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RfC: Effectiveness of chiropractic care

Latest comment: 16 years ago218 comments17 people in discussion

This is an updated version of Talk:Chiropractic/Archive 18 #RfC: Effectiveness of chiropractic care. It attempts to address some of the comments brought up in that discussion. There seems to be no serious dispute that there is a serious POV problem in the current coverage of effectiveness in Chiropractic, so I won't repeat Talk:Chiropractic/Archive 18 #POV in existing coverage. Again, this is a controversial issue that may require some work to resolve; please bear with the following exposition as it covers many issues. Eubulides (talk) 08:50, 12 May 2008 (UTC)

To help other editors follow this discussion better, please place comments below, after the the proposal.

Criticisms of earlier proposed fix

Earlier I proposed Scientific investigation 2, a draft that relies on recent high-quality scientific sources, along with a proposal to remove the obsolescent material. This draft has been discussed extensively in Talk:Chiropractic/Archive 18 #Comments on Scientific investigation 3, so far with no consensus. To help move matters forward I have drafted a new section below, #Scientific investigation 3, which attempts to respond to some (but not all) the concerns expressed. These concerns (italicized below) included the following:

  • Effectiveness of treatments should not be discussed in chiropractic; it should be discussed under each form of treatment. Most of the literature cited in #Scientific investigation 3 focuses on effectiveness of chiropractic treatment, not simply treatment by any practitioner. It is therefore inappropriate to move it to treatment pages per se. The few counterexamples are highly relevant to chiropractic; if there is a specific complaint about any of them, please mention it. To help underscore the relevance I have added a citation to Meeker & Haldeman 2002 about the relationship between chiropractic and research into SMT effectiveness.
  • Undue weight given to spinal manipulation. The weight given is appropriate: spinal manipulation is the core treatment modality of chiropractic, and is naturally heavily empahsized in reviews of the effectiveness of chiropractic care.
  • Clinical practice guidelines are omitted. They were present in the 1st draft, and were omitted from the 2nd draft in the interest of brevity. I have restored them in the 3rd draft.
  • Ernst is fringe. No, he's a mainstream researcher who gets cited a lot.
  • More sources are needed. None were suggested. I did turn up some more sources on my own, which are included in #Scientific investigation 3.

(Again, please place further comments below.)

Revised proposal for fix

The revised proposed fix is to replace the sections Chiropractic #The Manga Report through Chiropractic #Scientific investigation with the following text (between the horizontal lines), to keep Chiropractic #Safety unchanged, and to replace the "===Vaccination===" with "==Vaccination==" (as that section has nothing to do with scientific investigation).

(Again, please place further comments below.)

Scientific investigation 3

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care.[1] Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims.[2]

Effectiveness 3

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective.[3] Chiropractic care, like all medical treatment, benefits from the placebo response.[4] The efficacy and cost-effectiveness of maintenance care in chiropractic is unknown.[5]

Research has focused on spinal manipulation therapy (SMT) rather than specifically on chiropractic SMT,[1] but the distinction is not significant: chiropractors use all forms of SMT, more than 90% of SMT in the U.S. is done by chiropractors, and SMT research is equally of value regardless of practitioner type.[6] There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.[1] Many controlled clinical studies of SMT are available, but their results disagree,[7] and they are typically of low quality.[8][9] It is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect.[10] Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference,[11] a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.[12]

Available evidence covers the following conditions:

  • Low back pain. Opinions differ on the efficacy of SMT for nonspecific or uncomplicated low back pain.[13] An authoritative 2004 review found that SMT or mobilization is no more or less effective than other interventions.[14] A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care.[12] A 2007 literature synthesis found good evidence supporting SMT for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.[15]
  • Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain.[16] An authoritative 2004 review found that SMT/mobilization is effective only when combined with other interventions such as exercise.[17] A 2008 review found that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis.[18] A 2007 review found that SMT and mobilization are effective for neck pain.[16] A 2005 review found little investigative research into chiropractic manipulative therapy for acute neck pain.[19]
  • Headache. An authoritative 2004 review found that SMT may be effective for migraine and tension headache, and SMT and neck exercises may be effective for cervicogenic headache.[20] A 2006 review found no rigorous evidence supporting SMT or other manual therapies for tension headache.[21] A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[22]
  • Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs,[23] and a lack of higher-quality publications supporting chiropractic management of leg conditions.[24] A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg.[15] There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine)[25] and no scientific data for idiopathic adolescent scoliosis.[26] A 2007 systematic review found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions.[8] Other reviews have found no evidence of benefit for baby colic,[27] bedwetting,[28] fibromyalgia,[29] or menstrual cramps.[30]

(End of proposed replacement text.)

(Please place further comments below.)

Comments on Scientific investigation 3

Reading the article on the scientific effectiveness of chiropractic care, I think it's important to site specific studies with links to the data mentioned. If one merely writes, "Studies indicate...", it's vague and actually doesn't help. If there are no late phase broad-based studies to prove chiropractic claims, then that specific comment needs to be made.

One question I have that is not addressed in this article is why chiropractic claims to help varieties of symptoms can be made without specific clinical studies of safety and effectiveness to back up every single claim. In the pharmaceutical industry, every single claim is backed with a study. Where are the billion dollar clinical studies in the chiropractic industry?

  • I agree that specific articles should be cited. Currently Chiropractic #Effectiveness (which is derived from #Scientific investigation 3 above) does that.
  • The chiropractic profession is not nearly as rich as the pharmaceutical industry, and cannot afford billion dollar clinical studies. Also, a significant minority of chiropractors do not believe that the scientific method is useful for determining effectiveness, and this complicates the quest of doing studies. However, this is just my opinion; to put anything like this into the article we'd need a reliable source to that effect. I just now quickly looked for one and didn't find anything.
Eubulides (talk) 21:53, 27 June 2008 (UTC)

I was editing this article in February, and have been meaning to return when I have time. I've heard that there are difficult disputes here and thought I might at least see what's happening and maybe even help resolve some disputes, as well as participating in editing. For now, I'm offering my opinion for this RfC.

