Utilization of the Cervical Flexion Rotation Test to Confirm Rotation Directional Preference in People With Neck Pain: A Case Series

Despite the prevalence of neck pain, evidence is lacking regarding the relationship of pathophysiology to function in people with neck conditions. Although movement-based diagnoses based on directional preference (DP) are described for lumbar spinal conditions, how these diagnoses guide interventions is not supported in the Cervical Spine Clinical Practice Guidelines. To date, there are no case studies in the literature that demonstrate the efficacy of cervical spine management based on a rotation DP. This case series highlights patient response to repeated end-range neck movements to inform DP and how the cervical flexion rotation test (CFRT) was used as a clinical baseline to assess mechanical and symptomatic changes. Three consecutive patients were evaluated by a physical therapist fellow trained in orthopedic manual physical therapy and diplomaed in mechanical diagnosis and therapy. The patients’ baseline pain ranged from 3 to 7/10 on the Numerical Pain Rating Scale (NPRS), and disability scores ranged from 20% to 52.6% on patient-reported outcome (PRO) measures. All three cases demonstrated a limited and painful CFRT. Examination procedures included repeated end-range movement testing in the sagittal and frontal and transverse planes. Across five to six visits in five to eight weeks, a decrease in the primary outcome measures from baseline to discharge were observed: NPRS, 50-85%; PRO, 60-82%. The CFRT may be a key baseline when screening patients with neck pain for DP. Following repeated end-range sagittal and frontal plane movements, the rapid change in the CFRT following targeted upper cervical rotation techniques confirmed a rotation DP.


Introduction
Neck pain is among the most burdening, costly, and prevalent musculoskeletal conditions [1,2].The point prevalence of neck pain has been reported approximately 5-39% with a lifetime prevalence of 1-71% [2,3].The incidence of cervical radiculopathy is less common, with a prevalence of approximately 1-7% [4].Pre-validation studies have attempted to coordinate diagnostic testing with pain mechanism-based classifications, but treatment decisions based on the pathoanatomical source of neck pain are not fully supported in the literature [5].Evidence is lacking regarding the identification, prevalence, validity, or relationship of pathophysiology to pain and function in those with neck pain [6].
Directional preference (DP) is a movement-based diagnosis subtype and a phenomenon researched for those with spinal pain [7].DP is defined as a specific direction of movement that positively affects movement and either decreases, centralizes, or abolishes pain symptoms.A DP movement may be those opposite to the movement, which results in an increase in pain or restricted range of movement.Given the lack of evidence correlating pathophysiology and function, movement-based diagnoses are becoming increasingly popular for guiding rehabilitation for neck conditions [8].Although movement-based diagnoses based on DP are described for lumbar spinal conditions, DP is not referenced in the Cervical Spine Clinical Practice Guidelines [8,9].
The McKenzie Method of Mechanical Diagnosis and Therapy (MDT) is a reliable and valid system to assign a movement-based diagnosis and treat neck pain based on the clinical response to patient-and cliniciangenerated procedures [7,10].This method involves the assessment of symptomatic and mechanical baselines before, during, and after repeated end-range movement testing to classify patients into one of four syndromes: derangement, dysfunction, postural, and others [7].Repeated end-range movement testing, typically initiated with sagittal plane movements and exploring frontal and transverse plane movements as needed, may determine DP.Centralization, a subtype of DP, is confirmed when spinal-referred symptoms abolish in a distal to proximal pattern in response to repeated end-range movements or sustained postures [7].DP and centralization are characteristic of the derangement syndrome classification and have been shown to lead to favorable outcomes in those with heterogeneous neck pain [10].The prevalence of these findings in those with neck pain has been reported in the literature: derangement syndrome classification, 92%; centralization, 74-82%; DP to extension, 78.7%; and DP to lateral movements, 13.7% [11].Although neck rotation DP exercise is utilized clinically, there are presently no case-series reports in the literature demonstrating the efficacy of cervical spine management based on a rotation DP alone.
The cervical flexion rotation test (CFRT) is a useful clinical test for determining movement limitations in the upper cervical spine [8].This passive movement test of end-range cervical flexion followed by end-range upper cervical rotation may be a key clinical baseline to identify the cervical derangement syndrome with a relevant lateral rotation DP.The purpose of this case series is to describe the outcomes of three patients with neck pain who were managed with cervical rotation as their DP.

