ChiroACCESS Article



Cervicogenic Headache Diagnosis with the Flexion Rotation Test



This information is provided to you for use in conjunction with your clinical judgment and the specific needs of the patient.

ChiroACCESS Editorial Staff

  

ChiroACCESS



Published on

June 14, 2010

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HeadacheHeadache is the third most common presenting complaint of chiropractic patients.  Eighty-one percent of headache patents are treated solely in the chiropractic office with only 18% co-managed and 6% referred.  It is the most common (77%) non-subluxation based diagnosis made by chiropractors (Job Analysis of Chiropractic 2005).

New research continues to confirm the importance of a simple flexion rotation test (FRT) in the differential diagnoses of headaches.  Many headache cases are often similar in terms of presenting symptom and the FRT has demonstrated in multiple research studies to be highly sensitive to identifying cervicogenic headache from migraine and multiple headache forms.  A study last month (May 2010) found that “An experienced examiner using FRT was able to make the correct diagnosis 85% of the time (P<0.001)…”  Another study found the “overall diagnostic accuracy was 89%”.  A third study found the diagnostic accuracy to be 91%.

A more detailed discussion of headache diagnosis can be found here: Cervicogenic Headache: Diagnosis and here: Episodic Tension-type Headache: Diagnosis

Comparative analysis and diagnostic accuracy of the cervical flexion-rotation test.  [LINK]

J Headache Pain. 2010 May 28. [Epub ahead of print]

Hall TM, Briffa K, Hopper D, Robinson K.
School of Physiotherapy, Curtin Innovation Health Research Institute, Curtin University of Technology, Bentley, Perth, Western Australia, halltm@netspace.net.au.

The aim of this study was to compare the findings of the cervical flexion-rotation test (FRT) between subjects with probable cervicogenic headache (CGH), migraine without aura (Migraine), and multiple headache forms (MHF). An additional aim was to identify the diagnostic accuracy of the FRT in CGH evaluation. Sixty subjects were evaluated: 20 with CGH, 20 with Migraine, and 20 with MHF. Subject and headache symptoms were evaluated by questionnaire. A single-blind examiner conducted the FRT, reporting the test state (positive or negative) before measuring range of motion using a goniometer. The average range of unilateral rotation to the most restricted side was 25 degrees , 42 degrees and 35 degrees for groups CGH, Migraine and MHF, respectively. The difference between groups was significant (P < 0.001). Range of rotation was significantly reduced in the CGH group when compared to groups Migraine (P < 0.001) and MHF (P = 0.001), with an additional smaller significant difference between groups Migraine and MHF (P = 0.039). A receiver operating curve revealed that an experienced examiner using the FRT was able to make the correct diagnosis 85% of the time (P < 0.001), with a positive cut-off value of 30 degrees . Multivariate regression analysis revealed that 44% of the variance in FRT range of motion was explained by the presence of two variables: neck movement or positions provoke headache, and neck symptoms precede headache, but not by other factors associated with migraine. These findings provide further evidence supporting the clinical utility of the FRT in CGH evaluation.

Intertester reliability and diagnostic validity of the cervical flexion-rotation test.  [LINK]

J Manipulative Physiol Ther. 2008 May;31(4):293-300.

Hall TM, Robinson KW, Fujinawa O, Akasaka K, Pyne EA.
School of Physiotherapy, Curtin University of Technology, Australia. halltm@netspace.net.au

OBJECTIVE: This article evaluates reliability and diagnostic validity of the cervical flexion-rotation test (FRT) to discriminate subjects with headache because of C1/2 dysfunction. In addition, this study evaluates agreement between experienced and inexperienced examiners.

