ORIGINAL RESEARCH

IJSPT EFFECTIVENESS OF A MOTOR CONTROL

THERAPEUTIC EXERCISE PROGRAM COMBINED WITH
MOTOR IMAGERY ON THE SENSORIMOTOR
FUNCTION OF THE CERVICAL SPINE: A RANDOMIZED
CONTROLLED TRIAL
Amanda Hidalgo-Peréz, PT1
Ángela Fernández-García, PT1
Ibai López-de-Uralde-Villanueva, PT, Msc1-4
Alfonso Gil-Martínez, PT, Msc1-4
Alba Paris-Alemany, MD, PT, Msc1-4
Josué Fernández-Carnero, PT, Msc, PhD1-5
Roy La Touche, PT, MSc, PhD1-4

ABSTRACT
Background: Motor control therapeutic exercise (MCTE) for the neck is a motor relearning program that emphasizes the coordination and contrac-
tion of specific neck flexor, extensor, and shoulder girdle muscles. Because motor imagery (MI) improves sensorimotor function and it improves
several motor aspects, such as motor learning, neuromotor control, and acquisition of motor skills, the authors hypothesized that a combination of
MCTE and MI would improve the sensorimotor function of the cervical spine more effectively than a MCTE program alone.
Purpose: The purpose of this study was to investigate the influence of MI combined with a MCTE program on sensorimotor function of the cra-
niocervical region in asymptomatic subjects.
Study Design: This study was a single-blinded randomized controlled trial.
Methods: Forty asymptomatic subjects were assigned to a MCTE group or a MCTE+MI group. Both groups received the same MCTE program for
the cervical region (60 minutes), but the MCTE+MI group received an additional intervention based on MI (15 minutes). The primary outcomes
assessed were craniocervical neuromotor control (activation pressure value and highest pressure value), cervical kinesthetic sense (joint position
error [JPE]), and the subjective perception of fatigue after effort.
Results: Intra-group significant differences were obtained between pre- and post interventions for all evaluated variables (p<0.01) in the MCTE+MI
and MCTE groups, except for craniocervical neuromotor control and the subjective perception of fatigue after effort in the MCTE group. In the
MCTE+MI group a large effect size was found for craniocervical neuromotor control (d between -0.94 and -1.41), cervical kinesthetic sense (d between
0.97 and 2.14), neck flexor muscle endurance test (d = -1.50), and subjective perception of fatigue after effort (d = 0.79). There were significant inter-
group differences for the highest pressure value, joint position error (JPE) extension, JPE left rotation, and subjective perception of fatigue after effort.
Conclusion: The combined MI and MCTE intervention produced statistically significant changes in sensorimotor function variables of the cranio-
cervical region (highest pressure value, JPE extension and JPE left rotation) and the perception of subjective fatigue compared to MCTE alone.
Both groups showed statistically significant changes in all variables measured, except for craniocervical neuromotor control and the subjective
perception of fatigue after effort in the MCTE group
Level of Evidence: 1b
Key Words: Cervical disorders, motor imagery, motor control, therapeutic exercise.

1
Department of Physiotherapy, Faculty of Health Science, The
Center for Advanced Studies University La Salle, Universidad CORRESPONDING AUTHOR
Autónoma de Madrid, Aravaca, Madrid, Spain Roy La Touche
2
Research Group on Movement and Behavioral Science and
Study of Pain, The Center for Advanced Studies University La Facultad de Ciéncias de la Salud
Salle, Universidad Autónoma de Madrid, Aravaca, Madrid, Spain Centro Superior de Estudios Universitarios
3
Institute of Neuroscience and Craniofacial Pain (INDCRAN),
Madrid, Spain La Salle.
4
Hospital La Paz Institute for Health Research, IdiPAZ. Madrid, Calle La Salle, 10
Spain 28023 Madrid
5
Department of Physical Therapy, Occupational Therapy,
Rehabilitation and Physical Medicine, Universidad Rey Juan SPAIN
Carlos, Alcorcón, Madrid, Spain Telephone number: + 34 91 7401980 (EXT.256)
The authors report no conflicts of interest. E-mail address: [email protected]

