

0

0

10. Ability to raise the right or left upper limb (shoulder joint bending) withmaximum effort; ability to the ground at the middle position of the adduction/
extorsion of the shoulder joint.
Yes/no: 3/0 points

0

0

0

0

3

3

3

At discharge

ASIA, American Spinal Injury Association; B-­SES, belt electrode skeletal muscle electrical stimulation; C, cervical vertebra; cPT, conventional physical therapy; FACT, functional assessment ofcontrol of trunk; FIM, functional impedance measure; L, lumbar vertebra; S, sacral spine; T, thoracic vertebra; VR, virtual reality.

catheterisation was switched to intermittent self-­catheterisation
on hospital day 70 under nurse guidance. In contrast, during
this period, although we approached trunk function throughbasic movements and balance training in the sitting position, nochanges were observed in the FACT score, trunk function index
or instability in the sitting position, indicating that independencein transfer movements was not achieved.
To improve trunk function, we tried sitting-­position balance
training by VR using mediVR KAGURA (mediVR, Toyonaka,
Japan) (figure 4). This device is used to encourage a reaching
movement with the patient in a sitting position by having themattempting to touch a falling object that appears in a three-­dimensional virtual space with a hand-­held controller.12–14 It
promotes repeating various reaching movements by adjusting
the distance and angle to the falling object and speed of falling.
We introduced it several times as part of the physiotherapy,
using customised distance and speed for the acquisition of thefalling objects to account for approximately 70% of the total
movements. Later, since the patient could perform the VRtraining safely by herself, she performed it for 20 min a day, fivetimes a week, as a self-­training replacement for B-­SES. WhenVR training was introduced, the number of reaches per sessionof self-­training was about 300; this figure became 600 by theend of the training programme. Therefore, the FACT score
improved from 2 points before the initiation of VR training toTable 35 points (figure 2); the previous problematic trunk instability
during transfer movements resolved, and the transfer movements in the ward were corrected independently. For walking,the knee–ankle–foot orthoses were changed to ankle–footorthoses, and the patient started walking under supervisionusing a walker.
Following this, for approximately 60 days until discharge,
movement training was conducted under the expected in-­home
setting after discharge, while changing the self-­training from VR
to walking training, the distance increased from 120 m to 600
m. The patient used an ankle–foot orthosis for both lower limbs
and a Lofstrand crutch at the time of discharge and was moving ashort distance in the house. She was able to put on the orthoses.
The light touch examination revealed reduced response atdischarge, likely due to myalgia in the lower extremities (tables 1
and 2). Although no improvement was seen in urinary function,
the patient could manage bladder emptying using intermittent
self-­catheterisation. As defecation required a nurse’s intervention, home-­visit nursing care was planned.

OUTCOME AND FOLLOW-UP
After discharge, the patient continued to undergo physicaltherapy through home-­visit rehabilitation for 6 months, henceforth with no significant change in physical function. The patient

Conventional physical therapy protocol

Days after admission (hospital day)

0–30

30–60

60–90

90–120Transferring operation practice

*

*

*

*

Sitting-­up practice

*

*

*

Roll-­over practice

*

*

*

Range-­of-­motion exercise

*

*

*

Upright position training on the stand

*

*

*

Upper limb muscle-­strengthening exercises

*

*

*

Wheelchair driving practice*Walking practice

*

*

*

120–150

150–180

*

*

*

*

Upright practice

*

*

*

Lower limb muscle-­strengthening exercises

*

*

*

Applied walking with obstacles*

Outdoor walking practice**Indicates that activity was performed.

4

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Table 2

Case report

is using a Lofstrand crutch while walking and a wheelchair while
sitting.

DISCUSSION

Higher ASIA impairment scale scores at onset are reportedly
associated with poor long-­term prognosis of physical function
in patients with spinal cord infarction.6 7 In the current case,where the prognosis was poor, we hypothesise that B-­SES andVR-­guided body trunk training may have contributed to theimprovement of the ASIA scores of the lower limb movement
and trunk function index, respectively (table 1 and figure 2).
Both modalities were feasible, and no adverse events or safetyconcerns were observed. The present findings are based on asingle case and should be interpreted with caution; nevertheless,they suggest that B-­SES and VR-­guided training may be used inclinical practice, where the relevant equipment is available.
Electrical stimuli reportedly do not contribute towards
improving the walking ability in a patient with spinal cord
injury; rather they only prevent skeletal muscle atrophy, impact
postural stability or positively affect lower extremity skeletal
muscle metabolic activity shown by positron emission tomography.9 15–18 A recent systematic review of five controlled trials

Figure 4 Image of self-­training of sitting balance using mediVR
KAGURA. The patient wears a head-­mounted display and is encouraged
to reach to catch a falling object appearing in the three-­dimensional
virtual space. The difficulty levels can be set by adjusting the size of thefalling object and falling speed.

