Motor Imagery and Cervical Proprioception Training: A Practical Evidence Update
Richard Wheatley
Cervical proprioception rehabilitation is often treated as a purely physical task: move the head, relocate a target and repeat. A 2026 randomised trial asks whether the mental representation of movement may also be useful.
Mahmoud and colleagues studied 44 people with mechanical neck pain. One group received conventional physiotherapy, while the other received kinesthetic and visual motor imagery with biofeedback in addition to conventional care.
What is motor imagery?
Motor imagery is the internal rehearsal of a movement without physically performing it. Kinesthetic imagery focuses on how the movement feels. Visual imagery focuses on seeing the movement, from either a first-person or external perspective.
In cervical rehabilitation, imagery may help a patient attend to direction, amplitude and the expected sensory consequences of movement before completing the physical task. Biofeedback then provides external information about performance.
What did the study report?
The combined intervention group showed greater improvements in cervical joint position sense, neck disability, pain and reach performance than the conventional physiotherapy group.
The result is promising because it suggests that proprioception training may be enhanced by combining internal rehearsal with external feedback. This could be relevant for patients who move cautiously, have difficulty sensing midline or show inconsistent repositioning performance.
Important limitations
The trial was small and short term. Motor imagery and biofeedback were delivered together, so the study cannot establish how much benefit came from imagery, feedback, additional therapist attention or the combination. The published registration information also appears incomplete, which makes it harder to assess whether every reported outcome followed a fully prespecified plan.
The findings should therefore be treated as an encouraging clinical signal, not definitive evidence for a universal protocol.
How might this translate into practice?
A simple progression could include:
- Establish a comfortable neutral head position and a clear target.
- Ask the patient to imagine the intended movement, including its direction and feel.
- Perform the movement slowly, initially with visual feedback.
- Return to the perceived starting position without visual feedback.
- Reveal the result and discuss accuracy, strategy and symptoms.
- Repeat across clinically relevant directions, changing speed or task complexity only when appropriate.
The purpose is not to chase perfect scores. It is to improve the patient's ability to plan, sense and correct movement with an appropriate level of challenge.
Where HeadX Kross and Duo may fit
HeadX Kross provides an intuitive visual target for movement and repositioning tasks. It can support the transition from visible guidance to eyes-closed relocation and then to more functional target sequences. HeadX Duo can add numerical feedback when objective measurement is required.
This is a practical match for the study's broader principle: combine an internal representation of movement with meaningful external feedback. However, the HeadX devices were not used in this trial, so the research should not be presented as direct product validation.
For related practical material, see the HeadX exercise programme and our overview of cervical sensorimotor complexity.
Clinical takeaway
Motor imagery may be a useful adjunct to cervical proprioception rehabilitation, particularly when paired with structured feedback. The current evidence is promising but preliminary. Clinicians should individualise the task and measure whether the approach actually changes performance and function for the patient in front of them.
Source: Mahmoud et al. Effect of kinesthetic and visual motor imagery with biofeedback on cervical position sense and balance in patients with mechanical neck pain, 2026.
This article is for professional education and does not replace individual clinical assessment.