Virtual reality for people who have limb loss or limb difference: a multidisciplinary perspective on needs for clinical translation and future research

Virtual reality programs, ranging from laboratory-based simulation environments to home-based immersive headsets, have the potential to improve rehabilitation for people with limb loss (e.g., acquired amputation) and limb difference (e.g., congenital limb absence). Over the past several years, virtual reality programs have become more ubiquitous in research studies and healthcare systems. However, the integration of virtual reality into rehabilitative care for people with limb loss or limb difference remains overlooked. While prior systematic reviews have evaluated the efficacy of virtual reality (VR) in rehabilitation and phantom limb pain, there is a lack of literature on how these findings translate into clinical rehabilitation for people with limb loss and limb difference while accounting for access, equity, workflow, and implementation barriers, along with considering multidisciplinary perspectives from researchers, clinicians, and people with lived experiences. Our perspective article discusses the potential benefits of virtual reality for people with limb loss or limb difference, areas of need for future research, and considerations for implementation in clinical practice to improve rehabilitation. We provide our multidisciplinary views as researchers in virtual reality (authors RBT and KT), psychological wellbeing (RBT and CM), motor functions (AK), physical activities (RP), and body composition (AG); clinical researchers with expertise in people with limb loss and limb difference, who are also prosthetists (CM and MGF), occupational therapists (KT), and physical therapists (SC); and a nurse who is also a person with lived experience (DH). The target audience for this article includes researchers and clinicians working with people who have limb loss and limb difference. Based on our views as experts across the spectrum of health, we present some future research needs and clinical implications to inform the adoption of virtual reality for people with limb loss and limb difference and to improve rehabilitation.

This perspective synthesizes current evidence on virtual reality (VR) in rehabilitation for people with limb loss and limb difference, along with advances three central arguments: 1) VR may improve rehabilitation engagement, symptom management, and functional training; 2) clinical translation is constrained by accessibility, safety, reimbursement, and workflow barriers; 3) implementation science and community-engaged research efforts are needed to guide equitable adoption. Although prior systematic reviews have evaluated the efficacy of VR in rehabilitation and phantom limb pain, few works have examined how these findings translate into clinical rehabilitation for people with limb loss and limb difference while accounting for access, equity, workflow, and implementation barriers.

Limb loss is defined as amputation, where the three most prevalent etiologies in the US include dysvascular (54%), traumatic (45%), and cancer-related (2%) causes (Ziegler-Graham et al., 2008; Caruso and Harrington, 2024; Rivera et al., 2024). The majority of people with limb loss are estimated to be older adults (between 44%–65%), and this proportion is projected to increase as the population ages and dysvascular diseases become more prevalent (Ziegler-Graham et al., 2008; Caruso and Harrington, 2024; Rivera et al., 2024). In contrast, limb difference is defined as a congenital etiology, meaning someone who was born without a limb or a portion of a limb (Ziegler-Graham et al., 2008; Caruso and Harrington, 2024). The scope of this perspective article includes people with lower-limb (e.g., leg) loss, upper-limb (e.g., arm) loss, and limb difference.

VR refers to a computer-generated environment that can lead to a sense of physical presence in a virtual world (Baños et al., 2005; Jones and Zenko, 2023). VR systems vary by level of immersion (Slater and Sanchez-Vives, 2016), where the most immersive devices are head-mounted VR displays; these systems allow users to navigate and interact within a scene from a full 360° perspective (Jones and Dawkins, 2018). VR head-mounted displays, such as the Meta Quests, are fully immersive because they block the physical reality of the individual, accommodate a range of senses, and provide a panoramic environment through a high-resolution display. Less immersive formats, such as VR flat-screen displays (e.g., phone application, television monitor), provide audiovisual stimulation but with lower interactivity, embodiment, and presence (Flavián et al., 2019).

Author DH has lower-limb loss and has used VR recreationally. None of the remaining authors have limb loss or limb difference but have used VR recreationally. This perspective article represents an effort to critically evaluate the available evidence and clinical use of VR to improve rehabilitation in people with limb loss and limb difference.

Overview of current literature

VR literature on people with limb loss and limb difference can be categorized into two main areas: motor function and psychological wellbeing.