Figure 3 Image of self-­training using belt electrode skeletal muscle
electrical stimulation. Muscle electrical stimulation was performed ina wheelchair sitting position. For electrostimulation, the belt electrode
was attached bilaterally to the proximal thighs (below the pants),
distal thighs and ankles. At a frequency of 20 Hz, the intervals of the on
and off stimuli were set to 5 and 2 s, respectively. The intensity of thestimulus was gradually increased from 0.1 mA or decreased by 0.1 mA
on the display. The intensity was set at the level at which the muscle
contraction appeared and set at the maximum tolerable pain. The
output strength was often set to about 0.7–1.3 mA in this case. B-­SES,
belt electrode skeletal muscle electrical stimulation.

evaluating the impact of neuromuscular electrical stimulation
therapy showed no strong evidence supporting its superiority
over other treatment strategies used to gain strength in partiallyparalysed muscles after spinal cord injury.16 However, in thepresent case, electrical stimulation seemed to improve lower
limb function, further improving walking ability, as the walkabledistance tripled from 20 m to 60 m. This discrepancy in findings might be, at least in part, owing to the partially reversible
neurological damage present, caused by ischaemia of the spinal
artery rather than complete spinal injury.6 7 Several reports havestated that physical function of patients with spinal cord infarction improves over time.7 15 In the present case, we speculated
that repetitive stimuli input may have activated the spinal nerves
that escaped damage (hibernating neurons) and reorganised theremaining neural circuit.
A study of the effect of sitting-­position balance training using
VR in patients with paraplegia demonstrated that the improvement in balance function index was proportional to the duration of intervention compared with task training, such as theactivity of daily living training.19 This report is consistent with
our results, and VR has elements that promote motor learningfor balance acquisition.19–21 The existence of sensory feedback is
critical in the motor learning process, and the mediVR KAGURA
used in this study can give three types of sensory feedback,including visual, auditory and tactile.12–14 Such feedback enabled
capturing of the reach distance errors from multiple angles,
which promoted relearning of sitting balance.13 14 19–21 Furthermore, using immersive VR with a game-­like feature assisted withinternal motivation to conduct many reach movements by thepatient, which may have been effective for learning.20 21
This report only described a single case, and distinguishing its
outcomes from the natural disease course is challenging due tothe timing of the intervention.6 That is, it is difficult to confidently say that B-­SES and VR mainly contributed to the patient’s
gains.6 In addition, the 20 min/day of additional self-­training
performed in this case might have boosted the improvements

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Figure 2 Rehabilitation schedule and changes in ASIA total motorscore of the lower limbs and FACT scores. ASIA, American Spinal Injury
Association motor score; B-­SES, belt electrode skeletal muscle electricalstimulation; FACT, Functional Assessment for Control of Trunk; PT,physical therapy; VR, virtual reality.

Case report

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Michibata A, et al. BMJ Case Rep 2022;15:e244091. doi:10.1136/bcr-2021-244091

Learning points► Owing to its low frequency of occurrence, reports on the

rehabilitation of patients with spinal cord infarction are
scarce.
► The combination of conventional physical therapy with belt
electrode skeletal muscle electrical stimulation and virtual
reality-­guided balance training may have contributed to
improving the lower-­limb movement and trunk function
index, respectively.
► Improved limb and trunk function of patients with spinal cord
infarction improved activities of daily living such as walking
and transferring.
Twitter Hideo Ishikawa @2YyKj5lWqFhKDUs
Contributors AM, MH, YM, HI contributed to the conception and design of thiscase report, the acquisition and interpretation of data, and drafting or revising themanuscript critically for important intellectual content.
Funding The authors have not declared a specific grant for this research from any
funding agency in the public, commercial or not-­for-­profit sectors.
Competing interests Yuichiro Murakawa is an employee of mediVR, Inc., acompany that holds several patents on VR-­guided rehabilitation. Ai Michibata,
Miyoko Haraguchi and Hideo Ishikawa have no conflicts of interest to declare.
Patient consent for publication Consent obtained directly from patient(s)Provenance and peer review Not commissioned; externally peer reviewed.
Open access This is an open access article distributed in accordance with theCreative Commons Attribution Non Commercial (CC BY-­NC 4.0) license, which
permits others to distribute, remix, adapt, build upon this work non-­commercially,and license their derivative works on different terms, provided the original work
is properly cited and the use is non-­commercial. See: http://creativecommons.org/​
licenses/by-nc/4.0/.
Case reports provide a valuable learning resource for the scientific community andcan indicate areas of interest for future research. They should not be used in isolation
to guide treatment choices or public health policy.

REFERENCESBMJ Case Rep: first published as 10.1136/bcr-2021-244091 on 9 March 2022. Downloaded from http://casereports.bmj.com/ on March 9, 2022 by guest. Protected by copyright.

of our patient’s symptoms because her functional improvement
coincides with the length of time the patient was seen for treatment. In addition, the FACT score is a tool for the assessmentof patients with stroke rather than for the assessment of thosewith spinal cord injury or infarction. Consequently, it is plausiblethat some improvements in trunk function were not detectedby this scale.22 However, we reported this case of spinal cord
infarction since it suggested the possibility that electrical stimulation therapy and sitting-­position balance training using VR
improved the paraplegic function and the trunk function index,
respectively. The benefits of neuromuscular electrical stimulation or VR-­guided training have been previously reported,23–28
and further studies on the clinical effects in patients with spinal
cord infarction are expected in the future.

Case report
BMJ Case Rep: first published as 10.1136/bcr-2021-244091 on 9 March 2022. Downloaded from http://casereports.bmj.com/ on March 9, 2022 by guest. Protected by copyright.

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