What do neck pain, jaw pain, headache and migraine all have in common?

A growing body of evidence that suggests including the Flexion-Rotation test (FRT) in your clinical assessment of these populations is best practice! If you already use the FRT, then this review might help you understand some of the diagnoses you should be using it with.  If you aren’t using the FRT, then you might find this quick blog helpful to start implementing this important test into your clinical decision making and assessment.

To begin, let’s give you some resources for a few different conditions that the FRT is showing usefulness.

Numerous studies show a correlation between a + FRT and Temporomandibular Disorder (TMD).  Consider that this study found Women with myogenic TMD had significantly lower FRT scores compared to their matched healthy women. No difference was found between groups in CROM in any of the standard evaluation planes of movement. The FRT was positive (less than 32°) in 90% of the TMD participants versus 5% in the healthy control but the findings were not correlated with TMD severity.

Similar findings were seen here.   Subjects with TMD had signs of upper cervical spine movement impairment, greater in those with headache. Only

subjects with TMD and headache had impairment of cervical spine sagittal plane mobility. This study provides evidence for the importance of examination of upper cervical mobility assessment using the FRT in patients who suffer from TMD.

Other studies, such as this one, have seen further evidence of weakness in the deep neck flexors along with + FRT findings.

Along with TMD, researchers are also seeing an association with Migraine, Cervicogenic headache (CGH) and the FRT.

So, why is this important?  Well, if your FRT is +, you need to find a correction for this dysfunction.  While  options like thrust joint manipulation and PAVIM’s are available, the  Mulligan Concept’s cervical SNAGS have been researched and determined to have a positive effect not only on the test, but also the symptomology.  Furthermore, Self-SNAGs have been proven effective, and can be performed by the patient as a HEP.

Core Mulligan Concept

recently published study concluded that Sustained Natural Apophyseal Glide (SNAG)  mobilizations were effective in reducing cervicogenic headache and dizziness in all groups with a greater improvement in the combined group. The use of this core Mulligan Concept technique is encouraged as a noninvasive intervention depending on the therapist’s assessment, findings, and clinical reasoning.   Learn this assessment and treatment procedure in any one of our Upper Quarter courses.

Similar findings in 2007, and in 2014, as well as some others, create a nice body of evidence supporting the use of SNAGS in patients who have a + FRT.  This premise has been part of the battery of tests suggested by both a Systematic Review in 2019 and A Delphi study in 2016They reported eleven physical examination tests that were considered clinically useful: manual joint palpation, the cranio-cervical flexion test, the cervical flexion-rotation test, active range of cervical movement, head forward position, trigger point palpation, muscle tests of the shoulder girdle, passive physiological intervertebral movements, reproduction and resolution of headache symptoms, screening of the thoracic spine, and combined movement tests.

So now that you know the FRT should be part of your screening exam for the above populations….are you doing it right?

The most common mistake I see when teaching the FRT on courses, is the lack of the examiner achieving full cervical flexion before performing the rotation part of the test.  Commonly, I observe the issue illustrated in the below photo.  The patient is not positioned with their shoulders to the end of the table.  This allows for the examiner to be directly over the crown of the head to perform the test.  Next, the neck is not fully flexed.  The FRT is not inherently comfortable for the patient, but ensuring full cervical flexion is a necessity for the test.  An easy cue is to watch for the patients shoulders to begin to lift off the table during the flexion.

Queue during Flexion

Your test position should look more like the below picture.

Test Position

Another common mistake is to allow the cervical spine to side bend to the same side s the rotation while performing the test.  This will often result in a false negative test.

I hope this information convinces you to adopt the FRT as part of your examination and helps to guide you through its effective utilization.

Please watch the video imbedded in this newsletter to help you perform the FRT correctly in the clinic.

Eric Dinkins, PT, MSPT, OCS, Cert. MT, MCTA
Mark Thomson PT, DPT, OCS, FAAOMPT, CMP, MCTA