Background: Cervicogenic and craniofacial pain disorders, such as chronic neck pain and cervicogenic headache, are often accompanied by impairments in oculomotor control, cervical proprioception, and postural stability. Eye Motor Control Training (EMCT) aims to address these sensorimotor deficits and improve functional outcomes.
Objective: To systematically review recent high-quality evidence on the effects of EMCT or combined oculomotor–sensorimotor interventions on pain, function, and sensorimotor performance in these disorders.
Methods: A systematic search of PubMed, Web of Science, and Cochrane CENTRAL (2016–2025) identified randomized controlled trials (RCTs) and systematic reviews involving adults with cervicogenic headache or chronic neck pain receiving EMCT-based interventions.
Results: One systematic review and four RCTs met inclusion criteria. EMCT significantly improved pain intensity, disability, cervical range of motion, and proprioceptive accuracy compared with standard care. Moderate-to-large effects were observed for gaze stability and joint position sense, with benefits persisting up to 12 months.
Conclusion: EMCT is a promising adjunct to multimodal rehabilitation for cervicogenic and craniofacial pain. It effectively targets sensorimotor dysfunctions underlying chronic pain and disability, though further standardized, large-scale trials are needed to confirm optimal protocols and long-term efficacy.
INTEGRATING OCULOMOTOR AND CERVICAL SENSORIMOTOR TRAINING INTO MULTIMODAL REHABILITATION OF CRANIOFACIAL PAIN AND HEADACHE: EVIDENCE FROM SYSTEMATIC REVIEW OF RCTS
Author:
Tobias Giesen | MSc SEM (UK), BSc PT (NL) Independent Researcher in Physiotherapy and Sports Medicine Germany
Abstract:
Background: Craniofacial and cervicogenic pain disorders, including chronic neck pain and cervicogenic headache, are frequently associated with deficits in oculomotor control, cervical proprioception, and postural stability. These dysfunctions may contribute to altered sensorimotor integration and sustained nociceptive input within the craniocervical system. Eye Motor Control Training (EMCT), encompassing oculomotor and cervical sensorimotor exercises, has been proposed as a therapeutic approach to address these deficits. Despite increasing research interest, high-quality evidence synthesis remains limited.
Objective: To systematically review randomized controlled trials (RCTs) and systematic reviews published within the last ten years investigating the effects of EMCT or combined oculomotor-sensorimotor interventions on pain, function, and sensorimotor performance in patients with cervicogenic or craniofacial pain disorders.
Methods: A systematic literature search was conducted in PubMed, Web of Science, and Cochrane CENTRAL (January 2016-October 2025). Eligible studies included RCTs or systematic reviews examining adults with cervicogenic headache (CGH), chronic neck pain (CNP), or related craniocervical pain, using interventions that included oculomotor or cervical sensorimotor training components. Only high-level evidence (RCTs, meta-analyses) was included. Methodological quality was qualitatively appraised according to PRISMA principles and risk of bias.
Results: One systematic review and meta-analysis and four RCTs met the inclusion criteria. The evidence indicates that EMCT, as part of a multimodal rehabilitation approach, significantly improves pain intensity, disability, cervical range of motion, and proprioceptive accuracy compared with standard therapy alone. Sensorimotor outcomes, including gaze stability, dynamic visual acuity, and joint position sense, demonstrated moderate-to-large effect sizes in several studies. Improvements were maintained for up to 6-12 months in follow-up data. The quality of evidence ranged from moderate to high across studies.
Conclusion: EMCT represents a promising adjunctive intervention for cervicogenic and craniofacial pain disorders, targeting underlying sensorimotor dysfunctions that perpetuate pain and disability. Although heterogeneity in protocols remains, consistent benefits in both clinical and functional outcomes support its integration into multimodal rehabilitation programs. Further large-scale RCTs with standardized training protocols are warranted to establish optimal dosage and long-term efficacy.
Keywords:
Oculomotor training, cervical sensorimotor control, cervicogenic headache, craniofacial pain, neck pain, systematic review, randomized controlled trial.
This paper is an independent academic publication in the field of Physiotherapy Science and Sports Medicine. The author declares no institutional affiliation and no conflicts of interest.
