Manual Therapy

Manual Therapy Diagnosis for C1/2 Cervicogenic Headache

By: Francois Prizinski, DPT, OCS

Hall et al. (2010) published an article in The Journal of Manual and Manipulative Therapy titled: “The influence of lower cervical joint pain on range of motion and interpretation of the flexion–rotation test.” They investigated the utility of this clinical test that is commonly used for assessing range of motion of the upper cervical spine. Mobility of C1/2 has been reported to be a source of subocciptial headaches, which should be assessed, in this clinical population. The study assessed 2 groups, subocciptial headache group from cervical facet pain group (diagnosed by guided facet joint injection), with the flexion rotation test (FRT).

FRT

“The subject lay relaxed in supine with the cervical and upper thoracic spine passively flexed to end range, or if pain prevented this, to a comfortable limit determined by the patient. The head was then passively rotated left and right. Range was determined either by the subject reporting the onset of pain, or firm resistance encountered by the therapist, whichever came first.”

Normal range of motion for unilateral rotation has been accepted to be 44 deg and symmetric

Results of this Study:

“The average range of unilateral rotation to the limited side during the FRT was 26 and 37.5deg for the cervicogenic headache and lower CFP groups respectively. The difference between groups was significant (P,0.01). Sensitivity and specificity for cervicogenic headache diagnosis was 75 and 92% respectively. A receiver operating curve revealed that an experienced examiner using the FRT was able to make the correct diagnosis 90% of the time (P,0.01), with a positive cut-off value of 32deg.”

The positive likelihood ratio for this test was 9.38, and negative likelihood ratio 0.27 which means that if a positive finding of 12 deg limitation unilaterally from a normal ROM of 44 deg will represent a very clinically significant interpretation of a true positive finding.

Clinically if a patient with cerviogenic headaches present with a unilateral rotation restriction >10 deg (normal 44 deg) with all other medical screening procedures cleared for vascular, neurologic, and upper cervical instability, than assess prone manually for mobility restriction and perform appropriate mobilizations with ability to use FRT as a reassessment tool. Try performing the test pre manual intervention and post manual intervention to assess a change in range of motion and patients self reported pain.

Also consider the possibility for positive FRT findings in subclinical populations, which may progress to pain later?

Though a meaningful article with clinically applicable findings, each clinician should be consumers of the literature and try to incorporate the evidence of the literature to improve your individual outcomes. Something as simple as not performing the test into end-range can bias the entire test and your interpretation. The test may have great clinical utility but always keep in mind that extraneous variables may bias your clinical findings. If your test is negative today it may be positive tomorrow, that’s the clinic . . .

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