Methods
Three consecutive de-identified patients classified as a cervical derangement, according to the MDT principles, who presented with a positive CFRT were treated with upper cervical rotation mobilization and muscle energy techniques.The manual procedures were followed with cervical rotation exercises.A clinician with a doctorate in physical therapy, diploma level in MDT, and fellow of the American Academy of Orthopedic Manual Physical Therapists performed the examination and interventions procedures with the three patients.
These examinations consisted of the following tests and measures: a review of constitutional, cardiovascular, integumentary, musculoskeletal, and neurological systems; past medical history; imaging; and assessment of body structures and functions, including screening for contraindications and barriers to exercise or manual therapy procedures.The examination procedures determined normal findings for upperextremity deep tendon reflexes, Hoffman's reflex, C3-T1 myotomes and dermatomes, and distraction, compression, and Spurling's tests.The physical examinations also included testing repeated end-range movements of the cervical and thoracic spine with the monitoring of symptomatic and mechanical responses.Provided that all three demonstrated DP, direction-specific patient-generated repeated end-range movements were prescribed as home exercises.Follow-up examinations included assessment of range of motion and patients' self-report of pain and function.
Range of motion was recorded based on the patient's active and passive procedures by clinician interpretation of goniometry, inclinometry, or by nil/min/mod/maj loss defined within the MDT examination nomenclature [7,8].Although visual observation is a reliable method of examination of the CFRT, a goniometer was utilized for case 3 (Figure 1, Figure 2) [8,12].Upper limb tension test 1 (ULTT1) was recorded as degrees of elbow extension.

Case 1
A 25-year-old male referred to physical therapy for cervical radiculopathy presented with a one-year history of insidious, intermittent, bilateral, asymmetrical left-sided neck pain and pain in the left scapular, shoulder, and upper arm regions.The NPRS was rated as 3/10 at worst and described as aching, dull, and tight.Symptoms worsened with neck movement and prolonged static activities and improved with recumbent positioning and heat.Radiographs were unremarkable.The patient reported good general health with no significant past medical history.

Case 2
A 38-year-old male referred to physical therapy for cervical radiculopathy presented with a five-week duration of asymmetrical, unilateral, left-sided neck, scapular, shoulder, and upper arm pain, which onset after repetitive lifting activities.NPRS was 4/10 at worst and described as aching, dull, and tight.Symptoms worsened with driving.He was previously examined by another physical therapist and was instructed to perform repeated cervical left lateral flexion with self-overpressure as a home program, with which the patient reported short-term pain relief.He denied other positions or activity, which improved symptoms.No diagnostic imaging was completed prior to examination.The patient reported good general health with no significant past medical history.

Case 3
A 76-year-old female referred to physical therapy for cervicalgia presented with a one-year duration of insidious, unilateral, left-sided neck pain.NPRS was 7/10 and described as aching and tight.Symptoms worsened with left neck rotation.She did not report positions or activities that improved her symptoms.Self-reported quality of life was excellent, and her past medical history included sleep apnea, coronary artery disease, gastroesophageal reflux, mild persistent asthma, peripheral neuropathy, restless legs syndrome, prediabetes, and urinary incontinence.At the time of examination, she was also receiving physical therapy services for balance deficits.No diagnostic imaging was completed prior to examination.

Examination and observation findings
A summary of examination findings for each individual case are presented on Table 1, Table 2, and Table 3. Seated active movement assessment was completed at the cervical spine for all three cases, with a significant asymmetrical cervical rotation toward the affected side in Cases 2 and 3. Special testing revealed a positive CFRT and limited and painful deep neck flexor endurance testing in all three cases.Additional significant findings included ULTT1 in Cases 1 and 2.