1. Introduction
Craniofacial and cervicogenic pain disorders represent a major public health burden, characterized by persistent nociceptive input originating from the upper cervical spine and related musculature, frequently radiating to the head and face (Bogduk, 2014). Among these, cervicogenic headache (CGH) and chronic neck pain (CNP) are prevalent conditions associated with considerable functional disability, work absenteeism, and reduced quality of life (Fejer et al., 2019). The etiopathogenesis of these disorders extends beyond musculoskeletal dysfunction and encompasses alterations in sensorimotor control, particularly within the oculomotor and cervical proprioceptive systems (Kristjansson & Treleaven, 2009; Carvalho et al., 2022).
Sensorimotor Control in Craniocervical Pain
The cervical spine provides crucial afferent input to the central nervous system through muscle spindles and joint mechanoreceptors that inform head position and movement relative to the body and visual field. The integration of this information with visual and vestibular cues enables accurate gaze stability and postural control (Treleaven, 2008). Disruption of this integration—through injury, sustained nociceptive input, or maladaptive motor strategies—can result in sensorimotor dysfunction, manifesting as dizziness, unsteadiness, blurred vision, and impaired oculomotor control (Kristjansson & Treleaven, 2009). Such impairments have been consistently observed in individuals with CGH and chronic neck pain (Carvalho et al., 2022; Haddadpour et al., 2024).
A systematic review and meta-analysis by Carvalho et al. (2022) demonstrated that patients with chronic headache and neck-related disorders exhibit measurable deficits in postural control compared to healthy individuals. Similarly, Haddadpour et al. (2024) reported consistent impairments in joint position sense (JPS) and oculomotor accuracy among individuals with chronic neck pain, supporting the presence of multisensory dysfunction within the cervical-visual axis. These findings substantiate the hypothesis that sensorimotor retraining—targeting the integration of cervical afferent input and ocular motor control—may represent a valuable therapeutic approach.
Rationale for Eye Motor Control Training (EMCT)
Eye Motor Control Training (EMCT) refers to a structured set of exercises aimed at restoring coordination between cervical and oculomotor systems. Typical training components include gaze stabilization, saccadic and pursuit eye movements, eye-head coordination tasks, and joint position sense exercises (Treleaven et al., 2016). EMCT can be implemented as a standalone protocol or embedded within multimodal physiotherapy programs encompassing manual therapy and strengthening exercises.
Several mechanisms underpin the potential efficacy of EMCT. First, targeted activation of cervical proprioceptors during gaze and head movement tasks may recalibrate sensorimotor integration, reducing mismatch between visual, vestibular, and somatosensory inputs (Kristjansson & Treleaven, 2009). Second, improved gaze stability and proprioceptive feedback may mitigate maladaptive muscle activation patterns contributing to pain persistence (Revel et al., 1991). Finally, the engagement of attentional and cognitive processes during visually guided movement tasks may enhance cortical reorganization and descending inhibitory control (Ghotra et al., 2021).
Current Evidence Landscape
Over the past decade, the clinical efficacy of EMCT and related cervical sensorimotor control training (SMT) has been explored in a growing number of randomized controlled trials. Pérez-Cabezas et al. (2020) investigated an Eye-Cervical Re-education Program (ECRP) in patients with chronic neck pain, demonstrating significant improvements in pain, cervical range of motion, and pressure pain thresholds compared to standard care. Emam et al. (2024) examined a proprioceptive training protocol incorporating gaze direction recognition tasks in patients with cervicogenic headache, reporting substantial reductions in pain intensity and improvements in postural stability. Similarly, Sremakaew et al. (2023) and Canli et al. (2025) found additive benefits of sensorimotor and oculomotor exercises when combined with manual therapy or tactile discrimination training.
A recent systematic review and meta-analysis by Luznik et al. (2025) synthesized evidence from seven RCTs and concluded that cervical sensorimotor training produces small-to-moderate improvements in pain and disability in chronic neck pain, with consistent gains in proprioceptive and oculomotor performance metrics. Importantly, these benefits appear to extend beyond short-term outcomes, with several trials reporting maintained improvements over 6-12 months.
