Is GDR effective in the treatment of chronic neck pain?

It was in 2005 that I came up with the idea of a “gaze direction recognition” (GDR) task as a possible treatment for chronic neck pain. At that time some of the rehabilitation patients visiting my rehabilitation department had suffered from neck pain for a long time because of cervical strain or previous cervical spine surgery. In those days, such patients were usually treated with physical therapy such as thermotherapy and traction. I asked myself if there was any better training method for such neck pain.

To begin with, I was inspired by the finding that the superior temporal sulcus – inferior parietal lobule – premotor cortex system is more strongly activated by observation of target-oriented actions than by simple observation of movements. I thus figured out a training program to have the patient observe sight line shifts which were target-oriented actions of the neck.

Additionally, at that time, a number of intervention studies of post-stroke hemiplegia were performed using exercise images, reporting efficacious results. Regarding chronic pain treatment, Dr Lorimer Moseley developed the Graded Motor Imagery Program, suggesting that intervention in exercise programs of the brain prior to real exercises might alleviate pain.[1]

Based on these findings I then developed “gaze direction recognition by observation from behind” as a task of simulating neck movements through their observation.

At Kio University graduate school I measured brain activity of the subject who was engaged in the task “recognition of gaze direction by observation from behind,” I found brain activity in the dorsolateral prefrontal area as well as premotor region as compared to simple observation, which was considered to reflect simulation activity of neck movement. Then I performed a small scale RCT to confirm that GDR alleviated chronic neck pain and improved the range of neck rotatory movement.[2] Chronic neck pain patients were found to have a longer correct reaction time of GDR than age- and gender-matched healthy people, suggesting these patients having difficulty with simulating neck movements.[3]

It is clear now that chronic pain patients have neurochemical, structural and functional changes in the brain. I would therefore like to study in future whether or not similar cerebral changes occur in chronic neck pain patients as well. When participants in RCT of GDR were individually analyzed for changes in the grade of pain, some were found to have worse pain in the beginning of the intervention. I now need to examine what RCT efficacy depends on.

About Satoshi Nobusako

Satoshi NobusakoSince receiving his physical therapist’s license in 2001 Satoshi has been working in a hospital rehabilitation department. In 2012, he earned PhD in health science as a result of his research work at Professor Shu Morioka’s Neurorehabilitation laboratory in Kio University. He is now engaged in research as a visiting fellow at the Health Science Institute of Kio University while working as a physical therapist at Department of Rehabilitation of Higashi Osaka Yamaji Hospital.


[1] Moseley GL (2004). Graded motor imagery is effective for long-standing complex regional pain syndrome: a randomised controlled trial. Pain, 108 (1-2), 192-8 PMID: 15109523

[2] Nobusako S, Matsuo A, & Morioka S (2012). Effectiveness of the gaze direction recognition task for chronic neck pain and cervical range of motion: a randomized controlled pilot study. Rehab Res Pract. Epub 2012 May 7. PMID: 22645685

[3] Nobusako, S. (2012). Gaze Direction Recognition Task for the Rehabilitation of Chronic Neck Pain. J Nov Physiother. (S1-006) DOI: 10.4172/2165-7025.S1-006


  1. This is fascinating – could you tell us more about what the actual ‘task’ was? I can guess, but would like to know what ‘sight-line shifts which are target oriented actions of the neck’ are. Thank you

    Satoshi Nobusako Reply:

    Thank you for your comment.

    Please refer to Figure 2 of “Effectiveness of the gaze direction recognition task for chronic neck pain and cervical range of motion: a randomized controlled pilot study.”

    Gaze Direction Recognition Task Procedure
    An experimenter sat 75cm apart from a subject, and the subject was asked to observe the experimenter from behind. A table (1800mm × 400mm) was placed 75cm in front of the experimenter, on which six blocks, numbered 1 to 6, were placed in regular intervals. Subjects were able to watch all of the blocks. The experimenter’s gaze changed to either one of the six numbered blocks in a random manner by voluntary eye movement and rotation of the neck. The experimenter initiated the performance following a specific signal by an assistant to the experimenter. The experimenter maintained gaze at a certain numbered box until the subject gave a response. Then, the subject observed the experimenter’s neck rotation from behind and was asked to imagine the block at which the experimenter was gazing and to provide a verbal response as to which imagined block the subject was gazing at as quickly as possible. Whether the subject’s recognition of the experimenter’s gaze of direction was correct was not fed-back to the subject until the end of the experiment. An assistant to the experimenter recorded the reaction times and correctness of the response. A single experimental GDR task consisted of 30 trials of the task outlined above, which was carried out in about 10 minutes.

  2. Betsan Corkhill says:

    It would be interesting to observe whether the eyes move when imagining neck/ head movements. I’ve just tried it and my eyes move when I imagine my head moving. Although controversial, eye movements are reported to lower stress and improve PTSD symptoms as in EMDR so in a trial it might be difficult to control for this.

    Satoshi Nobusako Reply:

    Thank you for your comment.
    I am sorry.
    I can not answer well.
    Please refer to Figure 2 of “Effectiveness of the gaze direction recognition task for chronic neck pain and cervical range of motion: a randomized controlled pilot study.”
    The experimenter moved the line of sight in the rotation movement of the neck.
    Patients were observed rotation movements of the neck from the back of the experimenter.
    Patients were to guess where the experimenter moved the line of sight.
    The experimenter and patients did not do eye movement.