Cranio‐cervical Flexion Test


The cranio cervical flexion test (CCFT) is a clinical test of neuromotor control of the deep flexors of the cervical spine.

The test has evolved over fifteen years. It was originally developed in response to increased interest in the functional roles of muscles, particularly in active spinal segment stabilization, and the clinical need for more directed and specific therapeutic exercises for patients with neck pain disorders[1].

Since 2001, the test has commonly been used in research, for example investigations into the development of motor dysfunction following a whiplash injury[2]. The CCFT was also used in research about the performance of the cranio cervical flexion test in patients with chronic tension type headache[3].

Clinical Importance

There is reason to believe that an impaired and delayed activation of the deep cervical flexor muscles causes headaches [4][5][3][2][6]. The CCFT is indicative of impairment of the deep cervical flexors.

Purpose of the test

The CCFT tests the neuromuscular control of the control of the deep cervical flexor muscles, the longus capitis, and colli. The test also assesses endurance of the deep cervical flexors and interaction of the deep cervical flexor muscles with the superficial flexors[1], i.e. the Sternocleidomastoid and the anterior scalene muscles[5]. It can also be used as a clinical indicator of impaired activation of the deep cervical flexor muscles [5][4], to measure the muscle activity of the deep [7] and superficial [2], cervical muscles or as a therapy approach[5][8][9].


Testing position

The patient is positioned on the table in a supine crook lying position, with the neck in a neutral position[7]. The neutral position of the neck can be visually determined by maintaining a horizontal face position between the forehead and chin, and observing that a line bisecting the neck longitudinally is parallel to the treatment table[10]. If necessary, the therapist can place towels under the patient's head to achieve a neutral position of the neck and head. Before performing the test, an uninflated pressure sensor (= PBU or pressure biofeedback unit) must be placed beneath the neck so that it abuts the occiput. The pressure sensor is inflated to a stable baseline pressure of 20 mmHg[1].

Testing procedure

The PBU will provide feedback and direction to the patient to perform the required stages of the test:

  1. The patient is instructed to move the head vertically (as if saying ‘yes’). The movement is performed gently and slowly [1]. This nodding action causes the pressure in the inflated pressure sensor to increase. For the first stage of the test the pressure should increase by 2 mm Hg.
  2. The patient is told to maintain this position for 5-10 seconds[3][2].
  3. Then the patient relaxes back to 20 mm Hg to increase the pressure again this time to 24 mm Hg using the same action and hold for five seconds. The patient has to do this until he/she has reached a pressure of 30 mm Hg[9].

This test should be repeated twice without substitution or fatigue[9]. Flexion of the neck requires activation of the deep cervical flexors. The superficial cervical flexors cannot be used to perform this movement.

The therapist should pay attention to compensatory strategies:

  • Loss of the neutral position of the neck and head
  • Palpable or visible contraction of the sternocleidomastoid and scalene muscle[9]

Treatment Approach[9]

If the patient is not able to complete the stages of the CCFT as instructed (i.e. the superficial cervical flexor muscles are active, or the patient cannot maintain the position) the deep cervical flexor muscles must be trained. The patient’s neck should be placed in a flexed position in which the patient does not have any difficulty maintaining the pressure level. This position should be considered as the baseline pressure to begin training/rehabilitation. The patient should be told to hold this position and maintain pressure for ten seconds. Repeat ten times.



The intra- and inter-reliability for the CCFT was between “fair to good” and “good to excellent” (ICC: 0.63 to 0.86)[11][12][13][14]. Studies of reliability on the CCFT in asymptomatic subjects have reported slightly higher ICC values, ranging from 0.81 to 0.98[13]


Construct validity has been demonstrated to be satisfactory[13]. The discriminative validity of the CCFT is not as strong[13]. One study found that the CCFT fails to discriminate between those with current neck pain, those with a history of neck pain but no current pain, and those without neck pain[11].


  1. 1.0 1.1 1.2 1.3 Jull GA, O’Leary SP, Falla DL: Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. J Manipulative Physiol Ther. 2008, 31 (7): 525-533.
  2. 2.0 2.1 2.2 2.3 Sterling M, Gwendolen J, Vicenzino B, Kenardy J, Darnell R. Development of motor system dysfunction following whiplash injury. Pain 2003 May;103(1-2):65-73.
  3. 3.0 3.1 3.2 Fernandez-de-las-Penas C, Perez-de-Heredia M, Molero-Sanchez A, Miangolarrapage JC. Performance of the craniocervical flexion test, forward head posture and headache clinical parameters in patients with chronic tension type headache: a pilot study. J Orthop Sport Phys Ther 2007;37(2).
  4. 4.0 4.1 Fernandez-de-las-Penas C, Arendt-Nielson L, Gerwin RD. Tension type and cervicogenic headache: pathophysiology, diagnosis and management.
  5. 5.0 5.1 5.2 5.3 Jull GA, Falla D., Vicenzino B, Hodges PW. The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain. Man Ther 2009 Dec;14(6):696-701.
  6. Beeton KS. Manual therapy masterclasses: the vertebral column. Elsevier, 2003
  7. 7.0 7.1 Falla D, Gwendolen AJ, Dall’Alba P, Rainoldi A, Merletti R. An electromyographic analysis of the deep cervical flexor muscles in performance of craniocervical flexion. Phys Ther 2003 Oct;83(10).
  8. Auee J. De rol van spierdisfunctie bij chronische nekpijn; afstudeer artikel; HvU afdeling fysiotherapie.
  9. 9.0 9.1 9.2 9.3 9.4 Wilson-O’Toole F, Gormley J, Hussey J. Exercise therapy in the management of musculoskeletal disorders: Blackwell Publishing Ltd, 2011
  10. Sterling M, Jull G, Wright A. Cervical mobilization: current effects on pain, sympathetic nervous system activity and motor activity. Man Ther 2001 May;6(2):72-81.
  11. 11.0 11.1 Hudswell S, Von Mengersen M, Lucas N: The cranio-cervical flexion test using pressure biofeedback: A useful measure of cervical dysfunction in the clinical setting?. Int J Osteopath Med. 2005, 8: 98-105.
  12. Juul T, Langberg H, Enoch F, Sogaard K: The intra- and inter-rater reliability of five clinical muscle performance tests in patients with and without neck pain. BMC Musculoskelet Disord. 2013
  13. 13.0 13.1 13.2 13.3 Jørgensen R, Ris I, Falla D, Juul-Kristensen B. Reliability, construct and discriminative validity of clinical testing in subjects with and without chronic neck pain. BMC musculoskeletal disorders. 2014 Dec 4;15(1):408.
  14. Hudswell S, Von Mengersen M, Lucas N. The cranio-cervical flexion test using pressure biofeedback: A useful measure of cervical dysfunction in the clinical setting?. International Journal of Osteopathic Medicine. 2005 Sep 30;8(3):98-105.