Motor function

Physical activity (PA)

PA is defined as any movement that is produced as a result of skeletal muscle contraction, thereby increasing caloric expenditure above the resting value (Caspersen et al., 1985). Peripheral artery disease is one of the leading causes of lower-limb loss and is a comorbidity often associated with type 2 diabetes (Varma et al., 2014); both conditions are associated with low PA levels (Tudor-Locke et al., 2002; Hernandez et al., 2019). An important aspect of rehabilitation following limb loss is assisting individuals to engage in regular PA to reap physical, psychological, and social health benefits (Bragaru et al., 2011; da Silva et al., 2011). However, many studies have reported that people with lower-limb loss do not receive adequate PA (Deans et al., 2012; Hordacre et al., 2015; Littman et al., 2017; Miller et al., 2019; Delbello et al., 2026).

In the general population, VR has been investigated as a potential tool to help individuals engage in PA and to promote health outcomes (Godoy-Cumillaf et al., 2025; Chang et al., 2025). Various studies have reported that VR interventions may improve psychological wellbeing and motor function in people following lower-limb amputation (Abbas et al., 2024; Hao et al., 2023). However, to the best of our knowledge, there are no studies that report PA parameters in people using VR compared to traditional rehabilitation interventions following lower-limb amputation. Thus, research is needed to determine if VR can improve the frequency and duration of PA in people with limb loss and limb difference. Additionally, people with limb loss and limb difference have reported experiencing barriers to PA, including transportation, lack of desire to perform PA in a public setting, lack of motivation, and having a formalized exercise program after concluding physical therapy sessions (MacKay et al., 2024; Olsen et al., 2023; Deans et al., 2012), which could potentially be mitigated by home-based VR systems.

Body composition

PA impacts body composition directly. For instance, physical inactivity combined with limb loss or limb difference promotes biomechanical deficits and systemic adaptations, including increased metabolic cost of movement (Czerniecki and Morgenroth, 2017) and tissue degradation (Bramley et al., 2021; Finco et al., 2023c). Skeletal muscle loss and motor function deficits alter the power-to-weight ratio, which reflects the force-generating capacity relative to body mass (Kuschel et al., 2022). Muscle quality is also compromised by intramuscular fat infiltration (myosteatosis) (Finco et al., 2023a). These changes contribute to a maladaptive cycle of physical inactivity, muscle loss, and fat accumulation, resulting in sarcopenic obesity across the lifespans of people with limb loss (Kyle et al., 2001; Donini et al., 2022; Finco et al., 2023b) while increasing the risk of cardiovascular disease, metabolic syndrome, and mortality. The body mass index is insufficient for capturing these changes, necessitating more sophisticated body composition assessments. Limb loss also leads to a decline in bone mineral density (BMD), particularly in the residual limb, increasing fracture risk despite prosthesis use (Finco and Menegaz, 2022; Finco et al., 2023b).

VR-based rehabilitation and exercise strategies offer a novel approach to address the compositional burdens that characterize individuals with lower-limb loss and limb difference. As an exergaming (combination of video games and exercise) modality, VR has the potential to increase energy expenditure and reduce fat mass while preserving or improving lean tissue, particularly when resistance, external loading, or power-oriented tasks are included within the gameplay. Prior studies indicate favorable body composition changes in individuals with lower-limb loss following the adoption of physical fitness programs. When VR incorporates weight-bearing or resistance-based components, it may attenuate BMD loss and promote favorable shifts in musculoskeletal composition. For geriatric patients with limb loss, where sarcopenic obesity is most prevalent, VR interventions are well suited for preserving muscle mass, muscle quality, and BMD rather than indiscriminate weight loss programs. Although VR appears to be feasible and safe, studies integrating comprehensive and objective body composition data remain scarce despite being essential for determining whether VR can address the musculoskeletal deficits undermining metabolic health and functional independence in individuals with limb loss and limb difference.

Balance, gait, and motor learning

Impaired PA and altered body composition can contribute to balance and gait deficits, which are associated with high fall risks in this population (Finco et al., 2023c; Tobaigy et al., 2023; Sawers and Hafner, 2022). A limited number of studies have examined how VR interventions can improve the motor function (i.e., kinematic and kinetic) properties of balance and gait (Arazpour et al., 2026; Hao et al., 2023; Paillet et al., 2025); however, the aspects of motor function that may improve with VR interventions or the manner in which such changes may potentially reduce fall risk remain unknown. Large and expensive systems (e.g., Computer Assisted Rehabilitation Environment (CAREN)) have shown clinical mobility improvements and gait mechanics alterations (Arazpour et al., 2026). However, lower-cost VR systems could offer similar benefits in terms of the spatiotemporal metrics of gait mechanics, as well as offer opportunities to target individual biomechanical deficits impacting functional activities to improve mobility.

