Cranio‐cervical Flexion Test: Difference between revisions

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== Purpose<br> ==
== Purpose  ==


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>.  
The cranio cervical flexion test (CCFT) is a clinical test of the anatomical action of the deep cervical flexor muscles ([[Longus Colli|longus colli]], [[Longus Capitis|longus capitis]], [[Rectus Capitis Anterior|rectus capitis anterior]], and [[Rectus Capitis Lateralis|rectus capitis lateralis]])<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 assesses the interaction of the deep cervical flexor muscles with the superficial flexors<ref name="GWENDOLEN" />, i.e. the [[Sternocleidomastoid]] and the [[Anterior Scalene|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>.  


=== Development of the Test ===
=== Development of the Test ===


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" />.  
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" />.  


=== 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" /><ref name="JULL" /><ref name="PEREZ">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).</ref><ref name="STERLING">Sterling M,  Gwendolen J, Vincenzino B, Kenardy J, Darnell R. Development of motor system dysfunction following whiplash injury. Pain 2003 May;103(1-2):65-73.</ref><ref name="BEETON">Beeton KS. Manual therapy masterclasses: the vertebral column. Elsevier, 2003</ref>. The CCFT is also indicative of impairment of the deep cervical flexors.  


=== Research  ===
=== Research  ===


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>.  
Since 2001, the test has commonly been used in research, for example investigations into the development of motor dysfunction following a [[Whiplash Associated Disorders|whiplash injury]]<ref name="STERLING" />. 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" />.  


== Technique<br> ==
== Technique  ==


'''Test'''
=== Testing position  ===


The test consists of five progressive stages.  
The patient is positioned on the table in a supine crook lying position, with the neck in a neutral position<ref name="FALLA" />. 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<ref name="WRIGHT">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.</ref>. 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<ref name="GWENDOLEN" />.  


<br>
=== Testing procedure  ===
 
The PBU will provide feedback and direction to the patient to perform the required stages of the test:


'''Testing position'''
#The patient is instructed to move the head vertically (as if saying ‘yes’). The movement is performed gently and slowly <ref name="GWENDOLEN" />. 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.
#The patient is told to maintain this position for 5-10 seconds<ref name="PEREZ" /><ref name="STERLING" />.
#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<ref name="WILSON" />.


The patient is positioned on the table in a supine crook lying position, the neck in a neutral position<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;. 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 <ref name="WRIGHT">STERLING M., JULL G., WRIGHT A.; Cervical mobilization: current effects on pain, sympathetic nervous system activity and motor activity; Manual Therapy; Harcourt Publishers; 2001</ref>). 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<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>.  
This test should be repeated twice without substitution or fatigue<ref name="WILSON" />. Flexion of the neck requires activation of the deep cervical flexors. The superficial cervical flexors cannot be used to perform this movement.  


<br>
The therapist should pay attention to compensatory strategies:


'''Testing procedure'''
*Loss of the neutral position of the neck and head
*Palpable or visible contraction of the sternocleidomastoid and scalene muscle<ref name="WILSON" />


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 <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>. 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<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>). 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. <ref name="WILSON">WILSON- O’TOOLE F., GORMLEY J., HUSSEY J.; Exercise therapy in the management of musculoskeletal disorders; Blackwell Publishing Ltd; 2011</ref>
{{#ev:youtube|9Utqy7RFcXQ}}


<br>  
<br>  


'''Features'''
=== Treatment Approach<ref name="WILSON" />  ===


This test should be repeated twice without substitution or fatigue.<ref name="WILSON">WILSON- O’TOOLE F., GORMLEY J., HUSSEY J.; Exercise therapy in the management of musculoskeletal disorders; Blackwell Publishing Ltd; 2011</ref>&nbsp;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. <ref name="WILSON">WILSON- O’TOOLE F., GORMLEY J., HUSSEY J.; Exercise therapy in the management of musculoskeletal disorders; Blackwell Publishing Ltd; 2011</ref>
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.  
 
<br> '''Rehabilitation technique<ref name="WILSON">WILSON- O’TOOLE F., GORMLEY J., HUSSEY J.; Exercise therapy in the management of musculoskeletal disorders; Blackwell Publishing Ltd; 2011</ref>'''
 
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  ==
== Evidence  ==


Provide the evidence for this technique here  
Provide the evidence for this technique here  
<br>


== 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 />  


[[Category:Cervical_Examination]]
[[Category:Cervical_Examination]] [[Category:Assessment]] [[Category:Musculoskeletal/Orthopaedics|Orthopaedics]]

Revision as of 04:18, 21 April 2014

Original Editor - Annelies Beckers

Top Contributors - Ashmita Patrao, Rachael Lowe, Admin, Annelies Beckers, Kim Jackson, Daphne Jackson, 127.0.0.1, Tony Lowe, Evan Thomas, Naomi O'Reilly, Erik Thoomes, Kai A. Sigel and WikiSysop  

Purpose[edit | edit source]

The cranio cervical flexion test (CCFT) is a clinical test of the anatomical action of the deep cervical flexor muscles (longus colli, longus capitis, rectus capitis anterior, and rectus capitis lateralis)[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 assesses 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]. The CCFT is also indicative of impairment of the deep cervical flexors.

Research[edit | edit source]

Since 2001, the test has commonly been used in research, for example investigations into 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]

Testing position[edit | edit source]

The patient is positioned on the table in a supine crook lying position, with 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 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[edit | edit source]

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[8][5].
  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[7].

This test should be repeated twice without substitution or fatigue[7]. 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[7]


Treatment Approach[7][edit | edit source]

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.

Evidence[edit | edit source]

Provide the evidence for this technique here

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

Failed to load RSS feed from http://www.ncbi.nlm.nih.gov/entrez/eutils/erss.cgi?rss_guid=1zYrsILa0sOkmYzfwG2_hwFt7zJGMICzY2dr5dQ3_AF1qkrMs6|charset=UTF-8|short|max=10: Error parsing XML for RSS

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.
  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).
  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
  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
  8. ↑ 8.0 8.1 8.2 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).
  9. ↑ Beeton KS. 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. Man Ther 2001 May;6(2):72-81.
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