EEG-based brain–computer interface with immersive virtual reality for phantom limb pain: a single-center pilot neurofeedback trial

Abstract

Background – Phantom limb pain (PLP) is a challenging neuropathic pain condition following limb amputation or brachial plexus injury. Non-pharmacological interventions such as motor imagery training, phantom motor execution and mirror therapy have shown potential to alleviate PLP by engaging sensorimotor circuits, but their effects are debated. We developed GHOST, a portable EEG-based brain–computer interface (BCI) coupled with immersive virtual reality (VR), allowing patients to control a virtual limb via motor imagery in real time, as a neurofeedback-based rehabilitation tool. Methods – We conducted a single-center exploratory pilot trial to assess the feasibility and preliminary efficacy of this device. Seven patients with chronic upper-limb PLP (amputees or brachial plexus avulsion, pain ≥3/10) underwent 10 training sessions over 2 weeks. Daily pain diaries (distinguishing continuous pain vs. paroxysmal pain episodes) were recorded for 1 month before and 1 month after the intervention, with follow-up to 6 months. Motor imagery ability, anxiety-depression (HADS), and quality of life (SF-36) were also evaluated. Results – Six patients completed ≥8 sessions. All participants achieved BCI control of the virtual hand, with high success rates (>70%) even as task difficulty increased, demonstrating system feasibility. No adverse events occurred. Compared to baseline, patients experienced a significant short-term reduction in paroxysmal pain (frequency and intensity of pain “flare-ups”), with up to >80% median decrease in weekly cumulated pain episode intensity (p < 0.001). Three of five patients also reported around 30% improvement in average daily pain during the first post-training month. HADS anxiety/depression scores showed a non-significant improving trend. By 3–6 months post-training, pain levels had largely returned to pre-intervention values. Conclusion – This pilot study supports the safety and feasibility of EEG-BCI with VR for PLP and suggests that it can yield short-term analgesic effects, particularly on paroxysmal pain. These findings support the hypothesis that sensorimotor re-engagement could effectively target maladaptive neural processes underlying PLP, while warranting confirmation in controlled trials. Future work will optimize the training protocol and investigate neuroplastic changes associated with this BCI-VR intervention.