When examining the applicability of VR interventions, it is critical to consider the long-term learning properties of motor functions. In the population considered herein, few studies have addressed the retention of motor functions or transfer of skills to real-world tasks. Existing VR interventions primarily use exergames without harnessing current technologies that afford the study of motor skill acquisition beyond clinical environments. A critical next step requires establishing the validity of VR as an adjunctive clinical strategy and identifying optimal frequency/duration guidelines for incorporation into clinical rehabilitation. The level of immersion offered by VR systems also needs to be considered, as some environments (e.g., CAREN) are cost prohibitive while others offer advantages for telerehabilitation.

Functional performance

Standard rehabilitation aims to restore physical function, with the goal of increasing independence and quality of life. For people with lower-limb loss, this includes performing transfers (e.g., sit-to-stand), navigating obstacles (e.g., curbs, objects, stairs, and crowds), maintaining balance (e.g., ability to remain standing), and ambulating with a prosthesis (e.g., capacity to walk or change speeds) successfully. For people with upper-limb loss, this includes completing daily living activities. A focus on task metrics, through standardized clinical outcome measures, allows monitoring the functional improvements but offers limited insights into the underlying mechanisms. Thus, there is a need to develop effective motor rehabilitation strategies that restore functional performance, as well as sensorimotor aspects such as proprioception, within home and community environments. VR offers opportunities to augment standard clinical strategies and target specific motor function deficits (e.g., asymmetric gait mechanics, proprioception, and reactive balance). Positive evidence of VR-based rehabilitation exists for neurologic, pediatric, and musculoskeletal populations (Voinescu et al., 2021; Chen et al., 2022; Gumaa and Youssef, 2019), yet there have been limited applications in people with limb loss and limb difference, particularly at-home VR interventions. One potential limitation is that the current VR head-mounted displays do not provide sophisticated tactile or haptic feedback, which may reduce their ability to support prosthetic motor learning.

Psychological wellbeing

While motor rehabilitation has been studied more commonly, VR can create immersive and controllable environments that the user can engage in for relaxation, mindfulness-based activities, or graded exposure therapy. These experiences may help address common psychological challenges following limb loss, such as disrupted mood, decreased self-efficacy, heightened anxiety, and difficulty adjusting to altered body image, which can impede rehabilitation, prosthetic acceptance, and quality of life (Calabrese et al., 2023; Maciver et al., 2024; Şimşek et al., 2020).

VR literature on the psychological aspects is largely focused on phantom limb pain, which affects over 60% of people with limb loss (Limakatso et al., 2020). VR provides a dynamic interface for manipulating a virtual limb and has been shown to reduce pain, with effects comparable to mirror therapy (Rajendram et al., 2022). Furthermore, studies indicate that VR-based limb representations can provide a better sense of embodiment, including improved perceived limb ownership and enhanced sense of agency, which collectively support psychological adjustment (Osumi et al., 2017; Tong et al., 2020). The current literature demonstrates that VR can reduce phantom limb pain, but it does not explore why reducing phantom limb pain matters in the broader context of the person’s life. Therefore, clinicians are essentially treating the symptom (i.e., phantom limb pain) while neglecting the opportunity to utilize VR as a comprehensive tool for psychological wellbeing to address the person as a whole.

Current research rarely examines the broader psychological outcomes beyond phantom limb pain. VR interventions have been shown to improve depression and other mental health scores (Abbas et al., 2024); in other populations, VR has been shown to improve anxiety, pain, and quality of life (Liang et al., 2025; Mao et al., 2024; Wang et al., 2025). However, these approaches have not been widely applied to people with limb loss and limb difference. Until research expands beyond phantom limb pain, VR will remain underutilized as a comprehensive psychological intervention.

Considerations for implementation in clinical practice

Although research evidence indicates that VR has the potential to improve several health aspects among people with limb loss and limb difference, many challenges remain for practical implementation in clinical practice.

