Cranio‐cervical Flexion Test: Difference between revisions

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== Purpose<br>  ==
== Purpose<br>  ==


The cranio cervical flexion test (CFFT) is a clinical test of the anatomical action of the deep cervical flexor muscles <ref name="GWENDOLEN">GWENDOLEN A.J., O’LEARY S.P., FALLA D.; Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test</ref>. The test could be described as a test of neuromotor control. The features that are tested are the activation of the deep flexors and the isometric endurance of the muscles<ref name="GWENDOLEN">GWENDOLEN A.J., O’LEARY S.P., FALLA D.; Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test</ref>. The test also allows to assess the interaction of the deep cervical flexor muscles with the superficial flexors<ref name="GWENDOLEN">GWENDOLEN A.J., O’LEARY S.P., FALLA D.; Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test</ref>&nbsp;i.e. the sternocleidomastoid and the anterior scalene muscles<ref name="JULL">JULL G.A., FALLA D., VICENZINO B., HODGES P.W.; The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain; Elsevier; 2009</ref>. It can also be used as a clinical indicator of impaired activation of the deep cervical flexor muscles <ref name="JULL">JULL G.A., FALLA D., VICENZINO B., HODGES P.W.; The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain; Elsevier; 2009</ref><ref name="FERNAN">FERNANDEZ-DE-LAS-PENAS C., ARENDT-NIELSEN L., GERWIN R.D.;  Tension type and cervicogenic headache: pathophysiology, diagnosis and management</ref>, to measure the muscle activity of the deep <ref name="FALLA">FALLA D., GWENDOLEN A.J., DALL’ALBA P., RAINOLDI A., MERLETTI R.; An electromyographic analysis of the deep cervical flexor muscles in performance of craniocervical flexion; Physical therapy; Vol. 83; nr. 10; Oct. 2003</ref>&nbsp;and superficial <ref name="STERLING">STERLING M.,  GWENDOLEN J., VICENZINO B., KENARDY J., DARNELL R.; Development of motor system dysfunction following whiplash injury; Elsevier; 2002</ref>&nbsp;cervical muscles or as a therapy approach<ref name="JULL">JULL G.A., FALLA D., VICENZINO B., HODGES P.W.; The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain; Elsevier; 2009</ref><ref name="AUEE">AUEE J.; De rol van spierdisfunctie bij chronische nekpijn; afstudeer artikel; HvU afdeling fckLRfysiotherapie.</ref><ref name="WILSON">WILSON- O’TOOLE F., GORMLEY J., HUSSEY J.; Exercise therapy in the management of musculoskeletal disorders; Blackwell Publishing Ltd; 2011</ref>.  
The cranio cervical flexion test (CFFT) is a clinical test of the anatomical action of the deep cervical flexor muscles <ref name="GWENDOLEN">Gwendolen AJ, O’Leary SP, Falla D. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. J Manipulative Physiol Ther 2008 Sep;31(7):525-33.</ref>. The test could be described as a test of neuromotor control. The features that are tested are the activation of the deep flexors and the isometric endurance of the muscles<ref name="GWENDOLEN" />. The test also allows to assess the interaction of the deep cervical flexor muscles with the superficial flexors<ref name="GWENDOLEN" />, i.e. the sternocleidomastoid and the anterior scalene muscles<ref name="JULL">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.</ref>. It can also be used as a clinical indicator of impaired activation of the deep cervical flexor muscles <ref name="JULL" /><ref name="FERNAN">Fernandez-de-las-Penas C, Arendt-Nielson L, Gerwin RD. Tension type and cervicogenic headache: pathophysiology, diagnosis and management.</ref>, to measure the muscle activity of the deep <ref name="FALLA">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).</ref> and superficial <ref name="STERLING">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.</ref>, cervical muscles or as a therapy approach<ref name="JULL" /><ref name="AUEE">Auee J. De rol van spierdisfunctie bij chronische nekpijn; afstudeer artikel; HvU afdeling fysiotherapie.</ref><ref name="WILSON">Wilson-O’Toole F, Gormley J, Hussey J. Exercise therapy in the management of musculoskeletal disorders: Blackwell Publishing Ltd, 2011</ref>.  


<br>
=== Development of the Test ===
 
Evolution


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<ref name="GWENDOLEN">GWENDOLEN A.J., O’LEARY S.P., FALLA D.; Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test</ref>.  
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<ref name="GWENDOLEN" />.  


<br>
=== Clinical Importance ===


Clinical importance
There is reason to believe that an impaired and delayed activation of the deep cervical flexor muscles causes headaches <ref name="FERNAN" /><ref name="JULL" /><ref name="PEREZ">FERNANDEZ-DE-LAS-PENAS C., PEREZ-DE-HEREDIA M., MOLERO-SANCHEZ A., MIANGOLARRAPAGE J.C.; Performance of the craniocervical flexion test, forward head posture and headache clinical parameters in patients with chronic tension type headache: a pilot study; Journal of orthopaedic and sport physical therapy; vol. 37; nr. 2; Feb. 2007</ref><ref name="STERLING">STERLING M.,  GWENDOLEN J., VICENZINO B., KENARDY J., DARNELL R.; Development of motor system dysfunction following whiplash injury; Elsevier; 2002</ref><ref name="BEETON">BEETON K.S.; Manual therapy masterclasses, the Vertebral column; Elsevier; 2003</ref>. As mentioned earlier, the CCFT is also indicative if the deep cervical flexors are impaired.


