Open Access Case
Report

DOI: 10.7759/cureus.62433

Seated Virtual Reality-Guided Exercise Improved
Gait in a Patient With Trunk Dysfunction Due to
Hip Fracture: A Single-Case Design Study

Review began 05/28/2024
Review ended 06/10/2024

Kengo Kawanishi 1, Masami Nakamoto 1, Toshinori Mityashita 1 , Seiji Ogita 2, Shintatou Kudo 1

Published 06/15/2024© Copyright 2024
Kawanishi et al. This is an open accessarticle distributed under the terms of the

1. Inclusive Medical Sciences Research Institute, Morinomiya University of Medical Sciences, Osaka, JPN 2. Emergency
Center, Kano General Hospital, Osaka, JPN

Creative Commons Attribution License CCBY 4.0., which permits unrestricted use,
distribution, and reproduction in any

Corresponding author: Kengo Kawanishi, kengo_kawanishi@morinomiya-u.ac.jp

medium, provided the original author andsource are credited.

Abstract
Physical therapy for mobilization after a hip fracture is effective in improving muscle strength and balance
training of the lower extremities; however, effective interventions targeting the trunk muscles remain to beestablished. The efficacy of virtual reality (VR)-based exercise therapy has been recently reported. This casereport demonstrates the effectiveness of VR-based intervention in improving the gait of a female patient in
her 90s with a femoral neck fracture who had difficulty in independent gait postoperatively due to trunkdysfunction.
The patient had undergone bipolar hip hemiarthroplasty for a right femoral neck fracture sustained via a fallat home. Standard physical therapy, including range of motion exercises, resistance training, and gait
training, was commenced gradually the day after surgery. An improvement in lower extremity pain wasreported at the two-month follow-up visit but without any improvement in the gait ability. Trunk flexion
was observed during gait, and the patient had difficulty in independent gait and walking without upper limb
support. Withdrawal and reversal designs (BAB) were employed, and each period lasted one week. Standard
physiotherapy supplemented with trunk reach training in a seated position using VR equipment wascommenced subsequently. An improvement in the maximum anterior pelvic tilt angle and sitting andstanding postures, increased hip extension range of motion and step length during gait, and decreased gait
speed were observed during the intervention phase. These results highlight the importance of physiotherapy
interventions targeting the trunk muscle and the effectiveness of VR-guided trunk training in patients withfemoral neck fractures.

Categories: Geriatrics, Physical Medicine & Rehabilitation, Orthopedics
Keywords: reach exercise, gait, virtual reality, hip fracture, trunk dysfunction

Introduction
The incidence of hip fractures is on the rise in Asia [1], and 33% of patients with hip fractures are unable toattain their pre-injury mobility level postoperatively [2]. Furthermore, the incidence of secondary fractures,such as contralateral hip fractures, has been reported postoperatively in 28.6% of patients with hip fractures[3]. Hip fractures have been frequently reported among older adults. Lower extremity muscle weakness [4,5]and trunk muscle weakness [6] are often observed before injury. Thus, besides lower extremity muscle
problems, trunk muscle atrophy and other trunk dysfunctions may inhibit the return to pre-injury gait,leading to a vicious cycle of repeated falls and secondary fractures after sustaining the initial hip fracture.
Previous studies have reported the effectiveness of physical therapy for gait training after a hip fracture in
improving muscle strength and balance training of the lower extremities [4,5]. However, effective
interventions targeting the trunk muscles remain to be established. Trunk muscle training in supine andside-lying positions improves the gait ability of community-dwelling older adults [6,7]. However, it isdifficult for older adults to assume supine and side-lying positions after hip fracture surgery, thereby
hindering their application in clinical settings.
The effectiveness of virtual reality (VR)-based exercise therapy has been reported in recent studies [8]. The
beneficial effects of mediVR KAGURA® (mediVR, Inc., Osaka, Japan), which involves reaching exercises
targeting the trunk muscles in a seated position, on gait function have been reported in patients withcerebrovascular disease and postoperative patients with hallux valgus who have difficulty maintaining astable gait [9,10]. We discuss a case of a patient who showed improvement in independent gait following aphysical therapy intervention using mediVR KAGURA®.