The proposed text above is, in my opinion, a vast improvement over that section of the current article, in terms of being organized in a logical and relevant way. The current article gives undue prominence to the name of a particular study and to funding issues, which are not of fundamental importance and which will become dated. Focussing on effectiveness for various parts of the body is a relevant way to organize the information. It's readable, and I didn't see any problems with it.

Re "Effectiveness of treatments should not be discussed in chiropractic; it should be discussed under each form of treatment." Different articles can have some overlap of content; see WP:SUMMARY. If any particular section forms too long a stretch of text which overlaps between two articles, one of them can be shortened to a summary, with a {{main}} hatnote directing the reader to a section-link of the other article for more information. I don't think any one of the above short sections about each condition or body part is long enough to merit such summarizing. In my opinion, effectiveness is of fundamental relevance to this subject and belongs in this article (though it can also occur in other articles too).

Re "Undue weight given to spinal manipulation": I agree that spinal manipulation is fundamental to chiropractic; it's hard to imagine how it could be given undue weight in this article. (Unverified; don't have clear definition of SMT or fraction of chiros who use it.04:40, 26 June 2008 (UTC)) I'd have to see specific arguments about what else needs to be mentioned. ☺ Coppertwig (talk) 10:20, 12 May 2008 (UTC)

Thank you Coppertwig, for coming back to weigh in on this edit! Please stick around as long as you can. I agree with your points. Spinal manipulation is fundamental and needs to be here in this article. Another objection often made is that studies of non-chiropractic manipulation are not relevant in considering effectiveness of SMT. Even Dr. Meeker, a prominent chiropractic researcher says that "research on spinal manipulation, like that of any other treatment method is equally of value regardless of the practitioner"(from #111, above)--—CynRN (Talk) 16:24, 12 May 2008 (UTC)
While I do feel that this version is better than the previous versions, I am unsure about two things:
  1. That even though one researcher is saying it is okay to correlate general SMT studies with the effectiveness of chiropractic, our following this researcher's advice still may cause a WP:SYN violation. Even though we are spelling it out for the reader that these studies are about SMT and not chiropractic specifically, we are also implying (or rather now directly stating) that the conclusions of these general SMT studies can be applied to the effectiveness of chiropractic.
  2. DigitalC, CorticoSpinal, and several others have raised objections that Chiropractic is an occupation which employs many services and modalities and not any one specific modality. As such, the inclusion of the above material would be like the inclusion of an effectiveness section at the Dentistry article based on the effectiveness of Fluoride as administered by dentists, hygienists, the gov't via tap water, etc.
Levine2112 discuss 17:26, 12 May 2008 (UTC)
I hear the argument (re #2), but the fact is that SMT is the centerpiece of chiropractic. Is there much controversy about the effectiveness of a dentist removing caries from teeth? Is there a long, involved holistic philosophy connected with dentistry? Apples and oranges. There is controversy surrounding chiropractic, in part because of the whole subluxation paradigm. As long as the section explains again that chiropractors do a range of treatments besides SMT, the effectiveness of SMT really belongs here.There are plenty of studies, and reviews of same, regarding the effectiveness of SMT.--—CynRN (Talk) 18:37, 12 May 2008 (UTC)
Actually, yes there is much controversy surrounding dental caries: Dental amalgam controversy. And holistic dentistry has been around for at least 30 years; specifically founded by the anti-mercury/amalgam movement. So you see, it's not apples to oranges after all. -- Levine2112 discuss 18:51, 12 May 2008 (UTC)
Of course, I figured you'd bring that up! How many holistic dentists are there as a percentage of all, vs 'holistic chiropractors'? Are there any non-holistic chiropractors? What is non-controversial, I would think, is 'treatment of dental decay'. Whether we choose composite fillings or amalgam is a different issue.--—CynRN (Talk) 23:00, 12 May 2008 (UTC)
Holistic dentistry is quite different from Dentistry, just as Chiropractic is quite different from mainstream Medicine. If there were an article on Holistic dentistry (there isn't, yet), I'd expect it to cover effectiveness in some detail, as that's an important part of the controversy about holistic dentistry. Eubulides (talk) 07:35, 13 May 2008 (UTC)
"There are plenty of studies, and reviews of same, regarding the effectiveness of SMT". Agreed. There are pleny of sources discussing the effectiveness of SMT. However, SMT is not chiropractic, and the effectiveness of SMT belongs over at the SMT article. DigitalC (talk) 00:03, 13 May 2008 (UTC)
The cited sources in #Scientific investigation 3 are by and large not talking just about SMT. They are mostly talking about chiropractic care. Is there any particular source being objected to here? Eubulides (talk) 07:35, 13 May 2008 (UTC)
  • Re Levine2112's #1, it's not just "one researcher"; Meeker & Haldeman are two of the very top chiropractic researchers. For example, Haldeman is the editor in chief of PPC, the leading chiropractic textbook. These reliable sources say there's no significant distinction between chiropractic and non-chiropractic SMT. There doesn't seem to be any real controversy over this issue among reliable sources. It is not WP:SYN to report what these sources say. That being said, if there is a specific source being objected to on the grounds that it talks about SMT and not chiropractic SMT, which source is it and why? If this is just a matter of a few sources and how they're characterized perhaps we can come up with compromise wording that will address this concern.
  • Re Levine2112's #2:
More generally, the question is not whether #Scientific investigation 3 is perfect; it's not. The question is whether it's better than what's in Chiropractic now. It is. It's way better. It fixes serious POV problems, among other things. We should not let the relatively minor problems of the current proposal blind us to the fact that it's a real improvement and it therefore should go in. We can always improve it later. Eubulides (talk) 07:35, 13 May 2008 (UTC)
Well, I guess that's your opinion - that chiropractic is closer to Traditional Chinese medicine than it is to Dentistry. I don't share that opinion; not do I think that either of our personal opinions should dictate what kind of information we include in this article. -- Levine2112 discuss 16:15, 13 May 2008 (UTC)
  • All I meant was that chiropractic is neither fully mainstream (like dentistry) nor fully fringe science (like homeopathy). It has elements of both, as does traditional Chinese medicine. Even a cursory treatment of chiropractic needs to address the issue of whether it is effective, because this is a serious question as to commonly-practiced parts of chiropractic care. In this sense, chiropractic is more like traditional Chinese medicine than it is like dentistry.
  • One doesn't have to take my word for this. Just type "fringe chiropractic" into Google Scholar and you'll find lots of papers about chiropractic vis-a-vis fringe medicine. Type "fringe dentistry" and you'll find lots of papers about fringe benefits and fringe patterns, and precious little about fringe medicine. Or, please see Keating 1997, where it's explicitly stated that chiropractic uses scientific, antiscientific, and pseudoscientific rhetoric. One doesn't find similar articles about dentistry.
Eubulides (talk) 19:59, 13 May 2008 (UTC)