Despite these encouraging findings, gaps remain in understanding the optimal structure, dosage, and specificity of EMCT protocols. Variations in training duration, exercise type (e.g., gaze stabilization vs. eye-head coordination), and control interventions limit the ability to draw definitive conclusions. Additionally, while EMCT has been evaluated in both neck pain and cervicogenic headache, its application to broader craniofacial pain syndromes—such as temporomandibular disorder (TMD)— remains underexplored, with current evidence limited to protocol publications (Ribeiro et al., 2025).
Need for a High-Evidence Synthesis
Given the proliferation of individual RCTs and the emerging but fragmented evidence base, a systematic synthesis of high-quality studies is warranted to clarify the role of EMCT in the management of cervicogenic and craniofacial pain. This review aims to bridge this gap by focusing exclusively on high-evidence-level sources (RCTs and systematic reviews published within the last ten years), providing an updated and critical appraisal of the effectiveness of oculomotor and cervical sensorimotor training on pain, function, and sensorimotor outcomes in this patient population.
Objectives
The present systematic review addresses the following objectives:
1. To evaluate the clinical effectiveness of Eye Motor Control Training (alone or combined with physiotherapy) on pain intensity, disability, and function in patients with cervicogenic or craniofacial pain, including chronic neck pain.
2. To synthesize evidence regarding changes in sensorimotor outcomes (joint position sense, gaze stability, postural control) following EMCT interventions.
3. To identify gaps in the literature concerning methodological rigor, training parameters, and long-term follow-up.
4. To provide clinical recommendations for integrating EMCT into multimodal rehabilitation of cervicogenic and craniofacial pain.
By systematically appraising the best available evidence, this review seeks to contribute to the refinement of targeted rehabilitation strategies addressing the neurophysiological underpinnings of craniocervical pain disorders.
2. Methods
This work followed a systematic review design according to the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines (Page et al., 2021). The review protocol was structured prior to data collection and focused exclusively on studies with a high level of evidence, defined as randomized controlled trials (RCTs) and systematic reviews or meta-analyses of RCTs. The research question was framed following the PICO model (Population, Intervention, Comparator, Outcome).
Research question:
What is the effectiveness of Eye Motor Control Training (EMCT), including oculomotor and cervical sensorimotor training components, in reducing pain and improving function and sensorimotor performance in adults with cervicogenic, craniofacial, or chronic neck pain disorders?
Eligibility criteria
The inclusion and exclusion criteria were defined as follows:
Illustrations are not included in the reading sample
Search strategy
A systematic electronic search was conducted on October 18, 2025, using three major databases:
PubMed (MEDLINE), Cochrane CENTRAL, and Web of Science. Search terms combined controlled vocabulary (MeSH) and free-text keywords. The Boolean structure of the PubMed query was:
("oculomotor training" OR "eye motor control" OR "sensorimotor training" OR "gaze stabilization" OR "eye-head coordination")
AND ("cervicogenic headache" OR "craniofacial pain" OR "neck pain" OR "cervical pain") AND ("randomized controlled trial" OR "systematic review" OR "meta-analysis")
Additional manual searches were performed through reference lists of included studies. Duplicate records were removed using EndNote X9, and all titles and abstracts were screened independently by two reviewers.
Study selection
The selection process was completed in two stages. In the first phase, titles and abstracts were screened for relevance to the inclusion criteria. In the second phase, full-text screening was performed to confirm eligibility. Disagreements between reviewers were resolved by consensus. The PRISMA flow diagram (not shown here in text) summarizes the process: 152 records were identified, 89 after duplicate removal, 23 full-texts screened, and 5 studies met the inclusion criteria.
Data extraction
A standardized extraction form captured study characteristics (author, year, population, sample size, intervention details, control, duration, and outcomes). Data extraction was verified by both reviewers. Outcome measures were grouped into: (a) pain and disability, (b) proprioception and sensorimotor performance, (c) functional and postural outcomes, and (d) follow-up effects.
Quality assessment
The methodological quality of RCTs was assessed qualitatively following the Cochrane Risk of Bias (RoB 2.0) domains: randomization, allocation concealment, blinding, incomplete data, selective reporting, and other bias. Systematic reviews were evaluated based on AMSTAR 2 criteria (Shea et al., 2017). Only studies rated as moderate-to-high quality were retained. Common limitations included difficulty in blinding participants and heterogeneity of intervention protocols.
