Is it time to stop functional pre-manipulation testing of the cervical spine?

This paper considers and discusses the usefulness of functional pre-manipulation testing for clinical scenarios, involving dissection, spasm or stenosis of the vertebral artery, and makes the following recommendations: (1) Practitioners must assess the patient thoroughly, through careful history taking and physical examination, for the possibility of vertebral artery dissection. It is important to note that vertebral artery dissection (VAD) may present as pain only, and may not be associated with symptoms and signs of brainstem ischaemia. (2) If there is a strong likelihood of VAD, provocative pre-manipulation tests should not be performed, and the patient must be referred appropriately. (3) In the patient presenting with symptoms of brainstem ischaemia due to non-dissection stenotic vertebral artery pathologies, provocative testing is very unlikely to provide any useful additional diagnostic information. (4) In the patient with unapparent vertebral artery pathology, where spinal manipulative therapy (SMT) is considered as the treatment of choice, provocative testing is very unlikely to provide any useful information in assessing the probability of manipulation induced vertebral artery injury.