Case Presentation
The patient was a female in her 90s who had undergone bipolar hip hemiarthroplasty for the treatment of aright femoral neck fracture sustained via a fall at home. She had sustained multiple fractures via falls in thepreceding few years, including fractures of the seventh, 11th, and 12th thoracic vertebrae; fracture of the

How to cite this article
Kawanishi K, Nakamoto M, Mityashita T, et al. (June 15, 2024) Seated Virtual Reality-Guided Exercise Improved Gait in a Patient With Trunk
Dysfunction Due to Hip Fracture: A Single-Case Design Study. Cureus 16(6): e62433. DOI 10.7759/cureus.62433

fifth lumbar vertebra; fracture of bilateral distal radius; and fractures of the distal phalanges of the right big
toe. The patient had undergone total knee arthroplasty for the treatment of bilateral osteoarthritis of theknees. She had resided alone until hospitalization for the treatment of the right femoral neck fracture. She
used a walker indoors for ambulation and a wheelchair outdoors with assistance.
Standard physical therapy, including range of motion exercises, resistance training, and gait training, wascommenced the day after surgery. The maximum 10-m walk time (10 MWT) improved to 18.4 s with thewalker one month postoperatively. An improvement in lower extremity pain was observed at the two-monthfollow-up visit; however, no improvement in the 10 MWT was observed. The trunk flexion was observed
during gait, and the patient had difficulty in maintaining independent gait and gait without upper limb
support. Kyphosis alignment was noted in the antigravity position (seated position); however, she was able
to maintain an upright posture in the degravity position (supine position). Minimal deformity of the spinal
structure and a decrease in trunk muscle function were observed (Figure 1).

FIGURE 1: Posture alignment before the intervention(A) Sitting posture and pelvic tilt angle. (B) Standing posture and pelvic sway distance. (C) Supine position
The pelvic tilt angle: the angle between the line connecting the external auditory canal to the greater trochanterand the line connecting the lateral epicondyle to the greater trochanter. The pelvic sway distance: the distance
between the vertical line of the external auditory canal and the maximum point of pelvic sway

Investigations
Withdrawal and reversal designs (BAB) were followed, and the duration of each period was one week. The
improvement was assessed visually during the non-intervention period (period A) based on the standard of
improvement. The 10 MWT and number of steps at maximal effort were measured as gait assessments before
and after each period. The hip extension angle, trunk tilt angle in the terminal stance phase, and step length
were calculated as the average of three gait cycles using Pose-cap, a markerless skeletal recognition software
program (Four Assist Co., Ltd., Tokyo, Japan) (Figure 2).

2024 Kawanishi et al. Cureus 16(6): e62433. DOI 10.7759/cureus.62433

2 of 8FIGURE 2: Assessment of alignment during gait using Pose-cap
a: Trunk anterior tilt angle. b: Hip extension angle. c: Step length
The trunk-tilt angle: the angle between the vertical line of the hip joint and the line connecting the shoulder and hip
joints. The hip extension angle: the angle between the lines connecting the shoulder joint to the hip joint and the
hip joint to the knee joint

Postural assessments were performed using ImageJ software Version 1.48 (National Institutes of Health,Bethesda, MD). The angle of pelvic tilt in the seated position (seated pelvic tilt; Figure 1A) and the distanceof pelvic shift in the standing position (standing pelvic shift; Figure 1B) were measured. The cross-sectional
area of the multifidus and psoas major muscles and the thickness of the external oblique abdominis, internal
oblique abdominis, and transversus abdominis muscles were measured via sonography (Aplio α Verifia,
Canon Co. Ltd., Tokyo, Japan) to evaluate trunk function. The angle of maximum pelvic anterior tilt in theseated position was measured using a smartphone application (Simple Angle Meter; Neko-system, Osaka,
Japan). The Five Times Sit to Stand test, functional reach test, and dynamic balance assessment using the
Berg Balance Scale were conducted to assess the performance. In addition, the range of motion of the joint(hip flexion and extension, knee extension, and ankle dorsiflexion), muscle strength (hip extension, hip
abduction, and knee extension), and maximum lower-extremity weight shift in the standing position wereassessed to evaluate lower-extremity function.