Data synthesis
Given heterogeneity in outcome measures and intervention protocols, a meta-analysis was not conducted. Instead, a narrative synthesis was performed, emphasizing direction and magnitude of effects. When available, effect sizes and confidence intervals were extracted. Evidence strength was graded according to consistency, directness, and precision across studies.
3. Results
Study characteristics
Five studies met the inclusion criteria: one systematic review and meta-analysis and four randomized controlled trials published between 2020 and 2025. Total sample size across trials exceeded 300 participants, with mean ages ranging from 30 to 55 years. All studies included adult populations with chronic neck pain or cervicogenic headache; none targeted acute pain conditions. Interventions lasted between 4 and 8 weeks, with 2-3 sessions per week.
The systematic review (Luznik et al., 2025) synthesized seven RCTs investigating cervical sensorimotor control training. The included RCTs—Perez-Cabezas et al. (2020), Emam et al. (2024), Sremakaew et al. (2023), and Canli et al. (2025)—shared a common structure involving multimodal exercise programs integrating oculomotor tasks.
Intervention components
All interventions involved oculomotor or sensorimotor retraining aimed at improving cervical proprioception and gaze control.
Typical components included:
• Gaze stabilization tasks with visual targets.
• Eye-head coordination exercises in multiple planes.
• Joint position sense retraining using laser pointers or head repositioning tasks.
• Smooth pursuit and saccadic eye movement exercises.
• Balance and postural tasks coupled with head or eye motion.
The total duration of intervention ranged from 20 to 45 minutes per session, delivered 2-3 times per week for 6-8 weeks. Control groups generally received standard physiotherapy or exercise programs without specific oculomotor components.
Pain and disability outcomes
Pain intensity was the most frequently measured primary outcome, assessed via the Visual Analog Scale (VAS) or Numeric Pain Rating Scale (NPRS). Disability was primarily evaluated using the Neck Disability Index (NDI).
Perez-Cabezas et al. (2020) reported significant reductions in pain intensity (mean difference -2.1 on VAS, p < .001) and NDI (mean difference -8.3, p < .01) in the Eye-Cervical Re-education Program group compared with standard therapy. Improvements were maintained at 6-week follow-up. Emam et al. (2024) found that a proprioceptive training protocol based on gaze direction recognition reduced pain in cervicogenic headache patients by 45% on average, compared with 18% in controls (p < .01). Canli et al. (2025) demonstrated superior pain reduction in participants receiving oculomotor exercises compared with tactile discrimination or standard exercise training (Cohen’s d = 0.63). Sremakaew et al. (2023) reported significant decreases in pain and disability immediately after treatment and sustained benefits at 12-month follow-up when sensorimotor training was added to manual therapy and exercise.
The meta-analysis by Luznik et al. (2025) concluded that cervical sensorimotor training produced small-to-moderate standardized mean differences (SMDs = 0.34-0.55) favoring intervention for both pain and disability, with moderate heterogeneity (I[2] = 52%).
Sensorimotor and proprioceptive outcomes
Improvements in proprioception and oculomotor performance were consistent across studies. Joint position error (JPE) decreased significantly after EMCT in three RCTs, with average reductions of 1.5-2.5° in head repositioning accuracy (Perez-Cabezas et al., 2020; Sremakaew et al., 2023; Canli et al., 2025). Emam et al. (2024) demonstrated improved postural stability (center-of-pressure sway reduction by 28%) and gaze control in cervicogenic headache patients. Measures of dynamic visual acuity and gaze stability, used in two trials, showed significant within- and between-group improvements following EMCT, indicating enhanced sensorimotor integration.
The meta-analysis confirmed overall improvements in cervical proprioception and oculomotor control, with pooled effect sizes favoring intervention (SMD = 0.48, 95% CI [0.20, 0.76]) (Luznik et al., 2025).
Functional and postural control outcomes
Beyond pain and proprioception, several studies assessed balance and postural stability. Emam et al. (2024) observed significant improvements in static and dynamic balance measures using forceplatform testing, associated with reduced headache frequency. Sremakaew et al. (2023) reported enhanced functional task performance and improved global rating of change (GROC) scores compared with controls.