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INTRODUCTION motor learning, neuromotor control, and acquisition
Neck pain is one of the most frequent musculoskel- of motor skills,24,25 the authors hypothesized that a
etal disorders, with a one-year prevalence of around combination of MCTE and MI would improve the
37%, and a significant problem in healthcare.1 Neck sensorimotor function of the cervical spine more
pain has a high prevalence in triathletes and cyclists, effectively than a MCTE program alone. Thus, the
especially recreational athletes.2–6 Fortunately, ath- purpose of this study was to investigate the influ-
letic neck pain is usually the result of minor injury ence of MI combined with a MCTE program on sen-
and most athletes can return to full activity.7 sorimotor function of the craniocervical region in
asymptomatic subjects.
Therapeutic exercise is an effective intervention
in neck pain management in both the short (<1
month) and intermediate (1-6 months) terms.8 One METHODS
of the most interesting approaches used to manage Study Design
neck pain is therapeutic exercise with a focus on This study was a single-blind, randomized, and con-
motor control; some authors describe altered move- trolled trial; the assessor responsible for obtaining
ment patterns (e.g., less flexible movement pat- the study outcomes was blinded to intervention
terns, reduced range motion, and/or poor accuracy group allocation. This study was planned and con-
in maintaining maximal voluntary isometric con- ducted in accordance with the CONSORT require-
traction) in the cervical spines of patients with neck ments (Consolidated Standards of Reporting Trials).26
pain.9–11 Motor control can be defined as the capacity
of how the central nervous system produces of use- Recruitment of Participants
ful movements that are coordinated and integrated A convenience sample of asymptomatic volunteers
with the rest of the body and the environment.12 was obtained from a university campus and the
Thus, motor control therapeutic exercises (MCTE) local community through flyers, posters, and social
are relevant to improve the status of patients with media. Subjects were recruited between February
neck pain. In fact, MCTE have been demonstrated to and May 2014. The inclusion criteria were healthy
increase motor control and reduce pain and disabil- subjects between 18 and 65 years old. The exclu-
ity in patients with neck pain.13–15 Changes in motor sion criteria included the following: a) subjects who
control that could cause pain or dysfunction require experienced neck pain in the previous 6 months; b)
practitioners to work on the components of motor subjects who had been treated for neck pain in the
learning for a successful intervention capable of pro- previous 6 months; c) subjects with other chronic
ducing satisfactory motor learning and retention. pain conditions; and d) subjects with difficulty in
Such an intervention requires repetitive training.16,17 communication or understanding.
Alternatively, motor imagery (MI), defined as the
Informed consent was obtained from all subjects
mental representation of movement without any
before inclusion. All participants received an expla-
body movement, can be employed to improve motor
nation about the procedures of the study, and each
performance and learn motor tasks.18 This technique
one completed a questionnaire with demographic
has usually been used in sports, but recent research-
data. All of the procedures were planned under the
ers show that it is also effective in treating patients
ethical norms of the Declaration of Helsinki and
with neurological diseases or chronic pain.18,19 By
were approved by the ethics committee of the Cen-
inducing the activation of different cortical areas,18,20,21
ter for Advanced Studies University La Salle.
MI is useful for influencing the central nervous sys-
tem and causing plastic changes in the brain. Thus,
Randomization
this method should be considered for use in rehabili-
Randomization was performed using a computer-
tation, because its goals include the improvement of
generated random-sequence table with a two-bal-
motor performance and learning.18,22,23
anced block design (GraphPad Software, Inc., CA,
Considering that MI improves sensorimotor func- USA). A statistician generated the randomization
tion and it improves several motor aspects, such as list, and a member of the research team who was

