Cranio‐cervical Flexion Test


The Craniocervical flexion test (CCFT) is a clinical test of neuromotor control including the activation and endurance of the deep flexors of the cervical spine. This test involves the subject performing a "yes" like nod which is the anatomical action of the Deep Cervical flexors, against a pressure biofeedback.


The test has evolved over fifteen years. Based on the concept of how altered motor control and muscle morphology lead to impairments of the low back, a similar analogy seemed to be applicable to the cervical core (longus colli, longus capitus) as well. In addition, Janda proposed that the deep cervical flexors were important in supporting the motion segments and maintaining the cervical lordotic curve. Thus this test was 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,

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[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].


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[8]. 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 position

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 10 seconds[9][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 10 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]

Calculation and Interpretation

Activation score is indicates the activation of the deep cervical flexor musculature. The performance index is a term used to understand the isometric endurance of these muscles.

Activation score = The highest pressure level the subject can achieve and hold for a duration of 10 seconds

Performance index = The number of times the subject can maintain the pressure level achieved in the activation out of a maximum of 10 repetitions.

Clinical Importance

  • There is reason to believe that an impaired and delayed activation of the deep cervical flexor muscles causes headaches [3][2][9][5][10].
  • An increased activation of the superficial neck muscles contributing to the development of motor dysfunction following a whiplash injury [5]
  • The CCFT is indicative of impairments of the deep cervical flexors in in patients with chronic tension type headache[9].
  • Subjects with neck pain demonstrated altered performance in the CCFT test [11]
  • With an increase in the craniocervical flexion range there was an increased demand on the deep cervical flexors. [12]
  • A modest correlation (R2=0.16 ) between the activity of superficial muscles and pain intensity was noted, however there are many factors that could affect this. [13]
  • This test while performed in asymptomatic adults demonstrated and increased activation of the sternocleidomastoid, larger variability in the flexion range and a lower capacity to achieve a target pressure as compared to younger subjects. [14]

Treatment procedure

The subjects can perform the craniocervical action ("Yes" like nod) in supine position after achieving a pure craniocervical motion the progression could be to hold this against a pressure biofeedback with increasing levels of pressure maintained.[15]

Psychometric Properties

  • Reliability: The intra- and inter-reliability for the CCFT was between “fair to good” and “good to excellent” (ICC: 0.63 to 0.86)[16][17][18][19][20] Studies of reliability on the CCFT in asymptomatic subjects have reported slightly higher ICC values, ranging from 0.81 to 0.98[18]
  • Validity: Construct validity has been demonstrated to be satisfactory[18]. The discriminative validity of the CCFT is not as strong[18]. 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[16].


  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 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.
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  9. 9.0 9.1 9.2 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).
  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. 16.0 16.1 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.
  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. 18.0 18.1 18.2 18.3 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.
  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.