Cranio‐cervical Flexion Test: Difference between revisions

mNo edit summary
mNo edit summary
Line 4: Line 4:
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
'''Top Contributors''' - {{Special:Contributors/{{FULLPAGENAME}}}}
</div>  
</div>  
== Purpose ==
== Introduction ==


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


=== 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">Jull GA, O’Leary SP, Falla DL: [https://www.ncbi.nlm.nih.gov/pubmed/18804003 Clinical assessment of the deep cervical flexor muscles: the craniocervical flexion test.] J Manipulative Physiol Ther. 2008, 31 (7): 525-533.</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" />.  
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">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>. 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" />.


=== 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 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"/><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.  
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-Nielson L, Gerwin RD. Tension type and cervicogenic headache: pathophysiology, diagnosis and management.</ref><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><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" /><ref name="BEETON">Beeton KS. Manual therapy masterclasses: the vertebral column. Elsevier, 2003</ref>. The CCFT is indicative of impairment of the deep cervical flexors.  


=== Research ===
== 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<ref name="GWENDOLEN" />, i.e. the [[Sternocleidomastoid]] and the [[Anterior Scalene|anterior scalene]] muscles<ref name="JULL" />. It can also be used as a clinical indicator of impaired activation of the deep cervical flexor muscles <ref name="JULL" /><ref name="FERNAN" />, 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" />, 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>.
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  ==
== Technique  ==
Line 47: Line 46:
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.  
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  ==  
== Evidence  ==
 
=== Reliabiliity ===
The intra- and inter-reliability for the CCFT was between “fair to good” and “good to excellent” (ICC: 0.63 to 0.86)<ref name=":0">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.</ref><ref>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</ref><ref name=":1">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.</ref><ref>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.</ref>. Studies of reliability on the CCFT in asymptomatic subjects have reported slightly higher ICC values, ranging from 0.81 to 0.98<ref name=":1" />
 
=== Validity ===
Construct validity has been demonstrated to be satisfactory<ref name=":1" />. The discriminative validity of the CCFT is not as strong<ref name=":1" />.  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<ref name=":0" />.


== References  ==
== References  ==

Revision as of 12:20, 19 September 2017

Original Editor - Annelies Beckers

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

Introduction[edit | edit source]

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[edit | edit source]

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[edit | edit source]

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].

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[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[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[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][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]

Reliabiliity[edit | edit source]

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]

Validity[edit | edit source]

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].

References[edit | edit source]

  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.


Retrieved from "https://www.physio-pedia.com/index.php?title=Cranio‐cervical_Flexion_Test&oldid=178914"