The International Journal of Sports Physical Therapy | Volume 10, Number 6 | November 2015 | Page 878
not involved in the assessment or treatment of the pist instructed the participants regarding the MCTE
participants was in charge of the randomization and program in one one-to-one session that lasted approx-
maintained the list. imately 60 minutes. In this session, participants were
taught each exercise and all the details of the train-
Once the initial assessment and inclusion of the
ing program were explained (sets, repetitions, rest
participants were complete, the included were ran-
periods, frequency, and common mistakes in the
domly assigned to either of the two groups (MCTE
exercises). To ensure proper motor control, the ses-
alone or MCTE-MI) using the random-sequence list,
sion ended with the participant performing the entire
ensuring concealed allocation.
training program supervised by a physiotherapist.
Blinding The MCTE used for this research is based on retrain-
The assessor was blinded to the condition of the ing the cervical muscles and included the following
healthy subjects being assessed. The subjects were exercises:15 1) craniocervical flexor exercise (Figure
told to freely comment to the researcher in charge of 1, Exercise 1); 2) craniocervical extensor exercise
performing the allocation about how they were feel- (Figure 1, Exercises 2A-2B); 3) co-contraction of flex-
ing or regarding the intervention itself. Additionally, ors and extensors (Figure 1, Exercise 3); and 4) a syn-
the subjects were asked not to make any comments ergy exercise for retraining the strength of the deep
to the assessor. neck flexors (Figure 1, Exercises 4A-4B). Each of
these four exercises was performed for three sets of
Interventions
10-12 repetitions, taking an approximate total dura-
MCTE in isolation (MCTE) tion of 10 to 20 minutes. The subjects were asked to
The subjects in the MCTE group received a prescrip- practice the MCTE program at home once a day, 5
tion for MCTE for the cervical region. A physiothera- days a week, for 30 days.

Figure 1. Exercises that were used in the motor control therapeutic exercise program: 1) Craniocervical flexor exercise, 2) Cranio-
cervical extensor exercise [a=start, b=end], 3) Co-contraction of neck flexors and extensors, 4) Synergy exercise for deep neck
flexors [a=start, b=end].

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 Table 1. Phases of Motor Imagery Intervention.

MCTE in conjunction with MI (MCTE-MI) test; and 5) assessment of perception of fatigue after
The subjects in the MCTE-MI group underwent the deep neck flexors endurance test.
the MCTE program and also received an addi-
tional intervention based on MI. The MI interven- Self-report outcomes
tion was explained at the end of the MCTE session After consenting to the study, recruited healthy
and instruction lasted approximately 15 minutes. subjects were given a battery of questionnaires
The objective of the MI program was to modify the to complete on the day of the first measurement.
MCTE program. The four phases of the MI interven- These included various self-reports for sociodemo-
tion were performed one after the other, in order, graphic and psychological variables, collecting infor-
for 4 weeks: a) kinesthetic imagery (first week); b) mation about gender, age, height, and weight, and
visual imagery (second week); c) movement obser- included the validated Spanish versions of the Pain
vation therapy plus MI (third week); and d) exer- Catastrophizing Scale (PCS),27 the Tampa Scale for
cise execution with mirror feedback (fourth week). Kinesiophobia (TSK-11),28 the Hospital Anxiety and
(Table 1) Depression Scale (HADS),29,30 and the International
Physical Activity Questionnaire (IPAQ).31 Each of
All participants (both groups) also received a book-
these tools has acceptable validity and reliability.
let with written information about the indications
and exercises to be practiced at home to ensure that
Outcome Measures
the training program was performed properly. Each
week, participants received messages by email and Primary Outcome Measures
phone to remind and motivate them to undertake Craniocervical neuromotor control. The CCFT has
the exercise program as scheduled. been described as a neuromotor control test that
evaluates the activation and isometric endurance
Procedure of the deep neck flexors.16 The CCFT is performed
Outcomes were obtained twice in each group, and with the subject in a supine position, with 45º of hip
participants were supplied with a battery of self- flexion and 90º of knee flexion. A feed-back device
report questionnaires before the intervention. The “stabilizer” (Chattanooga Group, Inc., Hixson, TN,
neuromotor assessment of subjects in both groups USA) was applied under the suboccipital region
was performed before and 30 days after the inter- and inflated to 20 mmHg of pressure; subjects were
vention The measurements performed included: 1) verbally instructed to bend their heads, as if saying
cervical range of motion (ROM) measurements; 2) “yes,” to obtain a craniocervical flexion movement. A
craniocervical flexion test (CCFT); 3) joint position correct pattern movement of craniocervical flexion
error (JPE) test; 4) the deep neck flexor endurance was required and had to be verified by the evaluator