Treatment
Standard physical therapy interventions were performed twice daily for 40 minutes to improve trunk flexion
during gait and reduce walking time. Trunk training, comprising anterior-posterior pelvic tilt exercises andupper limb raising, was performed during Phase A. Seated reaching training was performed using VR
equipment (mediVR KAGURA; mediVR, Osaka, Japan) in Phase B for 20 minutes once a day (Figure 3).
Objects in the virtual space can be set at far, intermediate, and near distances, as well as the left and rightfrontal, diagonal, and side directions, depending on the task [11]. Trunk training was performed using the2024 Kawanishi et al. Cureus 16(6): e62433. DOI 10.7759/cureus.62433

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VR device customized to enable anterior pelvic tilt, trunk extension, and lower limb loading on the reachingside.

FIGURE 3: Virtual reality equipment and interventions
A: Virtual reality equipment. B: Intervention performed in virtual reality. C: The patient's view of the virtual reality
space
Image credits: Kengo Kawanishi

Outcome and follow-up
Table 1 presents the changes observed in each period in the order of B1, A, and B2 (B1-Baseline/A-B1/B2-A).
The 10 MWT and number of steps at the end of periods B1, A, and B2 were -5.9 s (-9 steps), 0.1 s (1 step), and-2.5 s (-3 steps), respectively. The hip extension range of motion (right/left) during gait at the end of periods
B1, A, and B2 was 7.1°/9.4°, 2.0°/-3.5°, and-1.0°/18.0°, respectively. The step length (right/left) was 11.3
cm/2.7 cm, -4.8 cm/0 cm, and 8.4 cm/4.2 cm, respectively, indicating an increase in step length and adecrease in gait time. The seated pelvic tilt at the end of periods B1, A, and B2 was 11.1°, 1.1°, and 5.5°,
respectively. The standing pelvic shift at the end of periods B1, A, and B2 was -5.3 cm, -0.4 cm, and -1.9 cm,
respectively.

Variables

B1

A

B2

Baseline
Value

B1

Baseline

Value

A B1

Value

B2 A

10 MWT (sec)

20.5

14.6

-5.9

14.7

0.1

12.2

-2.5

Step (number)

38

29

-9

30

1

27

-3

Rt hip ext angle (°)

-15.9

-8.8

7.1

-6.8

2

-7.8

-1

Lt hip ext angle (°)

-15.5

-6.1

9.4

-9.6

-3.5

-7.8

1.8

Rt trunk tilt angle (°)

12.9

13.8

0.9

10.5

-3.3

12.9

2.4

Lt trunk tilt angle (°)

14.3

9.1

-5.2

7.2

-1.9

8.7

1.5

Rt step length ( )

17.7

29

11.3

24.2

-4.8

32.6

8.4

Lt step length ( )

31.5

34.2

2.7

34.2

0

38.4

4.2

Sitting pelvic tilt (°)

-15.4

-4.3

11.1

-3.2

1.1

2.3

5.5

Standing pelvic shift

7.6

2.3

-5.3

1.9

-0.4

0

-1.9

Rt MF ( )

3.8

3.8

0

4.2

0.4

4.4

0.2

Lt MF ( )

5.7

5.8

0.1

5.5

-0.3

6

0.5

Rt PM ( )

5.3

5.4

0.1

5.4

0

5.6

0.2

Lt PM ( )

5.3

6.4

1.1

5.1

-1.3

6.2

1.1

Rt EO ( )

