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.
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.
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?