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during the CCFT. Craniocervical flexion is described - Cervical kinesthetic sense. JPE tests were used (in
as flexion of the head over the upper cervical region four motions) to assess this variable. JPE is an objec-
without any flexion of the middle or lower cervi- tive measure of neck reposition sense and can quan-
cal region. The movement was considered incor- tify the alteration of neck proprioception.35,36 This
rect when activation of the sternocleidomastoid and measure is based on the ability to relocate the natu-
anterior scalenus was palpable, a movement quickly ral head posture (anatomic position) after perform-
took place, and/or head retraction was performed ing several cervical movements.37 For this, a laser
instead of craniocervical flexion. Each of these com- pointer, mounted onto a light-weight headband, was
pensations were assessed by both observation and used. The test procedure was as follows: the subjects
palpation. The movement was taught to each partici- were placed in a sitting position with the head in a
pant and practiced before the test to ensure that the resting position. A target was positioned against a
craniocervical flexion was performed correctly, and wall 90 cm away from the subject’s head (Figures
the evaluator highlighted the importance of preci- 2A & 2B). Once the device was placed on the sub-
sion rather than force.32 ject, subjects were blindfolded and asked to perform
the neck movement being tested within comfort-
With the CCFT, two items were measured in two able limits and to return as accurately as possible to
phases, respectively: the starting position. The linear distance (assessed
in cm) between the center and the end positions
1) Activation pressure value (APV): the highest pres-
was measured and recorded. Four movements were
sure a subject could achieve and maintain for 10 sec-
evaluated: flexion, extension, and left and right rota-
onds while properly performing the CCFT, less the
tions; starting each time with the patient reposi-
baseline 20 mmHg (registered in mmHg). This first
tioned to the center position before performing the
part was undertaken to determine the contractile
tested movement. Regarding the reliability, the ICC
capacity of the deep neck flexors when performing
for this test has been reported to range from 0.35 to
the correct movement pattern. Intra-rater reliability
0.44, with a good agreement between days;38 and the
for this measure was very high [ICC=0.91; 95% CI
MDC ranged from 7 to 10 mm.34
(0.85 to 0.96)].33
Secondary Outcome Measures
2) Highest pressure value (HPV): the highest target
- Cervical ROM: Cervical ROM was measured with
pressure that a subject could achieve and hold for
a cervical goniometer called CROM (Performance
10 seconds, starting at a baseline of 20 mmHg and
Attainment Associates, Lindstrom, MN). This device
increasing by 2 mmHg at each phase, with a total of
has three inclinometers, one in each plane of move-
five phases and a top value 30 mmHg (target pres-
ment. A plastic support piece houses two inclinom-
sures of 22, 24, 26, 28, and 30 mmHg). The feed-back
eters, which allow for the measurement of flexion,
device provided information to the subjects regard-
extension, and lateral flexion of the neck. The third
ing the performance of the target pressure during
inclinometer and magnets around the neck allow for
the ten second hold, and a 30 second rest was given
rotation measurement39 (Figure 2C, 2D, & 2E). This
between phases. This second part was undertaken
device is valid and reliable for test-retest measures
to determine the pressure (registered in mmHg)
[r=0.98, 95% CI (0.95 to 0.99)], with MDC for flexion
that the asymptomatic subject could achieve with
of 2.2º, extension 2.8º, left rotation 2.1º, right rota-
the correct movement pattern held for ten seconds.
tion 2.6º, left lateral flexion 1.8º, and right lateral
When the subject could not perform the correct
flexion 1.6º.40
movement, the test finished and the pressure regis-
tered was the greatest pressure at which the subject -Neck Flexor Muscle Endurance Test. The aim of this
performed the correct movement without substitu- test was to assess neck flexor endurance, isometri-
tion, which corresponded to the previous phase. The cally against gravity. The participants laid in a supine
reported intra- and inter-rater reliability for this test position with the knees and hips bent to 45º. The test
was high [ICC = 0.82, 95% CI (0.67 to 0.91)]; the min- consisted of a craniocervical flexion position main-
imal detectable change (MDC) was 4.70 mmHg.34 tained isometrically followed by a lift of the head 2.5