METHODS: These were 2 single blind comparative measurement study designs. In study 1, 2 experienced blinded examiners evaluated the FRT in 10 asymptomatic controls, 20 subjects with cervicogenic headache (CeH) where C1/2 was the primary dysfunctional level, and 10 subjects with CeH but without C1/2 as the primary dysfunctional level. In study 2, 2 inexperienced and 1 experienced blinded examiners evaluated the FRT in 12 subjects with CeH and 12 asymptomatic controls. Examiners were required to state whether the FRT was positive and also to determine range of rotation using a goniometer. An analysis of variance with planned orthogonal comparison, single measure intraclass correlation coefficient (2,1), and Bland-Altman plot were used to analyze FRT range of rotation between the examiners. Sensitivity, specificity, and examiner agreement for test interpretation were analyzed using cross tabulation and kappa.

RESULTS: In study 1, sensitivity and specificity of the FRT was 90% and 88% with 92% agreement for experienced examiners (P < .001). Overall diagnostic accuracy was 89% (P < .001) and kappa = 0.85. In study 2, for inexperienced examiners, FRT mobility was significantly greater than for experienced examiners, but sensitivity, specificity, agreement, and kappa values were all within clinically acceptable levels.

CONCLUSIONS: The FRT can be used accurately and reliably by inexperienced examiners and may be a useful aid in CeH evaluation.

The diagnostic validity of the cervical flexion-rotation test in C1/2-related cervicogenic headache.  [LINK]

Man Ther. 2007 Aug;12(3):256-62. Epub 2006 Nov 16.

Ogince M, Hall T, Robinson K, Blackmore AM.
School of Physiotherapy, Curtin University of Technology, Noranda, Perth, WA, Australia. ogincem@gmail.com <ogincem@gmail.com>

This single-blind comparative group design aimed to investigate the sensitivity and specificity of the cervical flexion-rotation test in the diagnosis of C1/2-related cervicogenic headache. This study tested 23 cervicogenic headache, 23 asymptomatic controls and 12 migraine with aura subjects, all aged 18-66 years. In stage 1, an experienced manipulative physiotherapist who did not partake in the flexion-rotation test procedure identified C1/2 dysfunction using passive segmental mobility tests in the cervicogenic headache group. Those with C1/2 dysfunction participated in stage 2. In stage 2, using the flexion-rotation test, subjects were tested by two experienced manipulative physiotherapists blinded to the subjects' group allocation. Each therapist stated whether the test was positive or not based on the therapist's interpretation of range of motion. The sensitivity and specificity of the flexion-rotation test was 91% and 90%, respectively (P<.001), with an overall diagnostic accuracy of 91% (P<.001). The cervical flexion-rotation test significantly assists in the differential diagnosis of cervicogenic headache and in the identification of movement impairment at the C1/2 segment in patients with cervicogenic headache.

The flexion-rotation test and active cervical mobility--a comparative measurement study in cervicogenic headache.  [LINK]

Man Ther. 2004 Nov;9(4):197-202.

Hall T, Robinson K.
Curtin University of Technology, Hayman Road, Bentley, Western Australia, Australia. info@manualconcepts.com

A single blind, age and gender matched, comparative measurement study was designed to assess active range of cervical motion and passive range of rotation in cervical flexion in asymptomatic and cervicogenic headache subjects. Both procedures are commonly used in clinical practice to evaluate patients with cervicogenic headache. We studied 20 women and eight men with side dominant cervicogenic headache (mean age 43.3 years) matched with 28 asymptomatic subjects. Two experienced manipulative therapists, who were blind to each other's measurement, noted active ranges of cervical motion and passive cervical rotation performed in the flexion-rotation test using the Cervical Range of Motion Device. Headache severity was assessed by a questionnaire. Additionally, one therapist prior to neck motion assessment determined the dominant symptomatic cervical motion segment. Active cervical motion in each direction was identical between the cervicogenic and control groups. In contrast, average rotation in flexion was 44 degrees to each side in the asymptomatic group and 28 degrees towards the headache side in the symptomatic group. C1-2 was deemed to be the dominant segmental level of headache origin in 24 of 28 subjects. In those 24 subjects range of rotation during the flexion-rotation test was inversely correlated to headache severity.
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