Again, I find that this section fails to mention the many other treatments provided by Chiropractors, and the efficacy of such other treatments. There is no mention of Ultrasound, Laser, IFC, Orthotics, Prescribed Exercises, or even soft tissue therapy.DigitalC (talk) 23:59, 12 May 2008 (UTC)

Actually, #Effectiveness 3 mentions laser, and supervised / customized exercise. It also mentions many other non-SMT treatments provided by chiropractors, including mobilization, assurance and advice to stay active, educational videos, acupuncture, and the entire clinical encounter of chiropractic care. It does not cover the other treatments you mention (ultrasound, IFC, orthotics, soft tissue therapy) because as far as I know the cited sources don't say anything definitive about those forms of treatment. If someone can dig up reliable sources for those treatment forms, that would be nice; in the meantime, the #Effectiveness 3 is much better than the effectiveness material that is in Chiropractic now. Eubulides (talk) 07:35, 13 May 2008 (UTC)
We should certainly think carefully about the WP:SYN issue raised by Levine2112. Note that the Meeker et al. (2007) study uses the word "chiropractic" as well as the phrase "spinal manipulation", so I see no SYN problem in citing it. For the other studies, I think it would be an improvement if we simply cited the studies, implying but not stating outright that SMT studies shed light on chiropractic effectiveness. I would delete the sentence "Research has focused on spinal manipulation therapy (SMT) rather than specifically on chiropractic SMT,[18] but the distinction is not significant: chiropractors use all forms of SMT, more than 90% of SMT in the U.S. is done by chiropractors, and SMT research is equally of value regardless of practitioner type." I think this is good information for us to use here on the talk page while deciding whether the SMT studies can be used, but that including it in the article perhaps contributes to a SYN violation. If that sentence is deleted, the rest of the paragraph may need to be reorganized to flow smoothly.
Thanks, Eubulides, by the way, for your patience and diligence in coming up with yet another draft version.☺ Coppertwig (talk) 09:29, 13 May 2008 (UTC)
You're welcome. I removed that sentence from the draft in #Scientific investigation 3C. I agree that it's better to leave it out in future drafts as well; the citation was there only because of Levine2112's continuing concerns about generic SMT research versus research specifically on chiropractic care. Eubulides (talk) 20:55, 13 May 2008 (UTC)
I think that sentence was added to avoid any synthesis and to make it clearer to the reader. QuackGuru 09:36, 13 May 2008 (UTC)
I think that sentence is an attempt to justify the synthesis. Essentially, it may be the opinion of one researcheer (or one team of two researchers), but we can't then go ahead and apply it to the SMT research across the board. That is where the WP:SYN violation happens. That said, I maintain that we should remove all studies which are about SMT in general and do not make distinct conclusions about chiropractic specifically. These general SMT studies would be perfect for the spinal manipulation article. -- Levine2112 discuss 16:09, 13 May 2008 (UTC)
Spinal manipulation is inherent to chiropractic as its most commonly performed modality and we should not second-geuss the reviewers. QuackGuru 18:06, 13 May 2008 (UTC)

(outdent) I strongly disagree that generic SMT research should be excluded from Chiropractic. It's standard practice in high-quality chiropractic sources to include such research, we have a high-quality chiropractic source saying that there's no significant difference between chiropractic and non-chiropractic research data in SMT, and we have no high-quality sources disagreeing. However, to help move the discussion ahead I propose a new version #Scientific investigation 3C below, which excludes generic SMT research. That is, all the sources #Scientific investigation 3C talk explicitly about chiropractic care, not just about SMT (or mobilization or whatever) in general. Eubulides (talk) 19:59, 13 May 2008 (UTC)

Researchers commonly apply regular SMT research and sources indicate there is no sigificant difference among the high quality studies. This version is a bit short and could use a slight expansion. QuackGuru 11:50, 14 May 2008 (UTC)
Here is what the scientific investigation (now renamed scientific research) section of the article was at the beginning of year. The current version includes newer peer-reviewed references and is very concise. QuackGuru 13:11, 14 May 2008 (UTC)

Proposal for fix 3C

I view this "3C" draft as being far inferior to #Scientific investigation 3 due to 3C's weaker sourcing, but 3C is still much better than what's in Chiropractic now. I offer 3C as an attempt to fix Chiropractic's obvious datedness and POV problems now, and to continue the discussion here about what to do about the generic SMT studies.