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Figure 2: Cervical kinesthetic sense testing device and target (Figure A), lightweight headband with laser pointer (Figure B),
Cervical Cervical range of motion measured using the CROM (Performance Attainment Associates, Lindstrom, MN) (Figures C,
D, E).

cm above the plinth while the chin was maintained in Sample Size Calculation
the retracted position. The subjects were instructed to The necessary sample size was estimated using
bend their chin and lift their head up and hold it. To G*Power 3.1.7 for Windows (G*Power©, University
check whether the subject had failed, one researcher’s of Dusseldorf, Germany).44 The sample size calcula-
hand was placed under the head to monitor when the tion was considered as a power calculation to detect
participant failed to maintain the head lift, and visual between-group differences in the primary outcome
monitoring was used to establish when the chin had measures (craniocervical neuromotor control and
lost its retracted position; either event meant the test cervical kinesthetic sense). To obtain 80% statis-
was over. The outcome of the test was time in seconds tical power (1-β error probability) with an α error
that the subject could maintain the correct craniocer- level probability of 0.05, we used repeated-measured
vical flexion position.41 The ICC value for inter-rater analysis of variance (ANOVA), within-between inter-
reported reliability for this test ranged from 0.57 to action, and a medium effect size of 0.25 to consider
1.0 and the MDC was 6.4 seconds.42 two groups and two measurements for primary out-
comes, generating a sample size of 17 participants
-Subjective perception of fatigue after effort. The visual per group (total sample size of 34 subjects). Allowing
analogue fatigue scale (VAFS) was used to quan- a dropout rate of 15% and aiming to increase the sta-
tify fatigue after performing the neck flexor endur- tistical power of the results, the authors planned to
ance test. The VAFS consists of a 100-mm vertical recruit at least 40 participants to provide sufficient
line on which the bottom represents “no fatigue” (0 power to detect significant group differences.
mm) and the top represents “maximum fatigue” (100
mm). After the neck flexor endurance test, the sub- Statistical Analysis
ject was instructed to mark on the line the level of The Statistical Package for Social Sciences (SPSS 21,
fatigue felt after the effort of performing the test. SPSS Inc., Chicago, IL, USA) software was used for
The researcher recorded the mark in millimeters.43 statistical analysis. The normality of the variables

The International Journal of Sports Physical Therapy | Volume 10, Number 6 | November 2015 | Page 882
Figure 3: Flow diagram of recruitment and retention of subjects.

was evaluated by the Shapiro-Wilk test. Descriptive magnitude of the effect was classified as small (0.20
statistics were used to summarize the data for con- to 0.49), medium (0.50 to 0.79), or large (0.8).46
tinuous variables and are presented as mean ±stan-
dard deviation (SD), 95% confidence interval (CI), For variables with non-normal distributions, the
and median (interquartile interval), and categori- Mann-Whitney U test was utilized. The Wilcoxon
cal as absolute (number), and relative frequency signed-rank test was used to analyze the change
(percentage). A chi-squared test with residual anal- from the intra-group results. The α level was set at
ysis was used to compare categorical variables. Stu- 0.05 for all tests.
dent’s t-test and two-way repeated-measures ANOVA
were used to compare continuous outcome variables. RESULTS
The factors analyzed were group (MCTE in isola- Forty healthy subjects were included in this research,
tion, MCTE in conjunction with MI) and time (pre- and were randomly allocated in two groups of 20
intervention, post-intervention). The time x group subjects per group. There were no adverse events
interaction, which is the hypothesis of interest, was or drop-outs reported in either group. A CONSORT
also analyzed. Partial eta-squared (η2p) was calculated flow diagram is provided in Figure 3. No statistically
as a measure of effect size (strength of association) significant differences were present pre-interven-
for each main effect and interaction in the ANOVAs tion between groups in demographic data and self-
and 0.01-0.059 represented a small effect, 0.06-0.139 reported variables (p>0.05), meaning the groups
a medium effect, and > 0.14 a large effect.45 Post hoc were not significantly different from each other. The
analysis with Bonferroni correction was performed in demographic data and self-reported variables are
the case of significant ANOVA findings for multiple shown in Table 2. The Shapiro-Wilk test confirmed
comparisons between variables. Effect sizes (d) were that the data were normally distributed (p>0.05),
calculated according to Cohen’s method, in which the except for age and cervical ROM.