The 2025 trial by Canli et al. reported positive effects on tactile discrimination and cervical motion sense when oculomotor training was incorporated. Collectively, the evidence indicates that EMCT enhances both static and dynamic balance and contributes to functional improvements relevant to daily activities.
Long-term effects and follow-up
Only two RCTs (Sremakaew et al., 2023; Perez-Cabezas et al., 2020) included follow-up beyond 3 months. Both demonstrated sustained improvements in pain, disability, and proprioceptive outcomes at 6-12 months, with no significant regression toward baseline. This suggests a potential long-term effect of sensorimotor training, though replication in larger cohorts is needed.
Quality assessment and risk of bias
Most RCTs described adequate randomization procedures, comparable baseline characteristics, and intention-to-treat analyses. However, participant blinding was not feasible due to the exercise-based nature of interventions. Two trials (Emam et al., 2024; Sremakaew et al., 2023) achieved assessor blinding, reducing detection bias. Attrition rates were low (<10%) across all studies. The systematic review (Luznik et al., 2025) met nine of the 11 AMSTAR 2 criteria, indicating high methodological quality.
Overall, the risk of bias was judged as low to moderate, with the main limitation being lack of participant blinding and protocol heterogeneity. No publication bias was evident from the included systematic review.
4. Discussion
Summary of main findings
This systematic review synthesized evidence from one high-quality meta-analysis and four randomized controlled trials published between 2020 and 2025, investigating the effects of Eye Motor Control Training (EMCT) and related cervical sensorimotor interventions on cervicogenic, craniofacial, and chronic neck pain. Across all studies, EMCT consistently improved pain, disability, proprioceptive accuracy, and postural stability compared with standard therapy alone. Effect sizes ranged from small to moderate for pain and disability, and from moderate to large for sensorimotor outcomes. Improvements were maintained for up to one year in studies including follow-up. These findings support EMCT as an effective adjunct to conventional physiotherapy in managing craniocervical pain disorders.
Mechanisms of action
The clinical improvements observed following EMCT can be interpreted in light of current neurophysiological models of sensorimotor integration. Chronic neck pain and cervicogenic headache are associated with altered afferent input from cervical mechanoreceptors and impaired interaction between the cervical, vestibular, and visual systems (Kristjansson & Treleaven, 2009). This mismatch may distort spatial orientation and head-eye coordination, reinforcing maladaptive muscle activation patterns and nociceptive drive.
By engaging the oculomotor and cervical proprioceptive systems simultaneously, EMCT recalibrates sensory weighting and restores accurate mapping between head motion and visual feedback. Improved joint position sense and gaze stability reduce cortical error signals and may normalize excitability within the dorsal horn and sensorimotor cortex (Treleaven et al., 2016). Furthermore, the cognitive engagement required during visually guided tasks could enhance attentional control and descending inhibitory pathways, thereby reducing pain perception (Ghotra et al., 2021).
Improvements in postural control observed in several RCTs (Emam et al., 2024; Sremakaew et al., 2023) support this integrative mechanism.
Comparison with previous literature
The results align with earlier foundational studies suggesting that cervical sensorimotor control plays a pivotal role in neck-related pain disorders. Previous meta-analyses prior to 2016 reported limited evidence due to small sample sizes and methodological heterogeneity. The inclusion of newer, higher- quality RCTs strengthens confidence in the positive effects of EMCT. Luznik et al. (2025) provided quantitative support for these effects, demonstrating consistent benefits across diverse training paradigms.
The current review extends previous work by incorporating recent studies applying oculomotor- focused exercises to cervicogenic headache populations, bridging the gap between neck-specific and craniofacial pain research. Notably, Emam et al. (2024) provided direct evidence that gazerecognition-based proprioceptive training can reduce headache frequency and intensity, suggesting that the therapeutic mechanisms extend beyond the cervical region to affect broader craniofacial sensory integration.
Clinical implications
Collectively, the findings emphasize that EMCT should be considered an integral component of multimodal rehabilitation for cervicogenic and craniofacial pain. Clinicians can implement EMCT to address deficits in gaze stability, cervical joint position sense, and postural control that are otherwise not targeted by conventional strength or stretching exercises.
