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There have been several recent papers supporting a TWIST (pun intended) on standard cervical range of motion testing. Spinal ROM testing identifies deficits in joint motion across multiple segments of the spine; however, the Cervical Flexion-Rotation Test (CFRT) isolates a specific location of dysfunction within the cervical spine—C1/C2. This blog will teach you how to perform the test, specific diagnoses associated with a positive test, and interventions to correct this dysfunction. Also, watch the video below as I will cover the treatment and patient education pieces to use with a positive test.

What is the Cervical Flexion-Rotation Test (CFRT)

The cervical flexion–rotation test assesses for a loss of cervical spine rotation or reproduction of pain due to joint dysfunction. The CFRT differentiates a ROM deficit between the upper and lower cervical spine. (1)

The upper cervical spine motion segment (C1/C2) accounts for 40–60% of the total cervical rotation.

How to perform the CFRT

With the patient lying supine, the examiner fully flexes the patient’s cervical spine to block rotation below the atlanto-axial junction. The examiner then passively rotates the patient’s head in each direction, assessing motion and end feel. The normal cervical rotation for this test is 44 degrees. Diminished movement or pain indicates an upper cervical restriction.

What makes this test positive?

The CFRT is positive when [1] a 10-degree difference in motion between painful and non-painful sides or [2]  there is a provocation of pain during the test. (2) The usual range of rotation motion of C1/C2 is 44° to each side.  In contrast, subjects suffering from headaches with C1-C2 dysfunction have an average of 17° less rotation. (3)

Specific Diagnoses Associated with a Positive Test.

Temporomandibular Joint Dysfunction (TMD)

“Women with myogenic TMD have significantly reduced cervical rotation when performing the CFRT as compared to performance compared to ROM tested in standard evaluation planes of movement. The FRT was positive (less than 32°) in 90% of the TMD participants versus 5% in the healthy control, but the findings were not correlated with TMD severity.” (4)

TMD and Headaches

“Subjects with TMD had signs of upper cervical spine movement impairment, greater in those with a headache. Only subjects with TMD and headache had impairment of cervical spine sagittal plane mobility. This study provides evidence for the importance of examination of upper cervical mobility determined by the FRT in patients who suffer from TMD.” (5)


“Women with migraine have a lower upper cervical range of motion than headache-free women. Women with chronic migraine demonstrated reduced global cervical range of motion when compared to headache-free women. Migraine was associated with an increased likelihood of a positive Flexion Rotation Test. Reduction in mobility was influenced by migraine frequency and disability-related neck pain.” (6)

If the CFRT is positive for loss of ROM or pain, then what interventions are reasonable to correct dysfunction of the upper cervical spine?

Spinal manipulation has been well researched and is one of the safest methods of conservative therapy for these patients! (7) Here are a couple of the success stories for manipulation if symptoms are related to upper cervical joint dysfunction:

  1. A survey of 381 chiropractors found that over 80% of plans for recent-onset headache (less than three months duration) required less than ten visits scheduled at 1-2 visits per week for less than eight total weeks. (8)
  2. Another randomized controlled trial demonstrated that 6-8 of SMT sessions produced good outcomes for headaches. (9)
  3. The Spine Journal found that spinal manipulation cuts the number of CGH symptomatic days in half, and the number of treatments has a linear dose-response to improvement (10).
  4. Fitz-Ritson demonstrated a 90.2 success rate when utilizing manipulation for the treatment of post-traumatic cervicogenic vertigo. (11)

Standard ROM testing of the cervical spine is essential during a physical exam. However, the CFRT adds valuable information in the diagnosis of specific disorders affecting the upper cervical spine; often undetected in typical ROM analysis. The CFRT should be performed passively for the best results. (12) Another benefit of testing the upper cervical spine in isolation is that age-related changes do not affect the results. The lower cervical spine is often affected by degenerative changes resulting in a range of motion loss. C1/C2 is rarely affected by arthritic changes (13) Chiropractors should address the loss of cervical ROM with safe and effective conservative measures, including spinal manipulation.

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  1. Amiri M, Jull G, Bullock-Saxton J. Measuring range of active cervical rotation in a position of full head flexion using the 3D Fastrak measurement system: an intra-tester reliability study. Man Ther. 2003:176–9. Link
  2. Ogince M, Hall T, Robinson K, Blackmore A. The diagnostic validity of the cervical flexion–rotation test in C1/C2 related cervicogenic headache. Man Ther. 2007;12:256–62. Link
  3. Dwyer A, Aprill C, Bogduk N. Cervical zygapophyseal joint pain patterns I: a study in normal volunteers. Spine (Phila Pa 1976). 1990;15:453–7. Link
  4. Greenbaum T, Dvir Z, Reiter S, Winocur E. Cervical flexion-rotation test and physiological range of motion–a comparative study of patients with myogenic temporomandibular disorder versus healthy subjects. Musculoskeletal Science and Practice. 2017 Feb 1;27:7-13. Link
  5. Grondin F, Hall T, Laurentjoye M, Ella B. Upper cervical range of motion is impaired in patients with temporomandibular disorders. Cranio®. 2015 Apr 1;33(2):91-9. Link
  6. Oliveira-Souza AI, Florencio LL, Carvalho GF, Fernández-De-Las-Peñas C, Dach F, Bevilaqua-Grossi D. Reduced flexion rotation test in women with chronic and episodic migraine. Brazilian journal of physical therapy. 2019 Jan 16. Link
  7. Chaibi A, Russell MB. A risk–benefit assessment strategy to exclude cervical artery dissection in spinal manual-therapy: a comprehensive review. Annals of medicine. 2019 Feb 17;51(2):118-27. Link
  8. Moore C, Leaver A, Sibbritt D, Adams J. The management of common recurrent headaches by chiropractors: a descriptive analysis of a nationally representative survey. BMC Neurol. 2018;18(1):171. Published 2018 Oct 17. Link
  9. Dunning JR, et al. Upper cervical and upper thoracic manipulation versus mobilization and exercise in patients with cervicogenic headache: a multi-center randomized clinical trial. BMC Musculoskelet Disord. 2016 Feb 6;17(1):6. Link
  10. Haas M. et al. Dose-response and efficacy of spinal manipulation for care of cervicogenic headache: a dual-center randomized controlled trial. Spine J. 2018 Feb 23. Link
  11. Fitz-Ritson D. Assessment of cervicogenic vertigo. JMPT 1991;14:193-198. Link
  12. Bravo Petersen SM, Vardaxis VG. The flexion–rotation test performed actively and passively: a comparison of range of motion in patients with cervicogenic headache. Journal of Manual & Manipulative Therapy. 2015 May 1;23(2):61-7. Link
  13. Dreyfuss P, Michaelsen M, Fletcher D. Alanto-occipital and lateral alanto-axial joint pain patterns. Spine. 1994;19:1125–31. Link

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