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 Table 2. Summary of demographic and psychological variables. Values are mean ±SD and n (%).

Primary Outcomes differences in the HPV at the post-intervention mea-

Craniocervical neuromotor control. Statistically signifi- sure, all with large effect sizes (p<0.001; Table 3).
cant differences were found for CCFT revealing differ-
ences for the group x time interaction [APV (F=9.85, Cervical kinesthetic sense. The were no significant
p=0.003; η2p = 0.21); HPV (F=10.18, p=0.003; η2p = group x time interaction differences for any of the
0.21] and for the time factor [APV (F=7.54, p= 0.009; measures of JPE; however, statistically significant
η2p = 0.16); HPV (F=43.56, p<0.001; η2p = 0.53)]. Pre- differences were observed for the time factor in all
post intervention differences were observed in APV ROMs measured for JPE (flexion: [F=38.52, p<0.001;
and HPV in the MCTE-MI group and between groups η2p=0.50]; extension: [F=24.53, p<0.001; η2p=0.39];

The International Journal of Sports Physical Therapy | Volume 10, Number 6 | November 2015 | Page 884
right rotation: [F=28.84, p<0.001; η2p=0.43]; left The greatest effect sizes were found in the MCTE-
rotation: [F=19.12, p<0.001; η2p=0.33]). The post MI group in all measures; the largest effect size that
hoc analysis revealed differences between the pre- equates to a large effect size was for the JPE exten-
and post-intervention results in both groups for all sion measure (d=2.14). The descriptive data and
the movements (p<0.05), but not between groups. multiple comparisons are presented in Table 3.

Table 3. Descriptive data and multiple comparisons of the primary variables.

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Secondary Outcomes groups but not between groups (p<0.001) for the
Cervical ROM. Statistically significant differences deep flexor endurance test; however, there were
in cervical ROM were found in both groups when differences between groups post-intervention in
the pre-intervention data was compared with the the VAFS (p<0.001) and only pre-post differences
post-intervention data; however, the Mann-Whitney in the MCTE-MI group (p<0.001). The effect sizes
U-test showed no statistically significant differences were greatest in the MCTE-MI group in both mea-
between groups. The descriptive data and multiple sures, especially in the neck flexor endurance test
comparisons are presented in Table 4. (d=1.50). The descriptive data and multiple com-
parisons are presented in Table 5.
Neck flexor endurance and fatigue perception. Statisti-
cally significant differences in group x time interac- DISCUSSION
tion were found for only for VAFS (F=10.38, p=0.03; This study was designed to determine the effect of
η2p=0.22). Regarding pre- to post- interaction for MI combined with a MCTE program on the cervi-
both groups, statistically significant differences cal region in asymptomatic subjects. This study pro-
were found for the deep neck flexor endurance test vides new evidence of the effects of MI and MCTE
(F=119.80, p<0.001; η2p=0.75) and VAFS (F=4.2, on sensorimotor variables measured in the cervical
p=0.047; η2p =0.1). Post hoc analysis revealed dif- region in asymptomatic subjects. An intervention of
ferences between pre- and post-intervention in both MCTE combined with MI was effective in improving

Table 4. Descriptive data and multiple comparisons of cervical ROM outcomes.

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 Table 5. Descriptive data and multiple comparisons of the secondary variables.