The revised proposed fix is to replace the sections Chiropractic #The Manga Report through Chiropractic #Scientific investigation with the following text (between the horizontal lines), to keep Chiropractic #Safety unchanged, and to replace the "===Vaccination===" with "==Vaccination==" (as that section has nothing to do with scientific investigation).

(Please place further comments below.) Eubulides (talk) 19:59, 13 May 2008 (UTC)

Scientific investigation 3C

In the current healthcare environment, The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which treatments are legitimate and perhaps reimbursable under managed care. Chiropractic treatments are evaluated using those same standards.[1] Evidence-based guidelines are supported by many chiropractors while others remain pseudoscientific and antiscientific and make unsubstantiated claims.[2] Research has focused specifically on spinal manipulation therapy (SMT) rather than on the whole chiropractic visit and all that is involved in the patient encounter, some of which may be the result, as with all healthcare encounters, of the placebo effect[31], The distinction is not significant regarding who performs SMT for musculoskelatal conditions.[32]

Effectiveness 3C

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective.'As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective'.[33] Chiropractic care, like all medical treatment, benefits from the placebo response.[34] Few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality.[8] The efficacy and cost-effectiveness of maintenance care in chiropractic is unknown.[35]

Research has focused on spinal manipulation therapy (SMT) in general, rather than specifically on chiropractic SMT.[1] There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.[1] A 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition.[36]

Available evidence covers the following conditions:

  • Low back pain. A 2007 literature synthesis found good evidence supporting SMT for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.[15] A 2008 critical review found that chiropractic SMT is possibly effective for back pain, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference.[36]
  • Other musculoskeletal conditions. A 2005 review found little investigative research into chiropractic manipulative therapy for acute neck pain.[37] There is a small amount of research into the efficacy of chiropractic treatment for upper limbs,[38] and a lack of higher-quality publications supporting chiropractic management of leg conditions.[39] A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg.[15] There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine).[40]
  • Nonmusculoskeletal conditions. A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[41] A 2007 systematic review found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions.[8] Other reviews have found no evidence of benefit for baby colic,[42] bedwetting,[43] or fibromyalgia.[44]

(End of proposed replacement text.)

(Please place further comments below.) Eubulides (talk) 19:59, 13 May 2008 (UTC)

Comments on Scientific investigation 3C

(Please put comments here.)

I agree that if the premier chiropractic researchers use generic SMT studies in their reviews, we should be able to use them too. However, Sci Inv 3C is far better than what's in the article now, so let's replace Manga and Worker's Comp with it.--—CynRN (Talk) 04:41, 14 May 2008 (UTC)