VR rehabilitation settings

People with limb loss and limb difference are cared for by multiple rehabilitation professionals across varied clinical settings, with differences in scope of practice and reimbursements that complicate the implementation of VR-based interventions. A person with limb loss may undergo amputation surgery within a hospital system, participate in inpatient rehabilitation, and then transition to outpatient care involving prosthetists, physical therapists, and occupational therapists. These settings operate under different clinical responsibilities and reimbursement mechanisms (Gavette et al., 2024), which could create fragmentation that poses challenges for continuity and scalability of VR integration.

A hospital-based VR rental model may offer a feasible strategy for supporting both inpatient and outpatient rehabilitation. In outpatient settings, VR has been increasingly integrated into supervised physical and occupational therapy sessions using time-based billing structures. In contrast, to our knowledge, VR has not been incorporated into prosthetic practice, which may reflect differences in reimbursement. Prosthetic services are primarily reimbursed through device-based billing using Healthcare Common Procedure Coding System L-codes, which offer limited mechanisms to support VR-based rehabilitation. These differences suggest that a next step toward clinical integration may involve generating evidence to support hospital-based VR rental programs and using the existing time-based reimbursement pathways within physical and occupational therapy practices.

VR implementation in clinical practice should account for variability in both the person (i.e., upper limb or lower limb) and the clinical environment, with adaptability as a key priority. VR systems should match an individual’s comfort with technology and allow progression for more advanced users. In busy clinical environments, quick setup, clear clinical benefits, and efficient transitions between patients are essential. If the clinicians are required to spend more than a few minutes in setting up the system, it is unlikely that the technology will be used consistently. Thus, VR workflows must be efficient and tied to clinical goals. The rehabilitation programs should also be adaptable across limb loss levels and mimic prosthesis use to improve transfer to real-world function. Finally, if an individual plans to use a prosthesis, VR should mimic prosthesis use by offering engaging ways to practice with similar control strategies, such as relevant prosthetic components and a realistic sense of load demands, to improve transfer to real-world prosthetic function.

Establishing protocols

Prior to wide-scale clinical adoption, protocols should be developed for safety, education, and clinician scope of practice; these should also offer methods for ensuring patient privacy during and after data collection and transfer. Ensuring proper patient orientation, assessing contraindications, and arranging caregiver support are important factors, particularly for immersive at-home VR use. The United States Food and Drug Administration provides resources related to VR medical devices (U.S. Food and Drug Administration, 2026), which could be adapted. Patient data should remain HIPAA compliant, and the data ownership should be defined. Practical aspects related to clinical burden and workflow integration should also be considered. The time required for VR setup and calibration must also be efficiently integrated into clinical workflows. Factors such as technology costs, IT support, reimbursement, lack of high-speed internet, availability of space, and scalability may pose barriers (Threapleton et al., 2016), which can be assessed in implementation science research.

People-centric focus

People with limb loss and limb difference should be kept at the center of their personal rehabilitation journey. VR integration requires clinicians to collaboratively develop meaningful goals with the patients while considering safety and appropriateness. Researchers, clinicians, and policymakers should incorporate the perspectives of people with limb loss and limb difference when developing VR-related studies, clinical procedures, and policies. VR has the potential to improve quality of care, particularly in terms of patient-centeredness and equity (Agency for Healthcare Research and Quality, 2025), but more research efforts on VR interventions and implementation are needed.

Future research needs

While specific future research needs within the motor function and psychological wellbeing aspects are detailed above, several broader needs exist across VR literature.

Inclusion in research

VR research is heavily weighted toward people who use lower-limb prostheses and remains underexplored in people with upper-limb loss or difference. Hence, VR research that assesses applications specific to upper-limb loss and difference (e.g., myoelectric pattern-recognition training, bimanual coordination tasks, virtual object manipulation for activities of daily living) are needed. Even in people with lower-limb loss or difference, VR research is needed for those who have a limb difference, do not use a prosthesis, or are older adults. Regardless of lower-limb or upper-limb status, people who do not use a prosthesis can still benefit from VR-based interventions, with a potential focus on seated activities and upper-limb motor functions. Many people with limb loss or limb difference are older adults or have dysvascular etiologies. However, most VR literature is based on adults under 65 years. While there is a common misconception that older adults are not likely to adopt new technologies, literature shows that the digital divide is decreasing and that many older adults demonstrate high engagement with technology for their health, including VR (Yang et al., 2024; Finco et al., 2024). Thus, VR studies and rehabilitation protocols should include older adults with limb loss or difference, as such interventions may be particularly beneficial owing to the combined risk factors of age and limb loss or limb difference.