Case 1
Initial assessment explored repeated cervical movements in the sagittal plane, including retraction and extension movements with overpressure and manual therapy procedures (Table 1).Response to repeated end-range movements led to assessment of cervical retraction with extension and clinician overpressure, resulting in improved cervical ROM and ULTT1.Based upon the positive observed changes to clinical baselines, further testing was stopped.The patient's home exercise program (HEP) included cervical retraction with extension and self-overpressure to be completed throughout the day.The patient was advised to discontinue the exercise if he experienced peripheralization of pain or worsening symptoms.
The patient returned seven days later for visit 2.He reported improvements in GPE and pain, demonstrated improved ULTT1 symmetry, and improved left cervical rotation by 10 degrees (Table 1).Further assessment of repeated cervical sagittal and frontal plane movements, following the MDT system algorithm, resulted in no additional improvements, so transverse plane procedures were explored.Following right upper cervical rotation clinician mobilizations (Figure 3), the patient showed improved right cervical rotation ROM and CFRT, indicating that he responded positively to this intervention.The patient's HEP was modified to repeated right cervical rotation in flexion with self-overpressure (Figure 4).

FIGURE 4: Right upper cervical rotation in flexion with self-overpressure
The patient returned seven days later for visit 3.He reported improvements in GPE and pain and demonstrated within-normal symmetrical cervical ROM and ULTT1.Pain persisted at repeated end-range right cervical rotation.Based upon the observed improvements in clinical baselines, right upper cervical rotation clinician mobilizations were continued, and antagonist muscle energy technique procedures were performed to facilitate improved right cervical rotation (Figure 5).The patient was instructed to continue his previous HEP in order to maintain improvements.

FIGURE 5: Supine right upper cervical rotation clinician mobilization from flexion preposition
Position is the same for thrust mobilization or muscle energy technique.
The patient returned for visits 4 and 5 at two-week intervals.Through visit 5, he reported a GPE of 95% improvement and self-reported function of 95%, and the NPRS was rated as 1/10 at worst.Cervical ROM was without loss and ULTT1 remained symmetrical and without significant tightness.Deep cervical flexion endurance testing improved from three seconds at evaluation to 38 seconds before fatigue and without pain.
Prior to discharge, the patient was guided to perform scapulothoracic movement control and strengthening exercises while monitoring maintenance of improvement and recovery of functional activity tolerance.At discharge, the patient met the MCID for all outcome measure scores and was independent with his HEP (Figure 6, Table 1).Initial assessment included repeated end-range cervical movements in the frontal plane to assess his response to the previously prescribed HEP (Table 2).Reassessment of patient response indicated improved upper arm pain and cervical ROM; however, improvements plateaued.Due to the lack of improvement, the target examination treatment plane was altered at this time to assess the patient's response to sagittal plane movements.Repeated slouch-overcorrect exercise was performed to assess symptoms and assess his ability to maintain an upright posture, which resulted in reduced upper arm pain, improved cervical ROM, and improved ULTT1.Based upon changes in clinical baselines, further testing was stopped.The patient's HEP was updated to include cervical left lateral flexion with self-overpressure and slouch-overcorrect posture during sitting throughout the day.The patient was advised to discontinue the exercise if he experienced peripheralization of pain or worsening symptoms.
The patient returned four days later for visit 2.He reported a gradual worsening of pain and GPE.Despite these subjective reports, his cervical ROM and ULLT1 were improved.Review of his HEP and re-assessment of repeated frontal plane movements did not result in any additional improvements.Based on this lack of change, the effect of repeated end-range sagittal plane extension procedures was assessed, which resulted in no additional benefit.Cervical flexion procedures resulted in abolished upper arm pain, improved cervical ROM, and improved movement associated pain.Based upon the positive changes to clinical baselines and symptoms, further testing was stopped.The patient's HEP was modified to repeated cervical flexion with self-overpressure to be completed throughout the day.
The patient returned seven days later for visit 3.He reported improvements in GPE and pain and demonstrated improved and symmetrical ULTT1.He continued to report asymmetrical and painful left cervical rotation.Reassessment of cervical flexion procedures did not result in any additional improvement.
Since he continued to have limited cervical rotation ROM and a positive left CFRT, left cervical rotation clinician mobilizations targeting the upper cervical spine were performed; this resulted in improved CFRT.Following procedures, antagonist muscle energy techniques were performed to facilitate improved left cervical rotation.Based upon positive changes in ROM and movement associated pain, additional testing was stopped.The patient's HEP was modified to include repeated left cervical rotation in flexion or contralateral flexion, with self-overpressure (Figure 2C, 2D).
The patient returned for visits 4 and 5 at one and two-week intervals.Through visit 5, he reported a GPE of 80% improvement and self-reported function of 90%, and NPRS was 2/10 at worst.Cervical ROM and ULTT1 were normal and symmetrical.Prior to discharge, the patient was guided to begin performing deep neck flexor endurance training and upper body strengthening while monitoring maintenance of improvement and recovery of functional activity tolerance.At discharge, the patient met the MCID for all outcome measure scores and was independent with his HEP (Figure 7, Table 2).