This extremely short version runs afowl with NPOV. More importantly, the reader deserves to read a comprehensive version. A comprehensive version is more imformative for the reader. This lack of information version is not it. It is way to short and is below Wikipedia's standard. QuackGuru 11:45, 14 May 2008 (UTC)
Where does it run afowl with NPOV?DigitalC (talk) 23:43, 14 May 2008 (UTC)
I am happy with 3C.DigitalC (talk) 06:08, 15 May 2008 (UTC)
I'm guessing maybe QuackGuru means that by being too short, it's not giving due weight to effectiveness of SMT to reflect how much that's discussed in the sources. I apologize in advance if I got that wrong, QuackGuru. ☺ Coppertwig (talk) 02:57, 16 May 2008 (UTC)
I think this version gives far too much wait to this opinion: "A 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition." This comes from a major chiropractic critic often accused of bias and not necessarily a neutral researcher. As such it should be balanced or removed. That said, I am all for keeping this section brief if we have it at all. This is an article about Chiropractic and not about SMT. All of the details about every study ever conducted about SMT should be saved for spinal manipulation. -- Levine2112 discuss 03:10, 16 May 2008 (UTC)
A major chiropractic critic often accused of bias and not necessarily a neutral researcher? Please provide your evidence. Ernst is peer-reviewed and meets the inclusion criteria for this article. We should edit based on NPOV and exclude any personal opinion. Thus, we can include Ernst. QuackGuru 03:20, 16 May 2008 (UTC)
Yes, but this version gives his opinion far too much prominence. -- Levine2112 discuss 03:26, 16 May 2008 (UTC)
That's your opinion. Please provide evidence of any bias by Ernst. QuackGuru 03:33, 16 May 2008 (UTC)
Not even mainstream medicine listens to Ernst re: his views on the safety and effectiveness of spinal manipulation for back pain. His view is fringe. It can be proved. To repeat: Ernsts (MD) views on spinal manipulation is the FRINGE viewpoint within respect to mainstream medicine. It will be weighed as such. He is not an expert on SMT nor chiropractic, but is simply a vocal critic who is coming off as increasingly righteous and pig-headed despite the mounting evidence which negates his POV. CorticoSpinal (talk) 05:33, 16 May 2008 (UTC)
Ernst is not fringe. His works are often cited by his peers. I just now visited Google Scholar and typed the query "chiropractic Ernst". This returned about 2390 citations. In the first page, one source by Ernst (the 2001 desktop guide) was cited 280 times. Another by Ernst (the 2000 BBC survey) was cited 170 times. All of these numbers beat the query "chiropractic Haldeman" (1230 citations, top two sources on the 1st page cited 107 and 97 times). By this measure, or any other reasonably neutral measure, Ernst is one of the top current sources in the area. Eubulides (talk) 07:35, 19 May 2008 (UTC)
Citations does not necessarily translate into positive remarks on his work. It has also generated significant controversy and those same papers would have to cite his work in order to talk about it. Since it is the most vocal anti-SMT voice, both chiropractic researchers and healthcare researchers reference it as the most extreme, which I would assume would be considered the "fringe" of science.. but you know what assuming does. But, regardless, we can't just assume that citations translates into quality or mainstream. -- Dēmatt (chat) 11:51, 19 May 2008 (UTC)
I tested the theory that citations to Ernst are to cover the controversy by taking the most-cited work of Ernst mentioned above (the desktop guide), going to Google Scholar, finding which works cite it, looking at the first page of results, and reading each of the papers that cite it. I skipped the papers cowritten by Ernst himself for obvious reasons. None of the citations mentioned any controversy; they all simply cited Ernst as an authority. The papers I examined were Marty 2002 doi:10.1089/107555302317371523, Mason et al. 2002 (PMID 12376448), Bair et al. 2002 (PMID 12406817), Cohen & Eisenberg 2002 (PMID 11955028), and Cherkin et al. 2003 (PMID 12779300). These papers are all highly-cited (all have at least 45 citations). Of course this is just a spot-check, but it suggests that Ernst is not considered to be fringe by mainstream researchers. Eubulides (talk) 20:47, 19 May 2008 (UTC)
Evidence of bias by Ernst:
DigitalC (talk) 06:40, 20 May 2008 (UTC)
Yes, Ernst is strongly opposed by many in the chiropractic profession, and those citations illustrate this opposition. However, this does not undercut the claim that citations to Ernst by high-quality mainstream publications are, by and large, positive. Eubulides (talk) 07:20, 20 May 2008 (UTC)
Being opposed by many in the chiropractic profession doesn't have anything to do with research. Research doesn't oppose anything, it is what it is; it either supports or it doesn't. DigitalC's information does show that at least some of those 2390 citations are not positive, which, of course, was my point above. I would suggest that no-one has disagreed with Haldeman's research because he is a neurologist/chiropractor. Maybe that is why he has only half the citations :-) Anyway, I think this shows that Ernst is Ernst and we use his information just as we would Haldemans's or anyone else's. -- Dēmatt (chat) 13:23, 20 May 2008 (UTC)
Obviously some of the citations are negative. But my spot-check from Google Scholar suggests that most of them are positive. (It doesn't prove this, of course; it was only a spot-check.) And it is not true that nobody has disagreed with Haldeman; I can easily cite sources strongly criticizing Haldeman's work. I agree that we should cite Haldeman as well as Ernst; both are leading and reliable sources. Eubulides (talk) 22:16, 20 May 2008 (UTC)
If most of them are positive, then why is more weight being given to the negative ones in the version above? Featuring this - "chiropractic SMT has not been shown to be effective for any medical condition" - so prominently in the lead of this section seems to violate WP:WEIGHT - especially in the context given. I believe enough concern has been raised about Ernst's lack of objectivity, that giving his opinions so much weight seem unjust to the article. -- Levine2112 discuss 22:38, 20 May 2008 (UTC)
That quote is preceded by "Although a 2008 critical review found that with the possible exception of back pain" so it is not as strong as that out-of-context snipped would make it appear. Furthermore, the sentence containing quote also says "a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments" (citing Bronfort et al. 2008, PMID 18164469). This is a strong criticism that immediately undercuts Ernst's claims. If anything, this is being unfair to Ernst; it's not the sort of treatment that any other source is being given here. Given all this context, it's not out of line to let Ernst briefly have his say. Eubulides (talk) 02:16, 21 May 2008 (UTC)
A mischaracterization of what was posted above. In some of the papers there is no way to know what degrees/professions the authors have. For example, in the Bronfort et al. paper, we get these associated groups, but no degrees. (Chalmers Research Group, Evidence-based Practice Center, Departments of Pediatrics, Epidemiology and Community Medicine, University of Ottawa, 401 Smyth, Ottawa ON, K1H8L1, Canada; 4Institute for Research in Extramural Medicine, Vrije Universiteit Medical Centre, The Netherlands; 5Texas Back Institute, 6300 W. Parker Road, Plano Texas 75093, USA; 6Department of General Practice and Nursing Home Medicine, LUMC Medical Centre, Leiden, The Netherlands). In addition, one of the Authors, Assendelft, is a prior co-author with Ernst, and an MD, NOT a Chiropractor. He's also writes cochrane reviews, so he probably knows how to assess evidence.DigitalC (talk) 07:56, 20 May 2008 (UTC)
It is not a mischaracterization. The Bronfort et al. paper has 10 authors, of which 5 have DCs (including Bronfort, the lead author) and 1 (Assendelft) has an MD. So it's strongly dominated by chiropractors. The other sources are even more strongly dominated by chiropractors. Ernst has cowritten more than a dozen Cochrane reviews so I daresay he knows how to assess evidence as well. What we have here is a difference of opinion among experts, a difference that should be reported fairly and neutrally; Ernst is not at all on the fringe here. Eubulides (talk) 09:17, 20 May 2008 (UTC)
It IS a misrepresentation of the sources to state as a summy that "Ernst is strongly opposed by many in the chiropractic profession", when the sources are not solely Chiropractors.DigitalC (talk) 11:20, 20 May 2008 (UTC)
It is not a misrepresentation. The sources given were:
  • A letter by a DC (Evans).
  • A paper with 5 DC and 1 MD coauthors, the lead being a DC (Bronfort et al.; 4 coauthors were neither DCs nor MDs)
  • A letter signed by 3 DCs and zero MDs (Hurwitz et al.).
  • A letter signed by 2 DCs and zero MDs (Morley et al.; 1 coauthor was neither DC nor MD).
  • An article about chiropractors lobbying against Ernst (Dynamic Chiropractic).
  • A position paper by the British Chiropractic Association.
  • A letter signed by 2 DCs and zero MDs (Breen et al.; 3 coauthors were neither DC nor MD).
It's true that there are some non-chiropractors there, but these sources are heavily dominated by chiropractors. They may represent the mainstream of opinion within chiropractic, but they do not represent mainstream opinion generally. They do not at all demonstrate that Ernst is a fringe researcher. Eubulides (talk) 22:16, 20 May 2008 (UTC)
I was responding to QG's request for evidence of claims of bias towards Ernst. That is what I provided.
Ernst's conclusions are fringe and so are his opinions on the subject. His work on SMT and Chiropractic care has been terrible. He's represents the extreme on one end; the WCA represents the fringe on the other end. Both views should be discarded because they are just that, extremist. Ernst has been used to 'bomb' CAM related articles with his 'reviews' which he essentially reviews himself. CorticoSpinal (talk) 12:50, 21 May 2008 (UTC)
We appreciate that's your belief, but just restating it isn't convincing. If an author is heavily cited then it's pretty clear that people are listening to him. Regardless of ones personal beliefs on his work that makes him a notable party. Jefffire (talk) 13:00, 21 May 2008 (UTC)

