This topic is parallel to a prior post showing EBP from evaluation to treatment for SIJ.  The past article is entitled, “EBP from CPR: From Exam to Treatment” and can be found here.

I feel physical therapists can have a significant impact and advantage on diagnosing and treating the C1-2 dysfunctional level; more specifically, cervicogenic headaches (CGH) compared to alot of other professions.  We have the palpatory skills to find the presence of upper cervical spine dysfunction, clinical measurement tools for diagnosing, and treatment approaches manually and with therapeutic exercise for relief and subsequent increase in function.

It seems that there has been more research on CGH, use of FRT and physical therapy in the literature recently evoking this and following posts.

The ensuing posts will be of the following:

1.  Diagnosis of CGH through the Flexion-Rotation Test (FRT).

2.  Treatment using one manual therapy technique.

3.  Treatment using therapeutic exercise.

This post is part 1 of 3: Diagnosis of C1-2 dysfunction & CGH through the Flexion-Rotation Test (FRT).

An easy, effective, valid and reliable method of measuring this motion is through the FRT.  Watch the video below to see how it is performed.

(for those whom this blog is linked to another site and possibly cannot see the video, go to

Why the FRT with CGH?

-FRT measures movement at AA joint, which has been shown to be a likely source of pain in patients with CGH (Hall and Robinson 2004 & Jull et al 1997)

-It has 91% sensitivity and 90% specificity for identifying CGH as opposed to migraine or control patients with HA.

What are normal values for FRT?

-Normal values for FRT range from 39-45 degrees.

-Individuals who have been diagnosed with CGH show values ranging from 20-28 degrees.

-Average PROM is 20 degrees for CGH (39 degrees for migraine and control patients)

What is a positive test? From Ogince et al. 2007.

-Less than or equal to 32 degrees was cut-off for positive test.

-This was shown to be 91% accurate in defining CGH.

Other data from recent study Hall T, et al. 2010.

-FRT is a stable and repeatable method of cervical spine examination.

-Reliable and has low measurement error if performed by an experienced clinician.

-MDC is 7 degrees.

Bottom Line:

Use of FRT is a valid and reliable method to determining if symptoms (HA, cervicalgia, referral symptoms, etc) are arising from C1-2.  The test just makes sense as ~50% of cervical spine mobility arises from AA; and also quick and easy. Honestly, unless I am documenting for research, I use a goniometer or just look at the ROM (which of course is not “right”), but effective for daily practice.  The patient appreciates this too (especially if you’ve ever worn the CROM!)

Do you ever use the FRT, with or without CROM?  Do you find on clinically that the limitation in degrees found through FRT is consistent with C1-2 dysfunction?  From this, do you feel C1-2 dysfunction is consistent with CGH or do you think it arises predominantly from another level, or is CGH even possible?!

Hall T, et al.  Long-Term Stability and Minimal Detectable Change of the Cervical Flexion-Rotation Test.  JOSPT. 2010. 40; 4:225-229.

Ogince M, Hall T, Robinson K, Blackmore A. (2007).  The diagnostic validity of the cervical flexion-rotation test in C1/2 related cervicogenic headaches. Manual Therapy, 12 (3), 256-262.

Hall T, Robinson K. (2004).  The flexion-rotation test and active cervical mobility–a comparitive measurement study in cervicogenic headache.  Manual Therapy, 9, 197-202.

Jull G. (1997). Management of cervical headache. Manual Therapy, 2 (4), 182-190.


  1. Not sure why you say looking at motion is not right? heck I think studies show that visual reliability of ROM is within 5 degrees, use of goiniometer only improves to 3-4 degrees of variance with ROM. (don’t have the references off the top of my head, but can search them if others are interested) I guess I think my eyes are pretty good, only 1-2 degree different, not sure if worth time to find gonio and measure.

    1. You’re right Kory. I just know there are real strict, old-school ROM guardians out there. “Right” was used in quotations as a term to state it is not as objective for research-based outcomes, but works very well day to day; especially more experienced clinicians. I have heard some of the same information about visual ROM measurements being within a very close match to goniometer but like you, don’t have the studies in front of me. Anyone out there know of any?

  2. Just to add to this post before the 2nd part of this series starts:
    You can read the abstract at link below but the authors basically summarized that an experienced examiner could make correct diagnosis (between CGH, migraine without aura and multiple headache forms) using FRT 85% of the time. 30 degrees was cut-off in this study…which is very close to the 32 degrees described above.

    Hall T, et al. Comparative Accuracy and Diagnostic Accuracy of the Cervical Flexion-Rotation Test. J Headache Pain. 2010(


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