Cervical Spine Range of Motion

Original Editor - Stacy Schiurring based on the course by Shala Cummingham
Top Contributors - Jess Bell and Stacy Schiurring

Introduction

Assessing cervical range of motion (ROM) is a fundamental component of the musculoskeletal examination for patients presenting with neck pain, cervical dysfunction, or upper quarter impairments. Accurately measuring cervical mobility provides baseline data for diagnosis and treatment planning. It also enables objective monitoring of patient progress throughout the rehabilitation process. Standardised measurement techniques help ensure reliability and patient safety.

While published normative values for cervical ROM vary widely across studies due to differences in equipment, procedures, and age categories, the ability to compare bilateral movements (rotation and lateral flexion) and document changes over time remains invaluable for guiding clinical decision-making and demonstrating treatment effectiveness. Understanding measurement techniques and common compensatory movement patterns enables rehabilitation professionals to obtain meaningful data while maintaining appropriate precautions in this sensitive region.

If you would like to learn more about the anatomy of this region, see Functional Anatomy of the Cervical Spine.

According to the American Academy of Orthopedic Surgeons, the normative active ROM measurements for cervical ROM are approximately:

• 80-90° for flexion
• 50-70° for extension
• 130° for full flexion to full extension
• 20-45° for lateral flexion (side-bending)
• 70-90° for rotation

These numbers vary between individuals and research studies.

The capsular pattern of the cervical spine presents as an equal limitation of extension, bilateral lateral flexion, and bilateral rotation. Flexion is the least restricted or "best" movement. It is important to note that capsular patterns are based primarily on clinical findings rather than robust research evidence, which may account for some inconsistency in their application across different clinical contexts.

Cervical ROM Testing Precautions

Due to its complex neurovascular anatomy and sensitive structures, clinicians must carefully consider patient safety when assessing cervical spine ROM. The primary concern during the cervical examination is maintaining the integrity of the blood supply to the brain through both the vertebral and internal carotid arteries, as compromise to either artery could be catastrophic.

It is generally not recommended to routinely assess end-feel or apply overpressure during cervical spine ROM testing. The weight of the head typically provides sufficient force for the ROM assessment, and patients tend to be highly sensitive in this region.

Clinicians must exercise caution when applying overpressure during rotation or any combination of rotation, side flexion, and extension. These positions can compress the vertebral artery, potentially leading to reduced blood supply to the brain. Extreme end-range positioning, particularly extension and rotation, should be approached with heightened caution.

Historically, the vertebral artery test (VAT) (also called the vertebrobasilar insufficiency (VBI) test) has been recommended before cervical procedures (e.g., cervical manual therapy). This test involves holding the neck in combined cervical rotation and extension while monitoring for symptoms, such as dizziness, visual changes, nystagmus, drop attacks, dysarthria, or tinnitus. However, contemporary evidence questions the validity of positional testing, with a systematic review finding that pre-manipulative VBI tests have a low sensitivity (0-57%) and variable specificity (67-100%). Researchers have, therefore, concluded that these tests do not appear valid for screening purposes. Research findings on cervical motion and brain circulation are also inconsistent. Some studies found no significant decrease in blood flow volume despite velocity changes, while others found decreased blood flow with combined extension and rotation in both the contralateral and ipsilateral vertebral arteries.

The International IFOMPT Cervical Framework (2023) recommends a comprehensive patient interview to identify risk factors for cervical arterial dysfunction combined with continuous monitoring for symptoms during examination, rather than relying on specific positional tests alone. Risk factors include age (particularly over 60 years), history of stroke or cardiovascular disease, hypertension, diabetes mellitus, smoking history, trauma to the head or neck, and sudden onset of severe headache or neck pain. When subtle signs or symptoms of vascular pathology are present, additional testing, such as measuring blood pressure, conducting a cranial nerve examination, and a gait assessment, may be warranted. These tests can support or refute the vascular hypothesis. A cervical spine examination should not be performed when clear signs of vascular pathology or unexplained red flags are present, as these might be associated with serious pathologies requiring immediate medical referral.

Cervical Flexion Range of Motion

Norms: 80-90°. Note, there is a wide range of normative values published and they often don't reflect what clinicians observe in practice.

End-feel: firm. Remember, assessing end feel and overpressure is not routinely recommended during cervical spine assessments.

Landmarks for Measurements

Goniometer

• Fulcrum: external auditory meatus (ear canal)
• Stable arm: perpendicular to the ceiling or ground (assuming they are parallel)
• Distal/moving arm: base of the nares (nose)
• If nose anatomy is unavailable, a tongue depressor placed in the mouth can serve as a reference point

Tape measure

• Landmarks: tip of the chin to the sternal notch
• Method: measure distance in a neutral position, then measure at end range. ROM = the difference between the two measurements.

Documentation

The starting position appears as 90° on the goniometer. Transpose this to 0°, as the starting position is always considered the zero position. Example: the goniometer reads 130° at end range. Document this as 0–40° of flexion (130° - 90° = 40°).

Cervical Extension Range of Motion

Norms: 50-70°. There is a wide range of normative values published, and they often don't reflect what clinicians observe in practice.

End-feel: firm. Remember, end-feel and overpressure are not routinely recommended in the cervical spine.

Landmarks for Measurements

Goniometer

Use the same landmarks as cervical flexion.