There is reason to believe that an impaired and delayed activation of the deep cervical flexor muscles causes headaches <ref name="FERNAN">FERNANDEZ-DE-LAS-PENAS C., ARENDT-NIELSEN L., GERWIN R.D.;  Tension type and cervicogenic headache: pathophysiology, diagnosis and management</ref><ref name="JULL">JULL G.A., FALLA D., VICENZINO B., HODGES P.W.; The effect of therapeutic exercise on activation of the deep cervical flexor muscles in people with chronic neck pain; Elsevier; 2009</ref><ref name="PEREZ">FERNANDEZ-DE-LAS-PENAS C., PEREZ-DE-HEREDIA M., MOLERO-SANCHEZ A., MIANGOLARRAPAGE J.C.; Performance of the craniocervical flexion test, forward head posture and headache clinical parameters in patients with chronic tension type headache: a pilot study; Journal of orthopaedic and sport physical therapy; vol. 37; nr. 2; Feb. 2007</ref><ref name="STERLING">STERLING M.,  GWENDOLEN J., VICENZINO B., KENARDY J., DARNELL R.; Development of motor system dysfunction following whiplash injury; Elsevier; 2002</ref><ref name="BEETON">BEETON K.S.; Manual therapy masterclasses, the Vertebral column; Elsevier; 2003</ref>. As mentioned earlier, the CCFT is also indicative if the deep cervical flexors are impaired.
=== Research  ===


<br>
Since 2001 the test is commonly being used in research, for example when investigating the development of motor dysfunction following a [[Whiplash Associated Disorders|whiplash injury]]<ref name="STERLING">STERLING M.,  GWENDOLEN J., VICENZINO B., KENARDY J., DARNELL R.; Development of motor system dysfunction following whiplash injury; Elsevier; 2002</ref>. The CCFT was also used in research about the performance of the cranio cervical flexion test in patients with chronic [[Tension-type headache|tension type headache]]<ref name="PEREZ">FERNANDEZ-DE-LAS-PENAS C., PEREZ-DE-HEREDIA M., MOLERO-SANCHEZ A., MIANGOLARRAPAGE J.C.; Performance of the craniocervical flexion test, forward head posture and headache clinical parameters in patients with chronic tension type headache: a pilot study; Journal of orthopaedic and sport physical therapy; vol. 37; nr. 2; Feb. 2007</ref>.  
 
Research
 
Since 2001 the test is commonly being used in research, for example when investigating the development of motor dysfunction following a whiplash injury<ref name="STERLING">STERLING M.,  GWENDOLEN J., VICENZINO B., KENARDY J., DARNELL R.; Development of motor system dysfunction following whiplash injury; Elsevier; 2002</ref>&nbsp;(http://www.physio-pedia.com/index.php/Whiplash_Associated_Disorders). The CCFT was also used in research about the performance of the cranio cervical flexion test in patients with chronic tension type headache <ref name="PEREZ">FERNANDEZ-DE-LAS-PENAS C., PEREZ-DE-HEREDIA M., MOLERO-SANCHEZ A., MIANGOLARRAPAGE J.C.; Performance of the craniocervical flexion test, forward head posture and headache clinical parameters in patients with chronic tension type headache: a pilot study; Journal of orthopaedic and sport physical therapy; vol. 37; nr. 2; Feb. 2007</ref>. (http://www.physio-pedia.com/index.php/Tension-type_headache)


== Technique<br>  ==
== Technique<br>  ==
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== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
== Recent Related Research (from [http://www.ncbi.nlm.nih.gov/pubmed/ Pubmed])  ==
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== References  ==
== References  ==
References will automatically be added here, see [[Adding References|adding references tutorial]].


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[[Category:Cervical_Examination]]
[[Category:Cervical_Examination]]

Revision as of 23:46, 20 April 2014

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Purpose
[edit | edit source]

The cranio cervical flexion test (CFFT) is a clinical test of the anatomical action of the deep cervical flexor muscles [1]. The test could be described as a test of neuromotor control. The features that are tested are the activation of the deep flexors and the isometric endurance of the muscles[1]. The test also allows to assess the interaction of the deep cervical flexor muscles with the superficial flexors[1], i.e. the sternocleidomastoid and the anterior scalene muscles[2]. It can also be used as a clinical indicator of impaired activation of the deep cervical flexor muscles [2][3], to measure the muscle activity of the deep [4] and superficial [5], cervical muscles or as a therapy approach[2][6][7].