VR modality and additional technology needs

Home-based and low-cost smartphone-based VR systems have rarely been reported in current literature, yet they may provide additional benefits to people with limb loss and limb difference who experience barriers to PA (e.g., transportation, lack of desire to perform PAs in public, and lack of motivation), particularly for people in rural areas (Littman et al., 2017; Ambron et al., 2018). Additionally, the option of using VR to attend a clinic visit is becoming more feasible, although this relationship has not been explored to our knowledge. Several limitations with home-based VR should be considered, including cybersickness from immersive headsets (Pawełczyk et al., 2025).

Equity needs

One of the critical components of ensuring adequate adoption and translation of any technology to clinical practice is access to such technology and health equity. People residing in rural locations are at greater risk for lower-limb amputations (Akinlotan et al., 2021; Brennan et al., 2022; McGinigle and Minc, 2021) and subsequently poorer outcomes following limb loss (Clemens et al., 2023). The recent proliferation of home-based telehealth for rehabilitation after limb loss offers opportunities to incorporate the use of VR in these endeavors. Expanding the use of VR could benefit not only the individuals residing in rural areas but also persons lacking accessibility or reliable transportation to rehabilitation appointments. To our knowledge, the use of VR to improve PA and psychological outcomes after limb loss in under-resourced populations remains unexplored.

Availability and access to the equipment necessary for VR-based rehabilitation interventions could be a barrier to implementation. Some potential solutions to these problems include low-cost systems (e.g., cardboard headsets incorporating a smartphone), rental options from reputable or hospital-based sources, and low-cost internet access. However, even if the accessibility barriers are overcome, people with limb loss and limb difference will need to be trained to use such technology, where the primary concern will be safety during use of the VR device. People with limb loss have increased fall risk, and previous studies using VR for rehabilitation in this population have included safety harnesses and/or the presence of a clinician/research personnel. Currently, the viability of independent VR use by the person with limb loss or difference in the home setting is undetermined. Technologies that allow a person to retain visual access to their real-world physical environment (e.g., mixed reality, augmented reality) will likely be safer alternatives during unassisted at-home rehabilitation. Although VR offers opportunities to expand effective rehabilitation to underserved populations, research is needed to assess the feasibility, efficacy, and safety in these patients.

Implementation needs

To avoid widening disparities, research is needed for optimizing inclusive design and implementation. For instance, researchers should elicit perspectives from people with limb loss and limb difference on their willingness to use and to experience using VR programs. Clinicians and clinic owners can provide inputs on the feasibility of translation to clinical practice. Further, many reviews mentioned in this perspective article have concluded that larger sample sizes and randomized controlled trials are still needed prior to VR implementation in clinical practice (Hali et al., 2024). Identifying the barriers and motivators to using VR programs, especially from the perspectives of people with limb loss and limb difference and of clinicians, could inform the development of relevant interventions and protocols (Gavette et al., 2024; Felsberg et al., 2025). Acceptability and feasibility metrics (e.g., usability, adherence, enrollment, and attrition rates) can also inform research and rehabilitation protocol development. Thus, people with limb loss and limb difference, as well as clinicians and clinic owners, should be included as participants when developing research studies to gain unique perspectives that help ensure adoption and translation to clinical practice.

Figure 1 depicts a summary of the future research needs and considerations for implementing VR in clinical practice. While there is evidence supporting the potential of VR to improve various components of health (i.e., motor functions, psychosocial wellbeing), research conducted with larger sample sizes and randomized controlled trials, particularly for people with upper-limb loss or difference, as well as those with limb difference, those who do not use a prosthesis, or those who are older adults, is necessary to determine the efficacy of VR. Although VR has the potential to improve rehabilitation for the person as a whole, there remain challenges in terms of access, health equity, safety, data privacy, reimbursement, and clinic workflow. Implementation science research is needed to assess these challenges and potential solutions, so that VR can be successfully used in the clinic to improve rehabilitation in people with limb loss and limb difference.