• Fulcrum: external auditory meatus
• Stable arm: perpendicular to the ceiling
• Distal/moving arm: base of the nares

Tape measure

Use the same landmarks as cervical flexion:

• Landmarks: tip of the chin to the sternal notch
• Method: measure in neutral, then at end range extension

Documentation

Cervical extension is documented using the same method as cervical flexion. Transpose the 90° starting position to 0°. Document from the zero position (e.g., 0 - X° of extension).

Cervical Lateral Flexion (Side-bending) Range of Motion

Norms: 20-45° bilaterally. There is a wide range of normative values published. The right and left sides can be compared to each other.

End-feel: firm. However, it is not necessary to obtain an end-feel when assessing cervical lateral flexion.

Landmarks for Measurements

Goniometer

• Fulcrum: C7 spinous process: to locate C7, find the longest spinous process. Alternatively, find the first rib in the upper trapezius area, and trace this to the spine. This is T1. Go up one spinous process to C7
• Stable/proximal arm: along the spinous processes of the thoracic spine or perpendicular to the ground; if scoliosis is present, always document which method was used
• Distal/moving arm: dorsal midline of the head (i.e., bifurcating the head)

Tape measure

• Landmarks: mastoid process to acromial process
• Measure in neutral, then at end range side bending

Documentation

Document from a zero starting position using the standard goniometric documentation system.

Watch for compensatory movements: a common compensation is to add rotation during side bending. Ensure the patient moves in a single plane of motion with straight side bending, and correct the patient if they add in rotation.

Cervical Rotation Range of Motion

Norms: 70-90° bilaterally. There is a wide range of normative values published. Right and left rotation can be compared to each other.

End-feel: firm. There is significant controversy on whether overpressure should be applied as the vertebral artery passes through the cervical spine. It may not be necessary to assess end feel—always use your clinical judgement.

Landmarks for Measurements

Goniometer

• Positioning: the therapist is positioned above the patient, looking down. The patient is seated in a chair or on a high-low table at the lowest position. The therapist can stand on a stool/step as needed. Position the goniometer as close to the head as possible for accuracy.
• Fulcrum: centre of the top of the head
• Stable/proximal arm: parallel line between the two acromial processes OR perpendicular to the wall
  • If the patient has rounded shoulders and a forward head position, use a parallel line between the acromial processes. If the patient has a good upright posture, perpendicular to the wall is acceptable
• Distal/moving arm: tip of the nose

Tape measure

• Landmarks: tip of the chin to the acromial process
• ROM = the difference between neutral and full rotation measurements

Documentation

Document from a zero starting position using the standard goniometric documentation system.

Variations in Normal Range of Motion

Instrument-related Factors

Different instruments (e.g., goniometer, inclinometer, cervical ROM (CROM) device, or tape measure) have varying levels of reliability and validity. It is also necessary to standardise where the central axis is placed, as changes in axis positioning by different examiners can affect consistency.

Examiner-related factors

Examiner-related factors include the clinician's training, skill, and experience in performing measurements, particularly for passive mobilisation techniques, where the examiner's ability to reach the physiological barrier and apply consistent force affects measurement accuracy. Other examiner-related factors include potential examiner bias and the subjectivity of identifying landmarks and aligning the goniometer.

Patient-related factors

Various patient-related factors can influence the cervical ROM assessment. Psychosocial factors, such as fear of movement (kinesiophobia), pain catastrophising, anxiety, and the level of voluntary effort during testing, can contribute to reduced or inconsistent ROM. The presence of pain can alter movement patterns and reduce ROM. Patients may also consciously or unconsciously exaggerate or minimise their symptoms. This can increase variability and affect the validity of measurements.

Demographic and biological variables also contribute to measurement variation. Age demonstrates an inverse relationship to cervical ROM, with all cervical movements decreasing significantly with age in both males and females. Gender influences ROM, with females generally demonstrating greater active range of motion than males for all movements except flexion. However, the clinical significance of these differences remains debated.

Temporal factors such as the time of day can impact the ROM assessment (e.g., a person with morning stiffness could have different ROM depending on the time of day). Ensuring testing is repeated at around the same time of day can help to avoid this variable.

Previous cervical trauma, whiplash-associated disorders, or chronic neck pain can cause altered muscle recruitment patterns and compensatory movement strategies, which may affect ROM measurements. Structural and postural factors, including forward head posture, thoracic kyphosis, shoulder protraction, and cervical muscle tone, influence the starting position and end range of cervical movements. The presence of muscle spasm, particularly in response to acute injury or pain, can also significantly limit range and introduce protective guarding that varies between testing sessions.

Additional patient factors to consider include: body mass index, which may affect a clinician's ability to accurately palpate anatomical landmarks; cervical muscle endurance and strength, which can influence a person's ability to maintain positions during testing; proprioceptive deficits, which affect movement accuracy and repositioning sense; the patient's understanding of instructions and ability to isolate single-plane movements without compensatory patterns (such as adding rotation during lateral flexion); and level of fatigue, which can decrease performance across repeated measurements.

Protocol-related factors

Protocol-related factors include: the testing position (e.g., sitting versus standing); whether measurements are active or passive; the number of repetitions performed; the speed of the movement; the presence or absence of warm-up exercises prior to testing; and whether a patient's eyes are open or closed during the assessment.

Resources

• Rushton A, Carlesso LC, Flynn T, Hing WA, Rubinstein SM, Vogel S, Kerry R. International framework for examination of the cervical region for potential of vascular pathologies of the neck prior to musculoskeletal intervention: international IFOMPT cervical framework. journal of orthopaedic & sports physical therapy. 2023 Jan;53(1):7-22.
• The following 26-minute video overviews the importance of active ROM assessment, then demonstrates a cervical ROM assessment.