Cranio‐cervical Flexion Test

The Cranio-Cervical Flexion Test (CCFT) is a clinical test for neuromotor control that evaluates activation and endurance of the deep cervical flexors. The test requires the patient to perform a gentle “yes”-like nodding motion, which represents the anatomical function of the deep cervical flexors, against a pressure biofeedback unit.

History

The CCFT was developed over a 15-year period. Based on findings that altered motor control and muscle morphology contribute to low back pain, a similar approach was considered relevant for the cervical core (longus colli and longus capitis). Janda emphasized the importance of the deep cervical flexors in supporting motion segments and maintaining cervical lordosis. The CCFT emerged from growing interest in the functional role of muscles in segmental stabilization and the need for specific therapeutic exercises for patients with neck pain².

Purpose of the Test

The CCFT assesses neuromuscular control of the deep cervical flexors (longus capitis and longus colli), as well as their endurance and interaction with superficial flexors such as the sternocleidomastoid and anterior scalene muscles²,³.It can be used as:

• A clinical indicator of impaired activation of the deep cervical flexors²,⁴

• A measure of muscle activity in both deep⁵ and superficial⁶ cervical muscles

• A therapeutic tool for training patients with neck pain²,⁷,⁸

Execution

• Patient position: Supine with knees bent and the neck in neutral². Neutral alignment is ensured by keeping a line from forehead to chin horizontal and parallel with the table². Towels may be placed under the head to achieve this.

• Setup: An uninflated pressure biofeedback unit (PBU) is placed under the neck against the occiput and inflated to 20 mmHg².

• Movement: The patient is instructed to nod slowly as if saying “yes.” This increases the pressure by 2 mmHg in the first stage, and the position is held for 10 seconds².

• The patient returns to 20 mmHg and repeats the process with incremental pressure increases (24 mmHg, 26 mmHg, etc.) up to 30 mmHg².

• The test is repeated twice without compensation or fatigue².

The therapist should observe for:

• Loss of neutral neck position

• Visible or palpable activation of sternocleidomastoid or scalenes²

Scoring and Interpretation

• Activation score: The highest pressure level maintained for 10 seconds

• Performance score: The number of times the patient can maintain this level (up to 10 repetitions)

Clinical Significance

• Impaired and delayed activation of deep cervical flexors can contribute to headaches²–⁶

• Increased activation of superficial neck muscles may cause motor dysfunction after whiplash injuries⁵

• CCFT shows reduced function of deep cervical flexors in patients with chronic tension-type headache⁴

• Patients with neck pain generally perform worse on CCFT⁹

• Greater cranio-cervical flexion range increases the demand on deep flexors¹⁰

Treatment Application

Patients can practice gentle cranio-cervical nodding in supine. Progression involves maintaining the position against the pressure biofeedback unit at gradually increasing pressure levels¹¹.

Psychometric Properties

• Reliability: ICC values from 0.63–0.86 (fair to excellent), up to 0.98 in asymptomatic subjects¹²

• Validity: Satisfactory construct validity, though not always able to clearly discriminate between symptomatic and asymptomatic groups¹³

Summary

The Cranio-Cervical Flexion Test is a validated and clinically relevant assessment for neuromuscular control and endurance of the deep cervical flexors. It provides insight into muscle dysfunction associated with neck pain, headaches, and whiplash-associated disorders, while also serving as a targeted therapeutic tool.

Sources:

1. 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. 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. Fernandez-de-las-Penas C, Arendt-Nielson L, Gerwin RD. Tension type and cervicogenic headache: pathophysiology, diagnosis and management.

4. 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. 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.

6. Auee J. De rol van spierdisfunctie bij chronische nekpijn; afstudeer artikel; HvU afdeling fysiotherapie.

7. Wilson-O’Toole F, Gormley J, Hussey J. Exercise therapy in the management of musculoskeletal disorders: Blackwell Publishing Ltd, 2011

8. 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.

9. 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).

10. Beeton KS. Manual therapy masterclasses: the vertebral column. Elsevier, 2003

11. Falla DL, Jull GA, Hodges PW. Patients with neck pain demonstrate reduced electromyographic activity of the deep cervical flexor muscles during performance of the craniocervical flexion test. Spine. 2004 Oct 1;29(19):2108-14.

12. Falla DL, Campbell CD, Fagan AE, Thompson DC, Jull GA. Relationship between cranio-cervical flexion range of motion and pressure change during the cranio-cervical flexion test. Man Ther. 2003 May 1;8(2):92-6.

13. O’Leary S, Falla D, Jull G. The relationship between superficial muscle activity during the cranio-cervical flexion test and clinical features in patients with chronic neck pain. Man Ther. 2011 Oct 1;16(5):452-5.

14. Uthaikhup S, Jull G. Performance in the cranio-cervical flexion test is altered in elderly subjects. Man Ther. 2009 Oct 1;14(5):475-9.

15. 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 1;14(6):696-701.

16. 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.

17. 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

18. 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.

19. 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.

20. James G, Doe T. The craniocervical flexion test: intra‐tester reliability in asymptomatic subjects. Physiother Res Int. 2010 Sep;15(3):144-9.