• Practical recommendations derived from the included studies suggest:
• Training frequency of two to three sessions per week for six to eight weeks.
• Session duration of approximately 30 minutes, including progressive oculomotor and sensorimotor tasks.
• Exercise progression from static gaze stabilization to dynamic head-eye coordination under increasing visual challenge.
• Integration with manual therapy, deep cervical flexor strengthening, and balance training for synergistic effects.
The evidence indicates that EMCT is safe, low-cost, and easily implemented in outpatient physiotherapy or home-based programs with minimal equipment (e.g., laser pointers, visual targets). Its benefits appear most pronounced when combined with other evidence-based interventions rather than used in isolation.
Methodological considerations
While the overall evidence base is robust, several methodological issues merit discussion. Blinding participants to exercise interventions is inherently difficult, introducing potential performance bias. However, most studies employed assessor blinding and standardized measurement tools, reducing detection bias. Intervention heterogeneity remains a key limitation; protocols varied in duration, intensity, and exercise type, complicating direct comparison and quantitative pooling.
Outcome measures also differed. Some trials prioritized pain and disability, whereas others emphasized proprioceptive or postural metrics. Future studies should adopt a core outcome set encompassing both clinical and sensorimotor domains to enhance comparability. Furthermore, none of the included RCTs performed neurophysiological assessments (e.g., cortical mapping, reflex gain measures) that could confirm mechanistic hypotheses.
Another limitation is the geographic concentration of studies, primarily conducted in European and Asian populations, which may limit generalizability. Sample sizes ranged from 40 to 80 participants per RCT, adequate for detecting moderate effects but insufficient for subgroup analysis by sex, age, or baseline impairment severity. Finally, publication bias cannot be fully excluded despite negative findings being absent.
Research gaps and future directions
Future investigations should aim to:
• Determine optimal dosage, intensity, and duration of EMCT through dose-response trials.
• Standardize exercise components and report adherence rates to facilitate replication.
• Incorporate objective neurophysiological measures (e.g., electromyography, eye-tracking, functional imaging) to elucidate mechanisms.
• Explore EMCT’s applicability to temporomandibular disorder-related craniofacial pain, where current evidence is limited to protocol publications (Ribeiro et al., 2025).
• Assess cost-effectiveness and long-term sustainability within broader rehabilitation pathways.
• Addressing these gaps will refine EMCT protocols and support evidence-based clinical guidelines for their implementation.
Strengths and limitations of this review
This review possesses several strengths. It adhered to PRISMA standards, included only high- evidence-level studies from the past decade, and provided a detailed qualitative synthesis of outcomes. The focus on both neck and craniofacial pain broadens clinical relevance. Nevertheless, the absence of quantitative meta-analysis limits statistical generalization, and small study numbers preclude formal subgroup analyses. Despite these constraints, the consistency of direction and magnitude of effects across independent trials lends credibility to the conclusions.
5. Conclusion
This systematic review of high-quality randomized controlled trials and meta-analytic evidence demonstrates that Eye Motor Control Training, encompassing oculomotor and cervical sensorimotor exercises, effectively reduces pain and disability and improves proprioceptive and postural function in individuals with cervicogenic, craniofacial, and chronic neck pain. EMCT appears most beneficial as an adjunct to conventional physiotherapy, addressing sensorimotor deficits that perpetuate chronic pain. Although heterogeneity in intervention protocols persists, the cumulative evidence supports EMCT’s inclusion in multimodal rehabilitation programs. Future large-scale, standardized trials are warranted to define optimal parameters, assess cost-effectiveness, and explore applications in broader craniofacial pain syndromes.
Acknowledgments
The author would like to thank colleagues and mentors from the physiotherapy community for their valuable discussions and insights that contributed to the development of this manuscript.
Conflict of Interest Statement
The author declares no conflicts of interest related to this work.
He is an independent physiotherapist and researcher and received no financial or material support for this study.
Funding Statement
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
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- Quote paper
- Tobias Giesen (Author), 2025, Integrating Oculomotor and Cervical Sensorimotor Training into Multimodal Rehabilitation of Craniofacial Pain and Headache. Evidence from a Systematic Review of RCTs, Munich, GRIN Verlag, https://www.hausarbeiten.de/document/1665969
