The Cervical Flexion Rotation Test assesses upper cervical rotation while the neck is held in flexion. It is commonly used to assess C1–C2 rotation limitation and may support reasoning in cervicogenic headache presentations. A 2022 perspective article noted that the CFRT has evidence for construct validity and good-to-excellent reliability, but also highlighted methodological issues and potential overestimation of diagnostic accuracy.
A client reports headaches that appear linked to neck movement or sustained posture. They may have reduced rotation when the neck is flexed, or symptoms may change with upper cervical movement.
The Cervical Flexion Rotation Test helps assess upper cervical rotation. It should not be used as the only basis for diagnosing cervicogenic headache, because headache presentations are complex and diagnostic accuracy depends on the reference standard and clinical context.
Test name: Cervical Flexion Rotation Test
Also known as: CFRT, Flexion Rotation Test
Body region: Upper cervical spine, especially C1–C2 movement
Purpose: Assess upper cervical rotation range and symptom response
Positive finding: Restricted rotation, asymmetry or familiar symptom reproduction depending on the clinical question
Negative finding: No meaningful restriction or symptom reproduction
Best used with: Headache history, cervical ROM, neurological screen, cervical segmental assessment and symptom behaviour
Key limitation: It supports reasoning but does not diagnose cervicogenic headache on its own
The Cervical Flexion Rotation Test is performed by placing the cervical spine in flexion, then rotating the head left and right. Cervical flexion is intended to reduce motion from lower cervical segments and bias rotation assessment toward the upper cervical spine.
The test can be performed manually or measured with a device such as a CROM device or digital goniometer.
The test is used to assess upper cervical rotation mobility, side-to-side differences and symptom response.
It may help inform cervicogenic headache reasoning, upper cervical mobility assessment, neck-related headache management and retesting after mobility or control interventions.
The test assesses rotation range in a flexed cervical position. It may reflect upper cervical movement limitation, pain inhibition, guarding, headache status, age, examiner technique or measurement method.
It does not identify one structure or confirm a headache diagnosis on its own.
This test may be useful for clients with neck-related headache symptoms, upper cervical stiffness, reduced cervical rotation, postural headache features or symptoms that appear related to neck movement.
Use when upper cervical mobility assessment is relevant and the client can tolerate cervical flexion and rotation safely.
Use caution with dizziness, vascular symptoms, acute trauma, suspected instability, severe neck pain, neurological symptoms, recent surgery, inflammatory disease or symptoms that worsen rapidly with cervical movement.
Treatment table or chair
Pain/symptom scale
Optional CROM device or digital goniometer
Measurz recording workflow
Optional headache notes
Position the client supine or sitting depending on the selected method.
Gently flex the cervical spine to the selected end position.
Stand or sit at the head of the client if supine.
Support the head and neck comfortably.
Maintain cervical flexion while avoiding excessive force.
Rotate the head gently to one side, then the other, while maintaining flexion.
Ask the client to report pain, headache reproduction, dizziness, stiffness, pressure, symptom location and whether symptoms are familiar.
A positive finding may be restricted rotation, side-to-side asymmetry or reproduction of familiar symptoms, depending on the stated purpose of the test.
A negative finding is no meaningful restriction, asymmetry or familiar symptom reproduction.
Stop if dizziness, neurological symptoms, visual symptoms, sharp pain, nausea, symptom escalation or poor tolerance occurs.
Do not force rotation. Record whether the test was limited by pain, stiffness, symptoms or examiner endpoint.
A positive CFRT may suggest upper cervical rotation limitation or symptom sensitivity in flexion. In a headache presentation, it may support cervicogenic headache reasoning when combined with history and other findings.
A negative test suggests no meaningful restriction or familiar symptom reproduction during the test. It does not exclude cervicogenic headache or other neck-related headache contributors.
Interpretation is stronger when paired with headache history, cervical ROM, symptom behaviour, neurological screen, manual assessment and response to intervention.
The CFRT has been studied in cervicogenic headache assessment, but current authors warn that diagnostic accuracy may be affected by cut-off inconsistency, pain during testing and imperfect reference standards. A 2022 perspective article concluded that the evidence supporting diagnostic validity is likely biased and that the test may be more useful as a prognostic or treatment-guidance factor than a stand-alone diagnostic tool.
No single sensitivity or specificity value is listed here because test accuracy depends on population, cut-off, measurement method and reference standard.
A 2020 BMC Musculoskeletal Disorders study examined concurrent validity and reliability of measuring range of motion during the CFRT with a digital goniometer. A 2022 perspective paper also summarised that CFRT has good construct validity for C1–C2 rotation and good-to-excellent reliability, while cautioning about diagnostic accuracy interpretation.
Common errors include not maintaining cervical flexion, forcing rotation, failing to record symptoms, using unclear positive criteria, ignoring dizziness and treating the test as a stand-alone diagnosis.
Limitations include pain inhibition, headache status, cut-off variation, examiner technique, measurement device variation and imperfect diagnostic reference standards.
Use the Cervical Flexion Rotation Test to assess upper cervical rotation limitation, compare sides, document headache-related symptom response and track change after mobility or motor control interventions.
Record test name, position used, direction tested, range or estimated restriction, pain score, headache symptoms, symptom location, dizziness or visual symptoms, endpoint quality, device used, side-to-side comparison, confidence in result and reason for stopping.
Add related cervical ROM, headache history, neurological screen, symptom behaviour and retest findings.
Neck Rotation Test
Neck Flexion Test
Cervical Distraction Test
Spurling’s Test
Sharp-Purser Test
Upper Limb Tension Test
Headache Symptom Tracking
Posture Assessment
It assesses upper cervical rotation while the neck is held in flexion.
Yes, it is commonly used to support cervicogenic headache reasoning, but it does not diagnose headache type on its own.
A positive result may be restricted rotation, asymmetry or familiar symptom reproduction, depending on the clinical question.
No. Stop at symptom limit, firm endpoint or safety concern.
Record direction, range, symptoms, headache response, dizziness, endpoint quality and device used.
The CFRT assesses upper cervical rotation in flexion.
It may support cervicogenic headache reasoning but is not stand-alone diagnostic.
Cut-offs and diagnostic accuracy require caution.
Safety screening is important with cervical testing.
Measurz should capture range, symptoms, direction and endpoint quality.
Luedtke, K., Schöttker-Königer, T., Hall, T., Reimer, C., Grassold, M., Hasselhoff-Styhler, P., & others. (2020). Concurrent validity and reliability of measuring range of motion during the cervical flexion rotation test with a novel digital goniometer. BMC Musculoskeletal Disorders, 21, 535. Needs verification.
Paquin, J.-P., Dumas, J.-P., Gérard, T., & Tousignant-Laflamme, Y. (2022). A perspective on the use of the cervical flexion rotation test in the physical therapy management of cervicogenic headaches. Archives of Physiotherapy, 12, 26. https://doi.org/10.1186/s40945-022-00153-2