craniocervical neuromotor control and the subjec- agree, based on the observation that both groups
tive perception of fatigue after effort, while MCTE improved in this variable; however, MI may enhance
in isolation did not produce changes for these same outcomes beyond MCTE alone, since it has been
variables. studied in other investigations that MI may contrib-
ute to improving the precision of movement48,49 and
The results of the JPE, cervical ROM, and deep neck
integrating relevant proprioceptive information.50 It
flexor endurance tests showed no statistically sig-
is important to note that extensive evidence supports
nificant differences between groups, but statistically
MI practice and its effects on motor behavior and
significant changes were observed within each group
motor recovery.51–58 MI has been useful in patients
for these variables. The reported effect sizes (d) of the
that have had a stroke, have Parkinson’s disease, have
differences obtained in most of these variables are
sustained spinal cord injury, and those who have had
larger in the combined intervention group than in
an amputation. In the case of post stroke rehabilita-
the MCTE group in isolation. Previous research sup-
tion, MI has demonstrated changes in cerebral acti-
ports the theoretical argument regarding the changes
vation observed with neurophysiological recordings
in the variables related to the cervical region for both
and improvements in the performance of the paretic
study groups, and MI seems to have an additional
limb, increasing functionality.52,54
effect on sensorimotor variables, such as cervical
neuromotor control, perceived fatigue, and kines- At present, the recovery strategies for cervical neuro-
thetic sense in the normal subjects studied. motor control are based mainly on models of motor
learning using therapeutic exercise, but there is no
Craniocervical Neuromotor Control and previous evidence on the use of MI to improve cra-
Cervical Kinesthetic Sense niocervical neuromotor control. The current results
The main measures of this study assessed the cervi- show promising findings about improving craniocer-
cal kinesthetic sense and craniocervical neuromotor vical neuromotor control with the combination of
control, measured by the ability to activate the deep MI and MCTE. Consistent with these results, several
cervical flexor muscles. These two variables serve an authors have demonstrated that MI combined with
important proprioceptive role in the integration of physical practice is effective in improving motor
sensorimotor control. Previous evidence has shown function.51,59,60 Adding the mental rehearsal (MI) to
that MCTE can improve JPE,47 and the current results the practice of physical exercise resulted in much bet-

The International Journal of Sports Physical Therapy | Volume 10, Number 6 | November 2015 | Page 887
ter performance and reduced movement time execu- in muscle strength and voluntary torque produc-
tion when performing a specific task with the upper tion after MI alone or in combination with physical
limb.51 Also, MI is an effective method for motor learn- activity.71–74 When MI was compared to no interven-
ing24,25,61,62 and the acquisition of new motor skills.24 tion in those studies, an improvement of endurance
was observed,74,75 while in the current study the non
Unlike other studies, craniocervical neuromotor
statistically significant improvement could be due
control did not improve in the group that performed
to the exercise itself, being not enough 4 weeks of
the MCTE alone, possibly because the MCTE pro-
intervention to obtain the results that other studies
gram was performed at home without any supervi-
have when combining with exercise.73,75 One of the
sion, which could have led to subjects performing
main differences between the previous studies and
the exercise with less precision. It is important to
the current study is the areas of the body where the
note that most studies of MCTE programs are con-
intervention was focused: the current focus on the
ducted under the supervision of a physiotherapist.
neck muscles, while previous studies focused on the
The authors believe that the combined intervention
muscles of the upper and lower limbs. These areas of
improved neuromotor control, because the MI pro-
the body have a greater cortical representation (par-
vided more information for motor learning and sen-
ticularly the hands and ankles) than neck muscles,76
sorimotor integration and promoted retention and
and this might make it difficult to achieve significant
acquisition of motor skills,63–66 and suggest that this
differences in strengthening in present sample.
may be helpful when practicing at home without
supervision to achieve a better performance. Regarding the perception of fatigue as measured by
the VAFS, the results showed a decrease only for the
Cervical Range of Movement group that used a combination of MCTE and MI. In
Prior scientific evidence has shown that MCTE support of this, Catalan et al75 showed that a treat-
improves cervical ROM.67,68 Thus, it is assumed that ment to improve motor planning based on MI was
the improvement observed in the cervical ROM was effective in reducing fatigue in patients with mul-
a result of the MCTE program performed by both tiple sclerosis. Also, Rozand et al77 recently showed
groups. Therefore, MI does not produce a signifi- that MI combined with physical practice does not
cant effect on ROM, and for that reason, no signifi- exacerbate neuromuscular fatigue.
cant differences between groups were found in this
variable. Unlike the current results, other authors
Practical and Scientific Implications
have found positive effects in improving flexibility
This is the first study investigating the effect of MI
through the combination of MI and physical prac-
in combination with a MCTE program for the cervi-
tice in healthy athletes.55,69 For example in a study by
cal region. The results of this research are promis-
Guillot et al55 that included MI in flexibility training,
ing with regard to the sensorimotor improvements
ROM improved after training. In present study, the
obtained, but these data should be interpreted with
subjects were healthy non-athletes; therefore, the
caution because the study was conducted with
improvements observed by Gillot et al55 may have
asymptomatic subjects. It is not acceptable to extrap-
been due to the high learning ability of the athletes
olate the results to patients with chronic neck pain.
in terms of MI training.70
The authors of this study believe that the investiga-
tion of this type of intervention applied to symptom-
Muscular Endurance and Fatigue Perceived
atic patients could generate additional information
No statistically significant differences were observed
therapeutic alternatives for those with neck pain
between the groups for the variable neck flexor
Moreover, having found differences in asymptom-
endurance, but there were differences in the pre- and
atic subjects, the combination of MI with an MCTE
post-intervention results in each group, which could
program may be recommended as a useful preven-
be due to the practice or performance of the exercise
tive treatment in the fight against chronic neck pain.
program. These results suggest that MI does not influ-
ence increases in muscular endurance. The current Both of the intervention programs used in this
results differ from many studies that show changes research could be considered cost-effective since

