Cervical Flexion-Rotation Test

Original Editors - Bram Sorel

Top Contributors - Bram Sorel, Evan Thomas, Annelies Beckers, Scott Cornish and Rachael Lowe


The Cervical Flexion-Rotation Test (CFRT), in contrast to other forms of manual examination, is an easily applied clinical test purportedly biased to assess dysfunction at the C1-C2 motion segment. The C1-C2 motion segment accounts for 50% of the rotation in the cervical spine.[1]

Manual examination has high sensitivity and specificity to detect the presence or absence of cervical joint dysfunction in neck pain and headache patients.[2] However, these tests involve a high degree of skill on the part of the examiner, and their reliability has been questioned.

In this test procedure, the cervical spine is fully flexed, in an attempt to isolate movement to C1-C2, which has an unique ability to rotate in flexion. Normal range of rotation motion in end range flexion has been shown to be 44° to each side. In contrast, subjects suffering from headache with C1-C2 dysfunction have an average of 17° less rotation.[3]

Smith et al. concluded that age did not significantly influence mobility during the CFRT.[4] One explanation for this is could be that the upper cervical spine undergoes minimal age-related degenerative changes, in comparison to joints lower in the cervical spine.[5] Also lifestyle factors including sleep position, time spent sitting, and side dominant lifestyle did not appear to influence variability in cervical mobility.[4]


  1. Patient is relaxed in supine
  2. Examiner fully flexes the cervical spine with the occiput resting against the examiners abdomen
  3. The patient's head is then rotated to the left and the right
  4. If a firm resistance is encountered, pain provoked, and range is limited before the expected end range, then the test is considered positive, with a presumptive diagnosis of limited rotation of C1 on C2


Hall et al. showed that diagnostic accuracy, sensitivity, and specificity of the CFRT were very high (90% and 88% with 92% agreement for experienced examiners (P<.001)). Furthermore, although inexperienced examiners reported greater range for the CFRT than experienced examiners, sensitivity, specificity and agreement were still within clinically acceptable levels. The CFRT is a useful clinical measure in cervical movement impairment and can assist in the differential diagnosis of Cervicogenic Headache.[1]

Good levels of inter- and intra-observer reliability were established by Takasaki et al. comparing the manual test outcome with the MRI measurement of cervical segmental rotation. ICCs were greater than 0.7 with narrow 95% confidence interval values for mean range of rotation. These data lend support to the content validity of the CFRT as a clinical test of atlanto-axial mobility.[8]

It is important to recognise that the CFRT is a relatively isolated test of movement impairment of the C1-C2 motion segment, and may not adequately test other motion segments.

Differential Diagnosis

Recently, it has been shown that cervical movement impairment, in association with palpable upper cervical joint dysfunction and impairment in cranio-cervical muscle control, has 100% sensitivity an 94% specificity to identify Cervicogenic Headache from Migraine.[9] This is clinically important since, for example, physiotherapy has been found to be effective for Cervicogenic Headache (CGH) but not for migraine.

Range was most restricted in subjects with CGH (25°), significantly more important impairment than either group’s Migraine (42°) or Multiple Headache forms (MHF) (35°). It would appear that presence of an aura has minimal effect on range of motion during the CFRT.[10]

As stated previously, the CFRT has been shown to be negative in subjects with CGH where pain arises from cervical levels other than C1-C2.[1]


  1. 1.0 1.1 1.2 Hall TM, Robinson KW, AkasakaK. Intertester Reliability and Diagnostic Validity of the Cervical Flexion-Rotation Test. J Manipulative Physiol Ther. 2008;31:293-300
  2. Sandmark H, Nisell R. Validity of five common manual neck pain provocating tests. Scand J Rehab Med 1995;27:131-136
  3. Ogince M, Hall T, Robinson K. The diagnostic validity of the cervical flexion-rotation test in C1/2 related cervicogenic headache. Man Ther 2007;12:256-262
  4. 4.0 4.1 Smith et al. The influence of age, gender, lifestyle factors and sub-clinical neck pain on the cervical flexion-rotation test and cervical range of motion. Manual Therapy 2008;13:552-559
  5. Dvorak J, Antinnes JA, Panjabi MM, Loustalot D, Bonomo M. Age and gender related normal motion of the cervical spine. Spine, 1992; 17(10S): S393–398.
  6. Stratton SA, Bryan JM. Dysfunction, evaluation, and treatment of the cervical spine and thoracic inlet (1994). Donatelli R, Wooden MJ (Eds.), Orthopaedic Physical Therapy (2nd ed); Churchill Livingstone, New York: 77–122.
  7. Physiotutors. Flexion Rotation Test | Upper Cervical Spine Rotation. Available from: https://www.youtube.com/watch?v=TziMAn77ZRU
  8. Takasaki et al. Normal kinematics of the upper cervical spine during the Flexion-Rotation test – In vivo measurements using magnetic resonance imaging. Manual Therapy 2011;16:167-171
  9. Jull G., Amiri M., Bullock-Saxton J, Darnell R, Lander C. Cervical musculoskeletal impairment in frequent intermittent headache. Part 1: Subjects with single Headaches. Cephalalgia 2007;27:793-802
  10. Hall M, Briffa K. Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test. J Headache Pain 2010;11:391-397