To the Editor:
Evidence-based chiropractic professional guidelines are clearly needed, and the article on evidence-based treatment of adult neck pain not due to whiplash provides useful information to the practitioner in most cases.
However, we disagree strongly with your recommendation to the practitioner concerning Doppler velocimetry, which states ... “Do not use Doppler ... to identify impaired vertebral artery flow, the presence of dissection, or patients with greater or lesser risk of symptomatic (ischemia-provoking) dissection subsequent to manipulation.”
We would like to make the following comments:
A single reference was used to support the recommendation, which surely fails to constitute “an extensive review of the literature.”
The focus of the paper by Margarey and Coll was not even on Doppler velocimetry. It briefly discussed Doppler studies mainly in the context of the validity of the positional VBI provocational tests.1 The overwhelming evidence indicates that the positional tests lack validity. Their paper omitted any reference to Doppler velocimetry validity and reliability trials that have been published. Hence no reasonable recommendation about Doppler in pre-manipulative screening can be based on their discussion.2,3
A more extensive review of the literature reveals that:
– Doppler velocimetry is a good screening tool (ie it has high sensitivity and specificity) for detecting high grade stenosis of the vertebral artery.4
– A high grade vertebral artery stenosis can be a sign of vertebral artery dissection, with or without the presence of signs and symptoms.4,5,6,7
– Doppler velocimetry can detect high-grade arterial stenosis prior to spinal manipulation being administered;4
– If the chiropractor detected abnormal vertebral artery Doppler velocimeter signals which were found to be normal in an earlier examination, this would be a strong indicator for dissection.4
– Doppler velocimetry can detect agenesis/non – functional vertebral arteries which are generally accepted as being a risk factor or at least of having a high index of suspicion concerning increased risk.4,8
– Doppler velocimetry can detect major changes in vertebral artery blood flow velocities during cervical rotation (rotational stenosis). Since there is compelling evidence that rotational stenosis is an independent risk factor for vertebro-basilar strokes,4,5,8,9,10 Doppler velocimetry appears to have its place in reducing the risk of such cerebro-vascular accidents.
Doppler velocimetry may not be the ultimate tool to prevent all vertebral artery accidents following manipulation but it provides valuable information to the practitioner. We suggest that the authors of the guidelines and your readers reconsider the use of Doppler velocimetry as a pre-manipulative screening test in the light of the information provided.
Footnotes
About the SOFEC:
The SOFEC is a Franco-European scientific society that stands for “Société Franco-Européenne de Chiropratique.” Its purpose is to study, analyse and conduct research on all aspects of chiropractic art, science and philosophy from a scientific standpoint, and thus contribute to the improvement of chiropractic care in terms of quality delivery and patient safety.
Aims and Objectives
- review current research to see if it supports the technology and validity of chiropractic tools and techniques,
- develop and offer diagnostic, therapeutic and preventive guidelines to the practitioner,
- circulate and/or webcast chiropractic references that are indexed on an international level,
- organise and/or support chiropractic scientific meetings, conference and publications
- develop strong relationships with other agencies or organisations with a similar purpose,
- offer support to students, field practitioners or scientists who want to increase their expertise in the science of chiropractic,
- Strengthen the scientific chiropractic model in the medical community.
References
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