The International Journal of Sports Physical Therapy | Volume 10, Number 6 | November 2015 | Page 888
there was only one supervision session, and the rest is speculation since a validated tool was not utilized
of the program was performed individually at home to quantify the level of adherence. However, the
for 30 days, for an average of 10 to 20 minutes per authors did include motivation to increase compli-
session. Beinart et al84 disclosed in their system- ance with the program, which is an important aspect
atic review that a large proportion of MI programs of promoting adherence with exercise programs at
(focused on motor skills, performance, or strength home.84
improvement, and applied to all ages) have a total
duration of 34 days and a duration of on average 17 Finally, although there were no statistical differ-
minutes per session. Unlike the program used in ences between the sexes, the MCTE group was only
the current study however, the MI programs in most 30% female, while the MCTE plus MI group was
other studies were conducted under professional 50% female. Along these lines, recent studies inves-
supervision.78 The method seems to be a safe inter- tigated the differences between males and females
vention, and so far, no author has reported adverse in sensorimotor cortical representation, and there is
effects after its completion.79 much we do not know about how the female body
is represented in the brain or how it might change
In this study, therapeutic exercise was combined with different reproductive systems, hormones, or
with a MI program consisting of several activities experiences.85
related to different mental tasks, such as kinesthetic
imagery, visual imagery, movement observation CONCLUSIONS
therapy, and MI plus exercise execution with mir- The results of the current study show that combin-
ror feedback. The authors believe that the combina- ing MI with MCTE produced statistically significant
tion of these mental tasks enhances motor learning, changes in sensorimotor function variables of the
enabling better results in the combined intervention craniocervical region and the perception of subjec-
group. This study is the first to integrate all these tive fatigue. Both interventions showed statistically
mental tasks with physical practice. significant changes in all variables measured, except
for craniocervical neuromotor control and the sub-
Study Limitations jective perception of fatigue after effort in the MCTE
This study has several limitations. The first and most group. However, APV (craniocervical neuromotor
important is that the subjects’ ability to generate control), JPE flexion and JPE right rotation (cervical
motor images has not been quantified. This is a fac- kinesthetic sense), cervical ROM, and neck flexor
tor to take into consideration, as there are validated muscle endurance were not significantly different
instruments to measure this variable in healthy sub- between the two groups. These findings must be
jects with restricted mobility.80–82 It is important to interpreted with caution because the study popu-
consider since it may influence the efficiency of lation was comprised of asymptomatic subjects.
generating images.83 Future studies should be directed toward perform-
ing the same study protocol for patients with neck
Secondly, variables were measured in only the short pain in order to check whether the combination of
term, so it is necessary to measure the impact in the MI and MCTE is more effective than MCTE alone for
medium and long terms. Also, it could be considered ameliorating their neck pain.
a limitation that there was not a control group. It
would also be interesting to include an experimental
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