Case 3
Initial assessment included repeated cervical movements in the sagittal and frontal planes.This included repeated end-range extension and flexion movements and lateral flexion movements, with clinician overpressure and mobilization procedures (Table 3).Following no significant changes to clinical baselines, transverse plane procedures were assessed.Left upper cervical rotation clinician mobilizations (Figure 8) were performed, resulting in improved cervical ROM.Based upon this positive change, further testing was stopped.The patient's HEP included repeated cervical rotation in flexion or contralateral flexion, with selfoverpressure.The patient was advised to discontinue the exercise if she experienced increasing or worsening pain.

FIGURE 8: Supine left upper cervical rotation clinician mobilization
Position is the same for thrust mobilization or muscle energy technique.
The patient returned 10 days later for visit 2.She reported 50% HEP adherence and 7/10 pain at worst.She demonstrated improved left cervical rotation ROM, but the left CFRT remained positive.Initially, reassessment of manual left upper cervical rotation clinician mobilization, prepositioned in right lateral flexion, resulted in increased neck pain and decreased cervical rotation ROM.The mobilization was then modified and performed in a cervical flexion preposition (Figure 9), resulting in improved ROM back to baseline.After reaching a plateau with increased repetitions, progression of forces was considered.The patient consented to receive a thrust mobilization prepositioned in flexion targeting the upper cervical spine (Figure 9), resulting in improved cervical ROM and movement associated pain.Antagonist muscle energy technique procedures were then performed to facilitate improved left cervical rotation.Based upon within-session improvements in ROM and movement associated pain, further testing was stopped.The patient's HEP was modified to repeated cervical rotation movements in flexion, with self-overpressure, to be performed throughout the day.The patient returned for visits 5 and 6 at eight-and 11-day intervals.The NPRS improved to 1/10 at worst.Cervical rotation ROM remained limited to the left, but her CFRT mobility improved and remained symmetrical.Prior to discharge, the patient was guided to begin performing upper extremity and scapulothoracic strengthening exercises while monitoring patient maintenance of improvement and recovery of function.At discharge, the patient met the MCID for all of her outcome measure scores and was independent with her HEP (Figure 10, Table 3).

FIGURE 3 :
FIGURE 3: Supine right upper cervical rotation clinician mobilizationPosition is the same for thrust mobilization or muscle energy technique.

FIGURE 6 :
FIGURE 6: Pain and patient-reported disability outcomes from initial examination to discharge n: number; NPRS: Numerical Pain Rating Scale; NDI, Neck Disability Index; QuickDASH, Quick Disabilities of the Arm, Shoulder, and Hand

FIGURE 7 :
FIGURE 7: Pain and patient-reported disability outcomes from initial examination to discharge n: number; NPRS: Numerical Pain Rating Scale; NDI: Neck Disability Index; QuickDASH: Quick Disabilities of the Arm, Shoulder, and Hand

FIGURE 9 :
FIGURE 9: Supine left upper cervical rotation clinician mobilizationPosition is the same for thrust mobilization or muscle energy technique.

FIGURE 10 :
FIGURE 10: Pain and patient-reported disability outcomes from initial examination to discharge n: number; NPRS: Numerical Pain Rating Scale; NDI: Neck Disability Index; QuickDASH: Quick Disabilities of the Arm, Shoulder, and Hand