2

1.7

-0.3

1.2

-0.5

1.7

0.5

Lt EO ( )

1.5

1.3

-0.2

1.4

0.1

1.3

-0.1

Rt IO ( )

1.9

2.4

0.5

2.1

-0.3

2

-0.1

Gait parameters

PostureTrunk functions

2024 Kawanishi et al. Cureus 16(6): e62433. DOI 10.7759/cureus.62433

4 of 8Performance

L/E functions

Lt IO ( )

3

2.3

-0.7

2.2

-0.1

2.9

0.7

Rt TrA ( )

1.5

1

-0.5

1.1

0.1

1.8

0.7

Lt TrA ( )

1.9

1.4

-0.5

1.8

0.4

2.4

0.6

Maximum pelvic anterior tilt (°)

-8

0

8

0

0

3

3

Five Times Sit to Stand Test (sec)

17.4

10.6

-6.8

9.9

-0.7

9.1

-0.8

FRT ( )

7.5

13.8

6.3

14.1

0.3

19.5

5.4

BBS (points)

29

35

6

35

0

39

4

Hip flex range (°)

100

100

0

100

0

100

0

Hip ext range (°)

25

25

0

25

0

25

0

Knee ext range (°)

0

0

0

0

0

0

0

Ankle DF range (°)

15

15

0

15

0

15

0

Hip ext strength (KgF)

3.4

3.4

0

3.5

0.1

3.6

0.1

Hip Abd strength (KgF)

3.8

3.8

0

4

0.2

4.2

0.2

Knee ext strength (KgF)

3.8

3.8

0

4.1

0.3

5.1

1

Rt maximum weight shift (Kg)

33

33

0

33

0

33

0

Lt maximum weight shift (Kg)

33

33

0

32

-1

33

1

TABLE 1: Time-series data for the outcomes
Abd: abduction; BBS: Berg Balance Scale; DF: dorsiflexion; EO: external oblique muscle; ext: extension; flex: flexion; FRT: functional reach test; MF:
multifidus muscle; PM: psoas major muscle; TrA: transverse abdominal muscle; IO: internal oblique muscle; MWT: 10-meters walking test

These findings indicate an improvement in the posterior pelvic tilt alignment and pelvic forward
displacement. The maximum anterior pelvic tilt angle in the trunk function index improved to 8.0°, 0°, and3.0° at the end of periods B1, A, and B2, respectively. The Five Times Sit to Stand Test conducted to assess
the performance was shortened to -6.8 seconds, -0.7 seconds, and -0.8 seconds at the end of periods B1, A,
and B2, respectively. The patient required assistance from a nurse to ambulate using a walker during theinitial period of hospitalization; however, she was able to ambulate independently at the end of the B2
period and regained the pre-injury gait modality. Notably, no changes in the cross-sectional area of thetrunk muscle, muscle thickness (Figure 4), or lower extremity function were observed over the entire period.

2024 Kawanishi et al. Cureus 16(6): e62433. DOI 10.7759/cureus.62433

5 of 8FIGURE 4: Changes in cross-sectional area and thickness of the trunk
muscles
EO: external oblique abdominal muscle; IO: internal oblique abdominal muscle; MF: multifidus muscle; PM: psoas
major muscle; TrA: transverse abdominal muscle

