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Purpose To survey the current practice of cervical spine pain assessment in relation to vertebrobasilar artery insufficiency (VBI), attitudes toward guidelines, and the practice of achieving informed consent in advance of planned orthopaedic manual therapy interventions. Method A self-administered postal survey was validated and sent to 325 physiotherapists working in the National Health Service (NHS) and private musculoskeletal practices in the Dorset and Hampshire region. Results The response rate was 53% from NHS physiotherapists and 20% from private practice, overall 34% (n = 111). Compliance rates with published guidelines were 50.4%; the sample holds them in neutral opinion (51.4%), and also holds cervical manipulation in neutral opinion (n = 50; 45.5%). Of these, 30.4% of respondents use cervical manipulation; a practice more closely associated with male practitioners (Φ = 0.35 P < 0.001), most use non-manipulative techniques such as manual traction (86.3%) or mobilizations (96.1%) with exercise (99%) as these are believed to be just as effective. Conclusions Physiotherapists in this sample do not appear to be adopting the VBI guidelines out of confidence or acknowledgment of their validity, but as a means to satisfy legality (76%) and enjoy that security (57.7%). Cervical spine assessment by a physiotherapist may be reliant on detailed subjective assessment that lacks objective testing, which could limit the scope of clinical reasoning between diagnoses of vascular (VBI, arterial dissection) and vestibular sources of symptoms. Those physiotherapists who had not attended postgraduate cervical manual therapy courses were associated with not practicing in agreement with the published evidence base; this finding lends support to the argument for a formal restriction of cervical manipulation by physiotherapists until a minimal requirement of postgraduate training is completed. [ABSTRACT FROM AUTHOR]