(Undent) Here is the rift here. If we were to accept that chiropractic researchers are biased, then that acknowledges that medical research is biased. I personally think they are equally biased, but that is just my experience. Therefore, we have two choices, use them both as equal, or consider them POV and attribute the findings to the different sources. One method requires a littel more writing, but either can be productive and get toward the end product. -- Dēmatt (chat) 13:01, 20 May 2008 (UTC)

Once again Dematt comes up with the Solomonic solution - inclusion of all POV using good sources. I also agree with most of his comments. We are all biased, controversies occur, and those biases and controversies need to be documented here. We just need to do it properly. -- Fyslee / talk 14:38, 20 May 2008 (UTC)
That is the goal of #Scientific investigation 3. It includes both supportive and critical sources and cites them appropriately, with due weight given to all sides. Eubulides (talk) 22:16, 20 May 2008 (UTC)
Unfortunately it does not seem like your interpretation of Scientific Investigation 3 is shared by the majority of editors nor does it generally represent the conclusions of the scientific community (due to cherry picking of sources). CorticoSpinal (talk) 12:50, 21 May 2008 (UTC)
Looks quite sound to me. Could you give specific advice for how to improve it, rather than baseless sniping, thanks. Jefffire (talk) 13:00, 21 May 2008 (UTC)

Is there a reason that effectiveness 3C has been struck out entirely, and that multiple editors comments are struck out as well? I seem to have missed something. DigitalC (talk) 06:42, 31 May 2008 (UTC)

The talk page is now archived automatically by a bot. Sections that haven't been changed for 14 days get archived. If you want the section back, you can resurrect it by hand from the archive. Eubulides (talk) 07:56, 31 May 2008 (UTC)
Effectiveness 3C has not been archived, it has been struckout struck out. As have comments of more than one editor in relation to it. DigitalC (talk) 07:58, 1 June 2008 (UTC)
Sorry, I misunderstood, and I don't know who struck it out or why or when. I assume the history could tell you? Eubulides (talk) 08:39, 2 June 2008 (UTC)
I assume the history COULD tell me, however the functionality of the history is subpar, IMHO, and it would take hours to try and sift through and find the diff. Since you drafted the section, and didn't strike it out yourself, and since CynRN didn't chime in to say she struckout her comment (which has since mysteriously been unstruck, as has QGs), I will unstrike the entire section.

Continued discussion of Scientific investigation 3C

Okay, back to work on SCI 3C. I've sticken through:

  • Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims.[2]

Evidence based medicine does not care what your philosophy is, if it works it works. It doesn't matter which side of any arbitrary line you are on. This just seems like an opportunity to use the word pseudoscience, but it doesn't really fit. -- Dēmatt (chat) 13:55, 21 May 2008 (UTC)

It's true that evidence-based medicine is independent of philosophy. However, the point is that some chiropractors accept the principles of evidence-based medicine, and others don't. This is quite relevant to the subject of scientific investigation, because the entire philosophical basis of scientific investigation is questioned by a significant minority of chiropractors. [citation needed] For the purpose of this section, I agree "pseudoscience" isn't needed so I struck that instead. Eubulides (talk) 16:43, 21 May 2008 (UTC)
I'm not sure I'm buying that one, Eubilides. Let's put the groups scientific orientation in the sections that address their scope and leave this for the science - which doesn't care what race, creed, or color you are. -- Dēmatt (chat) 19:36, 21 May 2008 (UTC)
Other sections (notably Chiropractic#Philosophy already discuss this issue at some length. However, it's useful to put in a brief mention of the problem here. We can't expect every reader of this section to have read the whole article. Eubulides (talk) 20:13, 21 May 2008 (UTC)
Absence of adherence to EBM does not automatically imply pseudoscience. I wouldn't even go that far characterizing the straight wing. As on the Physical therapy page, a significant chunk of PTs don't use the evidence (thus far) but I would not call them pseudoscientific. Even the MDs who use outdated methods (antibiotics for sinus infections) for the last 40 years which was found to be of 0 benefit. I'm actually beginning to see some quality research designs by straight-leaning chiropractic schools in the US. I think they're getting it. Publish or perish (or lose market share to professions who will fill the gap). CorticoSpinal (talk) 18:06, 21 May 2008 (UTC)
The current 3C draft omits "pseudoscience", which should address the concerns mentioned here. Eubulides (talk) 20:13, 21 May 2008 (UTC)
because the entire philosophical basis of scientific investigation is questioned by a significant minority of chiropractors - Then what we would have to do is explain why, i.e. this is where Keating ref would come in with antiscience - it's not that they don't believe science or rational thinking, it is not trusting the scientist that is doing the research, i.e. drug companies performing the research on drugs, MDs evaluating chiropractic methods. It is more a distrust than a true antiscience. -- Dēmatt (chat) 18:29, 21 May 2008 (UTC)
It might be helpful to add a discussion of this point. However, the source (Keating 1997) does not address the trust issue, so we'd need a reliable source to justify the discussion. Eubulides (talk) 20:13, 21 May 2008 (UTC)

This statement does not match the source. I changed it as shown, it still needs work, but just to get it on paper disk.

  • Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective. As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective.[50]

-- Dēmatt (chat) 14:37, 21 May 2008 (UTC)

    • It does match the source. The source says "Nevertheless, there are different views concerning the efficacy of chiropractic treatment, which is not surprising. Unfortunately, it is difficult to establish definitive, unarguable, and conclusive findings regarding much in the healing arts despite the millions of papers that have been written about presumably scientifically sound studies. Because of this difficulty, numerous medical procedures have not been rigorously proven to be effective either." The sentence in question is an abridged version of this quote. The stuff about "as of 2002" is obsolete and should not appear here. Also, in general it's not a good idea merely to quote the source; we should use the ideas and not degenerate into a list of quotes. Eubulides (talk) 16:43, 21 May 2008 (UTC)
      • While attempting to be constructive, Eubulides, the tone of your message to Dematt comes off rather condescending and paternalistic to a highly respected editor. I'm sure that was not the intent, but I had mentioned this concern before and hope you realize that Dematt's editorial skills are appreciated by both proponents and skeptics. CorticoSpinal (talk) 18:06, 21 May 2008 (UTC) I can tell he was smiling when he said that ;-) It's okay, really, down doggie, down :-)
I'm reading the Pubmed version and don't see your sentence there. The doi link is not working for me. -- Dēmatt (chat) 18:42, 21 May 2008 (UTC)
The source is copyrighted and only the abstract is freely readable. The above quote is from the "Efficacy and Patient Satisfaction" section of the source. Eubulides (talk) 20:13, 21 May 2008 (UTC)
Nevertheless, I think we can write it more neutrally and fit the source better if we say it this way:
  • Because it is difficult to establish definitive, unarguable, and conclusive findings regarding much in the healing arts, most medical procedures have not been rigorously proven to be effective. Chiropractic fits this category as well.
-- Dēmatt (chat) 19:31, 21 May 2008 (UTC)
That's less neutral than the current summary, because the cited source does not say "most medical procedures"; it merely says "numerous". Also, I don't see how adding all that other verbiage makes the summary more neutral. What's not neutral about the much-shorter "Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective."? Eubulides (talk) 20:13, 21 May 2008 (UTC)
I merged the second sentence to make it shorter, but don't want to lose the qualifying section of the sentence that explains to our readers who have no idea what 'rigorously proven' means. They need something to compare it to. All the reader sees is, "chiropractic treatment has not been proven to be effective" and of course that is not NPOV. We have to qualify it and still keep it along the lines of what the author was intending to say (which in the abstract was actually positive towards chiropractic), otherwise we are creating and SYN error, or OR. The other option is number three, where we use the information from the abstract itself:
  • "Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective."?
  • "Because it is difficult to establish definitive, unarguable, and conclusive findings regarding much in the healing arts; numerous medical procedures, including chiropractic care, have not been rigorously proven to be effective."
-- Dēmatt (chat) 20:50, 21 May 2008 (UTC)
It's not the case that 'All the reader sees is, "chiropractic treatment has not been proven to be effective"'. The reader also sees "Like many other medical procedures" at the start of the sentence. This places the claim in context. The wording also uses the word "rigorously" to make it clear that we're talking about proofs with a high degree of confidence. The quote from the source is wordy and the extra verbiage adds little; plus, we shouldn't just be stringing together quotes. I take it that the objection is that the summary does not mention the point that it's hard to establish definitive findings? Then how about rewording it to "It is hard to make definitive findings about much of medicine, and like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective." Eubulides (talk) 08:35, 22 May 2008 (UTC)

The placebo source is excellent, but the sentence is misplaced. I just struck it out for now.

-- Dēmatt (chat) 14:58, 21 May 2008 (UTC)

Thanks. But let's find a better home for it rather than just removing it. I unstruck it for now. Eubulides (talk) 16:43, 21 May 2008 (UTC)
I found one!, but you know that, it is below. I won't delete the other one until we're all happy with the new placement. -- Dēmatt (chat) 19:16, 21 May 2008 (UTC)


This sentence has problems with the source, too. It's about chiropractic care with Type O problems. It's giving suggestions about how to improve studies. It's not making any judgements about 'low quality"?

  • Many studies of chiropractic care are available, but they are typically of low quality.[8]

-- Dēmatt (chat) 15:30, 21 May 2008 (UTC) Thanks for catching that. The source says "the number of studies on chiropractic care and/or SMT and other manual therapies for patients with nonmusculoskeletal conditions is relatively small, and the quality of the studies is generally not high.". I think there was a similar source for MS that said "many studies" that got removed by later editing; I'll take a look for it but for now I reworded the claim. Eubulides (talk) 16:43, 21 May 2008 (UTC)

Again, I hope thatis the source that is not listed, or am I missing something with the doi ref? -- Dēmatt (chat) 19:19, 21 May 2008 (UTC)
Sorry, I don't follow. Many of the sources for Chiropractic are not free; Hawk et al. is one of them. That's life in the big research city, I'm afraid. All other things being equal we prefer free sources, but high-quality nonfree sources are fine when equal-quality free sources are not available. Eubulides (talk) 20:13, 21 May 2008 (UTC)


I'll take a break now. I feel like this version (3C) so far still does not follow the sources well enough to represent what they are saying. I think we might be trying to fit things into our "Efficacy", but we're having to use sources that aren't really addressing that. We're still not there. We may have to go to some primary sources as well. Perhaps a combination of this and that other version that CS brought us and call it something different. -- Dēmatt (chat) 15:37, 21 May 2008 (UTC)

