As manual physical therapists, we are concerned (and should well be) of some type of cervical artery dysfunction (CAD), or better known as vertebrobasilar insufficiency (VBI). Instead of getting into a detailed post about if and should you perform pre-manipulative testing of the cervical spine prior to SMT (or mobs, stretches, etc at that); I decided to provide several great resources to assist the physical therapist in an approach and decision-making.

In no particular order, here are what I use to assist myself:

The Australian Physiotherapy Association has detailed guidance to aid the clinician. One product I use is a $2.99 app for my Ipad that can be found here (linked from APA website). It provides resources in pdf format and videos to explain how to perform pre-manipulative procedures.

Photo courtesy:

The International Federation of Orthopaedic Manipulative Physical Therapists has a clinical reasoning framework that can be found online. A general google search surfaced it here. A very detailed assessment for any manual therapist and is well referenced. Definitely a good read and resource for you and your students. Highlighted in this documented is that it should be accepted this upcoming October so it has the newest data.

Photo courtesy:

Dr. Erson Religioso III has published some of the best content to a manual therapist that is easily accessible online in the past year. Here is a video that I found of him awhile back describing pre-manipulative consent prior to manipulation of the cervical spine (thanks for Dr. E for providing this link again!). Consent is definitely a topic that I am pretty sure is rarely used in our field.


David Pope interviews Roger Kerry in a podcast available on Physioedge’s website here. It is quite long (an hour) but has significant detailed information on anatomy of vertebrobasilar artery and internal carotid artery; signs and symptoms of a non-mechanical causation of pain; and what we should know about the typical pre-manipulative testing and 5 D’s and 3 N’s. The latter information is definitely worth your time.

Now there are a myriad of case reports, retrospective studies and editorials about this topic but I do feel these four resources are a good start to creating your own clinical assessment. I use these to help myself make a sound, reasoned clinical judgment for each patient that would be appropriate to refer out, or appropriate for a type of manual therapy approach. They also give excellent reviews on hot topics such as pre-manipulative holds, the subjective examination and what to look for as a manual clinician.

I am hoping the comment section will create more discussion on this topic. What are your thoughts?



  1. Thanks for the share HV! A few of my fellows were Dunning trained, and I know he doesn’t teach the premanipulative hold (or at least they said he doesn’t). Better safe than sorry. Although I rarely perform cervical thrust, it remains a great tool in my box that I wouldn’t ever give up as it really works well when indicated.

    1. No problem. Yeh he doesn’t. My formal training is under him so far and I do not either on a daily basis. I do not feel the clinical utility to be any more advantageous. That’s why I put this blog up, to see what most clinicians do out there. Thanks for your feedback.

Leave a Reply

Fill in your details below or click an icon to log in: Logo

You are commenting using your account. Log Out /  Change )

Google+ photo

You are commenting using your Google+ account. Log Out /  Change )

Twitter picture

You are commenting using your Twitter account. Log Out /  Change )

Facebook photo

You are commenting using your Facebook account. Log Out /  Change )


Connecting to %s