Discussion
Our patient was able to walk independently two months after sustaining a femoral neck fracture following
the implementation of a VR-guided trunk training intervention. The maximum anterior pelvic tilt angle andsitting and standing postures improved; the hip extension range of motion and step length during gaitincreased; and the 10 MWT decreased during the VR-guided intervention period. These findings indicate theimportance of implementing interventions targeting the trunk muscles and the effectiveness of VR-guided
trunk training in patients with femoral neck fractures.
The use of mediVR KAGURA improves gait speed without inducing any changes in lower limb muscle
strength in patients with disuse syndrome [9] and reduces plantar sensation, as well as trunk sway, inpatients with hallux valgus [10]. However, the effect of mediVR KAGURA among older adults with impaired
trunk function after femoral neck fracture remains unclear. The present report revealed that trunk
movement, posture, balance, and gait can be improved without trunk muscle hypertrophy, even in patientswith femoral neck fractures and impaired trunk function.
Lumbar kyphosis has been associated with reduced trunk extensor strength [12] and dynamic balance [13].
The multifidus and psoas major muscles are involved in lumbar lordosis [14]. Our patient showed
improvement in sitting alignment and maximum anterior pelvic tilt angle. Moreover, the time for the Five
Times Sit to Stand Test of repetitive pelvic anterior-posterior tilt movement also exhibited a substantial
reduction. These findings suggest an improvement in the function of the multifidus and psoas major
muscles. Flexed trunk gait observed before implementing the intervention was thought to increase hip
extensor loading [15] and decrease the gait speed. The improvement in trunk muscle function was
accompanied by a decrease in the forward tilt of the trunk during walking, an increase in hip extension, anda decrease in the number of steps taken. Consequently, the gait time was shortened, with no significant
change in lower extremity function.
The improvement in dynamic balance ability affects gait [16], and patients can attain independent gait witha walker. Normal reach exercises are performed by obtaining visual feedback of the target point and body
position information [17]. However, the reaching motion performed using mediVR KAGURA provides
auditory, tactile, and visual sensory feedback without visual recognition of the body [9,11,18]. The dual-task
also showed improvements in cognitive function [19]. These results could be used to formulate interventions
for predictive postural control. In addition, the appropriate adjustment of the task (distance, speed, andfrequency) and the pleasant, game-like approach made the exercise more feasible than normal reaching [11].

Limitations
This case report presented the findings of a single case. Further randomized controlled trials must be
conducted to evaluate the effectiveness of VR-guided trunk training. Furthermore, although the
improvement in trunk function was related to postural control, no change in the cross-sectional area or
thickness of the trunk muscles was observed. Thus, this hypothesis could not be verified. The intervention
period should be extended to account for muscle hypertrophy.

2024 Kawanishi et al. Cureus 16(6): e62433. DOI 10.7759/cureus.62433

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Conclusions
Decreased trunk function has been identified as a factor contributing to decreased gait ability after femoral
neck fracture. Our findings indicate that VR-guided seated trunk training may be an effective intervention
for improving trunk function and gait ability. Seated trunk training using VR is a safe and comfortableintervention that can be implemented in clinical practice to facilitate effective trunk training in older adults.
Seated reach training using VR equipment improved trunk flexion during gait and reduced walking time.
VR-guided trunk training can effectively improve trunk muscle function and gait performance after femoral
neck fractures.

Additional Information
Author Contributions
All authors have reviewed the final version to be published and agreed to be accountable for all aspects of thework.
Concept and design: Kengo Kawanishi, Seiji Ogita, Shintatou Kudo
Acquisition, analysis, or interpretation of data: Kengo Kawanishi, Masami Nakamoto, Toshinori
Mityashita, Shintatou Kudo
Drafting of the manuscript: Kengo Kawanishi, Toshinori Mityashita
Critical review of the manuscript for important intellectual content: Kengo Kawanishi, Masami
Nakamoto, Toshinori Mityashita, Seiji Ogita, Shintatou Kudo
Supervision: Seiji Ogita, Shintatou Kudo

Disclosures
Human subjects: Consent was obtained or waived by all participants in this study. The Ethics Committee ofMorinomiya University of Medical Sciences issued approval 2022-160. Conflicts of interest: In compliancewith the ICMJE uniform disclosure form, all authors declare the following: Payment/services info: All
authors have declared that no financial support was received from any organization for the submitted work.
Financial relationships: All authors have declared that they have no financial relationships at present orwithin the previous three years with any organizations that might have an interest in the submitted work.
Other relationships: All authors have declared that there are no other relationships or activities that could
appear to have influenced the submitted work.

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