Development of the Test[edit | edit source]

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].

Clinical Importance[edit | edit source]

There is reason to believe that an impaired and delayed activation of the deep cervical flexor muscles causes headaches [3][2][8][5][9]. As mentioned earlier, the CCFT is also indicative if the deep cervical flexors are impaired.

Research[edit | edit source]

Since 2001 the test is commonly being used in research, for example when investigating the development of motor dysfunction following a whiplash injury[5]. The CCFT was also used in research about the performance of the cranio cervical flexion test in patients with chronic tension type headache[8].

Technique
[edit | edit source]

Test

The test consists of five progressive stages.


Testing position

The patient is positioned on the table in a supine crook lying position, the neck in a neutral position[4] . 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 couch (literally copied from [10]). If necessary the therapist can place towels under the patients head to achieve a neutral position of the neck and head. Before performing the test the uninflated pressure sensor (= PBU or pressure biofeedback unit) must be placed behind the neck so that it abuts the occiput. Then it is inflated to a stable baseline pressure of 20 mm Hg[1].


Testing procedure

The PBU will provide feedback and direction to the patient to perform the required five stages of the test. The patient is instructed to move the head vertically (as of saying ‘yes’). The movement is performed gently and slowly [1]. Because of the nodding action the pressure in the inflated pressure sensor will increase. For the first stage of the test the pressure should increase with 2 mm Hg. The patient has to hold this position for 5 seconds (10 seconds[8][5]). 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. [7]


Features

This test should be repeated twice without substitution or fatigue.[7] The flexion of the neck can only be performed because of the activation of the deep cervical flexors. The superficial cervical flexors cannot be used. The therapist should pay attention to substitution strategies: the loss of the neutral position of the neck and head, and palpable or visible contraction of the sternocleidomastoid and scalene muscle. [7]


Rehabilitation technique[7]

If the patient is not able to finish the five stages of the CCFT as instructed (i.e. the superficial cervical flexor muscles are active, or the patient cannot hold the position he/she is in) the deep cervical flexor muscles must be trained. The patient’s neck is in a flexed position in which he does not experience any problems to hold the pressure. This position should be used as the basic pressure to start the training/ rehabilitation. The patient has to hold this pressure for ten seconds and this should be repeated ten times.

Evidence[edit | edit source]

Provide the evidence for this technique here


Recent Related Research (from Pubmed)[edit | edit source]

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References[edit | edit source]

  1. ↑ 1.0 1.1 1.2 1.3 1.4 1.5 Gwendolen AJ, O’Leary SP, Falla D. Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test. J Manipulative Physiol Ther 2008 Sep;31(7):525-33. Cite error: Invalid <ref> tag; name "GWENDOLEN" defined multiple times with different content Cite error: Invalid <ref> tag; name "GWENDOLEN" defined multiple times with different content
  2. ↑ 2.0 2.1 2.2 2.3 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.
  3. ↑ 3.0 3.1 Fernandez-de-las-Penas C, Arendt-Nielson L, Gerwin RD. Tension type and cervicogenic headache: pathophysiology, diagnosis and management.
  4. ↑ 4.0 4.1 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). Cite error: Invalid <ref> tag; name "FALLA" defined multiple times with different content
  5. ↑ 5.0 5.1 5.2 5.3 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. Cite error: Invalid <ref> tag; name "STERLING" defined multiple times with different content Cite error: Invalid <ref> tag; name "STERLING" defined multiple times with different content Cite error: Invalid <ref> tag; name "STERLING" defined multiple times with different content
  6. ↑ Auee J. De rol van spierdisfunctie bij chronische nekpijn; afstudeer artikel; HvU afdeling fysiotherapie.
  7. ↑ 7.0 7.1 7.2 7.3 7.4 Wilson-O’Toole F, Gormley J, Hussey J. Exercise therapy in the management of musculoskeletal disorders: Blackwell Publishing Ltd, 2011 Cite error: Invalid <ref> tag; name "WILSON" defined multiple times with different content Cite error: Invalid <ref> tag; name "WILSON" defined multiple times with different content Cite error: Invalid <ref> tag; name "WILSON" defined multiple times with different content Cite error: Invalid <ref> tag; name "WILSON" defined multiple times with different content
  8. ↑ 8.0 8.1 8.2 FERNANDEZ-DE-LAS-PENAS C., PEREZ-DE-HEREDIA M., MOLERO-SANCHEZ A., MIANGOLARRAPAGE J.C.; Performance of the craniocervical flexion test, forward head posture and headache clinical parameters in patients with chronic tension type headache: a pilot study; Journal of orthopaedic and sport physical therapy; vol. 37; nr. 2; Feb. 2007
  9. ↑ BEETON K.S.; Manual therapy masterclasses, the Vertebral column; Elsevier; 2003
  10. ↑ STERLING M., JULL G., WRIGHT A.; Cervical mobilization: current effects on pain, sympathetic nervous system activity and motor activity; Manual Therapy; Harcourt Publishers; 2001
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