A Four-Phase VR Program Aims to Retrain the Brain and Ease Phantom Limb Pain

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Summary:

• UGA engineers and OrthoCarolina surgeons built a four-phase VR therapy for phantom limb pain

• Targeted Brain Rehabilitation (TBR) moves from left-right recognition to imagery, mirror therapy, and active movement

• Developers report upper-limb pain scores falling from 9 to about 2 in recent amputees

• TBR is FDA-registered as a Class II device and used in clinics for upper-limb patients only

• A $100,000 Lulu Strong Foundation grant is funding the lower-limb version

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Phantom limb pain affects a part of the body that is no longer there, making it resistant to treatments focused on the residual limb. A virtual reality (VR) program developed by orthopedic surgeons in Charlotte, North Carolina, and engineers at the University of Georgia (UGA) takes a different approach: targeting the brain.  

The program, called Targeted Brain Rehabilitation (TBR), guides patients through four phases of exercises while they wear a headset. It concludes with an image of the missing limb in motion, which the patient controls. According to UGA’s research news office, the developers aim to relieve pain and prepare patients to use a prosthesis. As of this writing, physicians at the surgeons’ company, Axolo Health, are already treating patients with the upper-limb version.  

Why the phantom pain persists  

The brain maintains a map of the body, and that map doesn’t update as soon as a limb is lost. Signals still travel to the missing arm or leg, but no signals return. According to a UGA Research article, nearby areas of the brain then move into the unused space, which can cause burning or cramping pain—or the sensation that a missing hand is clenched shut.

Axolo co-founder Dr. Glenn Gaston told Healio that up to 80% of amputees experience phantom limb pain. Many take long-term medication that manages symptoms without treating the neurological cause. His fellow co-founder, Dr. Bryan Loeffler, said phantom limb pain differs from residual limb pain: it results from changes in how the central nervous system processes information, not from the surgical site.

Ryan Serbin, an orthopedic resident and Axolo co-founder, compares the solution to exercise. Someone with two intact hands uses both throughout the day, keeping that part of the brain active. After limb loss, he said, the connection needs deliberate, repeated work to remain strong.

The four phases  

TBR brings established rehabilitation methods, including mirror therapy and graded motor imagery, together in a single headset program. Patients control it with their gaze, without handheld controllers. The phases proceed in this order:

1. Left or right. Patients practice identifying whether the hand on screen is the left or right one (clinicians call this laterality recognition).

2. Guided imagery. In a calm, meditative setting, patients imagine moving the missing hand again.

3. Mirror therapy. Patients move their intact limb while the headset reflects it, prompting the brain to interpret the movement as coming from the missing hand.

4. Active movement. The headset places a virtual limb where the missing one would be, and patients practice moving it.

According to UGA Research, phase four is where VR matters most because software can project any limb into the space. Serbin said the system guides patients through all four phases, gradually training them to move the hand again. Ultimately, the goal is to treat the pain and help patients use the prosthesis they have been fitted with.

From a borrowed headset to a clinical program  

The idea began with a patient. A woman who had lived with limb loss for years told surgeons at OrthoCarolina’s Reconstructive Center for Lost Limbs that she had tried a relative’s VR headset, seen a hand on the screen, and felt her phantom pain ease. Loeffler and Gaston wondered if this effect could become a treatment.

Their resident, Ty Frix, who has an engineering degree from UGA, connected them with Kyle Johnsen, a professor in the university’s College of Engineering who runs its VR lab. Johnsen drove to Charlotte and built a rough version for one patient. The encouraging response led the team to pursue a broader application, supported by a UGA presidential seed grant and additional university funding.

Serbin took a year away from his residency to research the idea. He read hundreds of papers on existing phantom limb pain treatments, from mirror therapy to graded motor imagery, and worked to make them easy for amputees to use in VR. He collaborated with Johnsen and Ethan Bowmar, a UGA graduate in electrical and computer engineering who is now Axolo’s first employee, while clinic physicians and residents helped shape each development phase. Axolo licenses the software from UGA through the university’s technology transfer office, Innovation Gateway.

What the early numbers show  

The figures look promising; however, please keep in mind that they come from the team’s own reports on clinic use and involve only upper-limb amputees.

• The team found that one TBR session provides about six to eight hours of pain relief—roughly as long as relief from a dose of an opioid or anti-inflammatory, according to UGA Research.

• In trials involving 60 to 70 upper-limb patients, those treated immediately after surgery saw their average pain scores drop from 9 to about 2.

• According to the same report, patients with chronic pain said it fell by more than half.

• Gaston told Spectrum News that long-term patients reported roughly 50% less pain after 10 weeks, while recent amputees who began TBR immediately were not developing phantom limb pain.

Serbin described the first patient to try the completed fourth phase: a woman whose phantom hand had been stuck in one position for 15 years, despite everything she had tried to improve it. When the session ended, she was in tears. Serbin said he cried, too.   

Next steps  

Home use. The therapy is currently delivered in clinics, but the team is studying whether patients can take home their own headsets for a six-week protocol. Serbin said one session can reduce pain by about half. The team suspects that longer use may train the brain more thoroughly and lower a patient’s baseline pain over time. Frix added that if the therapy can limit brain changes after limb loss, it might prevent some of the long-term pain they cause, though he noted that much more research is needed.

Therapy for lower-limb loss is in the works. But these versions are more challenging. According to UGA Research, stationary cameras can track hands well but struggle with feet, and the team is not ready to discuss its solution in detail. Johnsen said the group has tested several approaches with patients and believes it is on the right track.

The good news is that there is funding for this work. Lulu Gribbin, an Alabama teenager who lost her left hand and part of her right leg in a 2024 shark attack and used TBR during her recovery, founded the Lulu Strong Foundation. In March 2026, the foundation awarded its first grant—$100,000 to Axolo Health—to help develop VR treatment for the lower limb.

Regulatory status. TBR is registered with the FDA as a Class II software medical device. Axolo said in February that it is commercializing the platform for in-clinic use and plans to expand access over time.

If you or someone you know has phantom limb pain and wants to know whether TBR is offered nearby, ask your surgeon or physiatrist, or check Axolo Health’s website.

Related Reading:

Virtual Reality Training Improves Phantom Limb Pain in Partial Hand Limb Loss

Virtual Reality: A Promising Frontier in Phantom Pain Therapy

Mr. MAPP Displays Advances in Virtual Therapy for Phantom Limb Pain

Possible Causes, Treatments of Phantom Limb Pain