Several weeks ago, I placed a survey for all to provide their answer to whether or not a premanipulative hold is necessary prior to performing an OMT procedure to the cervical spine.  Thanks for everyone who participated!  Here are the results:


Interesting results in regards to 50% of the readers (half of the clinicians!) thought we should discontinue the pre-manipulative hold.  That is quite a response for our very conservative practice patterns.  How do these results compare to a similar study in 2004 in Manual Therapy??…see figure below:


This figure is taken off of an upcoming powerpoint slide for a lecture I’m teaching (reason for more bullet points).  But, quite different results!  My survey resulted in 50% of individuals endorsing discontinuing the pre-manipulative hold compared to only 12% in a prior survey.


-The comparison study surveyed Musculoskeletal physiotherapy members in Australia, had 419 responses and published in 2004.

-My survey only had 22 responses, was not limited to any country or additional training, and reported over 10 years later in 2013.

So, over the course of a decade, have we learned more about the pathophysiology of cervical artery dysfunction (CAD), more studies to show that we are less able to predict a dissection, and/or improved clinical reasoning through our subjective profiling??

You tell me!  I believe it is all 3 of the above.

Did you think the results would be as shown??



  1. I don’t really think we learned more, and obviously the sample is much smaller, but seriously it only takes seconds, why not? If you’re too busy to do it, you’re not giving your patients enough time. I see why others say they don’t, because it’s not predictive of an adverse event, but I figure if it reproduces any of the D’s or N’s, I’d be cautious.

  2. I see your point here Erson, and OK the sample is too small to get totally excited about. However, I think we do know more about CAD since the idea of positional testing was developed. Now that test doesn’t really fit with the latest understating of CAD. There are better ways to understand a patients chance of adverse event than reading anything form a positional test. Empirically, any reproduction of “5Ds” etc is more likely to be indicative of a non-vascular cause, and possibly something treatable (cervicogenic sensory dysfunction, etc). So in fact the ‘test’ is giving the direct opposite of what we think it’s doing! Good for discussion though. Well done Harrison.

    1. If it’s only dizziness, I also assume much of it is cervicogenic. I rarely do thrust manip these days, maybe 1-2 times/month other than when I am teaching. I also only do the premanipulative hold in the position of my manipulation, which is very far from end range. If that position reproduces anything more than dizziness, I do not thrust. If it does reproduce dizziness, I try some MDT, then try the test again, if it’s modulated rapidly, I’m not worried.

      Either way, I do teach we can’t predict adverse events from positional testing.

      1. Great discussion here and good to hear points from both sides, in a constructive and collegial way too! (none of this nasty talk). It basically shows us the best practice pattern is still open for debate.
        Thanks for reading and commenting guys.

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