Okay, so much for the break, but I saw SC investigation 3 above and saw this sentence:
  • Research has focused on spinal manipulation therapy (SMT) rather than specifically on chiropractic SMT,[1] but the distinction is not significant: chiropractors use all forms of SMT, more than 90% of SMT in the U.S. is done by chiropractors, and SMT research is equally of value regardless of practitioner type.[52]
We could add the placebo reference here, like this:
  • Research has focused specifically on spinal manipulation therapy (SMT) rather than on the whole chiropractic visit and all that is involved in the patient encounter, some of which may be the result, as with all healthcare encounters, of the placebo effect[53], The distinction is not significant regarding who performs SMT for musculoskelatal conditions.[54]
Still needs work, but you get the idea. -- Dēmatt (chat) 16:10, 21 May 2008 (UTC)
I don't see why we'd want to move the placebo sentence from the generic paragraph to the SMT paragraph. The placebo effect applies to all treatments, not just to SMT. Eubulides (talk) 16:43, 21 May 2008 (UTC)
If placebo applies equally to all Tx (which it does) why redundantly mention it? CorticoSpinal (talk) 18:06, 21 May 2008 (UTC)
I'm okay with putting it in the generic paragraph, I'll do it now to see what it looks like. -- Dēmatt (chat) 18:48, 21 May 2008 (UTC)
By "generic" I meant "generic to effectiveness", not "generic to all research". Safety studies generally don't use placebos. How about moving it back to where it was, which was in the generic-to-effectiveness paragraph? Eubulides (talk) 20:13, 21 May 2008 (UTC)

I see that more material was added here, but I confess I don't see the point. I thought that the idea behind the 3C draft was to avoid all mention of sources unless they specifically talk about chiropractic care. And yet now a lot of material has been added that talks about SMT irrespective of chiropractic. But that's what Chiropractic#Effectiveness does. Why not start with that version, rather than the old 3C version whose goal in excluding all but specifically chiropractic sources was different (and by the way, was a goal I didn't agree with)? Eubulides (talk) 08:35, 22 May 2008 (UTC)

"Rigorously proven"

I agree with Dematt that the bit about "rigourously proven" is not a good abridgement of that source: it strikes me as implying much more strongly than the source does that chiropractic is unproven. I think a better abridgement of that source is the following direct quote from the source: "There are different views concerning the efficacy of chiropractic treatment." ☺ Coppertwig (talk) 00:10, 26 May 2008 (UTC)
And actually, I agree with Dematt that the quote about 30 of 43 studies is better. Eubulides, the quote you give from the source above does not actually state that the efficacy of chiropractic has not been rigorously proven. It leaves open the possibility, for example, that some people believe it to have been rigorously proven while others do not. Perhaps it implies that it has been rigorously proven and perhaps it does not, but it doesn't state it, so we shouldn't state it right out either based on that source. ☺ Coppertwig (talk) 01:31, 27 May 2008 (UTC)
  • Sorry, I don't know what you mean by "the quote about 30 of 43 studies"; there's no string "30 of 43" anywhere else on this talk page.
  • I don't see how to read the source[55] in the way that you say. Nobody seriously argues that the efficacy of chiropractic care has been rigorously proven.
  • That quote is there because of a common theme in many sources that although chiropractic care has not been rigorously proven, in this respect it's in the same boat as many other forms of medical treatment. That's an important point, which should be made. All too often, chiropractic critics say "the science isn't there" without noting that the science isn't there for many other forms of medical treatment, too. Perhaps DeVocht is not the ideal source to make this point, but it will do until we find a better one.
  • We don't need DeVocht to support the claim that there are differing views of the subject; that claim is already stated elsewhere in the section, and is well-supported already (by better sources than DeVocht).
Eubulides (talk) 08:08, 27 May 2008 (UTC)
Thanks for your reply, Eubulides. Sorry I wasn't clearer. By "30 of 43" I meant "As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective." However, as you point out, this would leave out the point about comparing with the situation with medical treatments.
I dispute whether the source supports the claim that "chiropractic treatment has not been rigorously proven to be effective". You said this was an abridgement of a paragraph you quoted above. I don't see how to read that paragraph the way you do. One possibility might be changing the footnote to a source which clearly makes this claim, if one can be found.
May I suggest another alternative wording: "It is difficult to establish conclusive findings regarding either chiropractic treatment or numerous medical procedures." Would you agree that that's a reasonable abridgement of the paragraph quoted?
I'll assume what you say is true, that "nobody seriously argues that the efficacy of chiropractic care has been rigorously proven." However, based only on this, it would be Original Research for Wikipedia to state that the efficacy of chiropractic care has not been rigorously proven. To state that, we would need a source which claims that the efficacy of chiropractic care has not been rigorously proven. Regards, ☺ Coppertwig (talk) 00:29, 2 June 2008 (UTC)
  • That "30 of 43" comment is not worth mentioning here. Chiropractic#Effectiveness already cites far more-systematic (and more recent) reviews talking about SMT for low back pain, reviews that (like DeVocht) are favorable to chiropractic (e.g., Bronfort et al. 2008, PMID 18164469; or Meeker et al. 2007, no PMID), and DeVocht's opinion piece isn't close to being in their league. DeVocht is a reasonable source for supporting the argument that chiropractic care is like many other forms of medical treatment in that it hasn't been rigorously proven, but this is true mainly because the more-reliable sources don't address the point.
  • I don't see how the proposed alternate wording solves the (to my mind hypothetical) problem. DeVocht nowhere says in one brief quote that it is difficult to establish conclusive findings regarding "chiropractic treatment". The proposed alternate wording relies on the fact that DeVocht is obviously including chiropractic treatment as being part of "much of the healing arts". But if there is some reluctance to say what DeVocht is obviously saying (namely that chiropractic care, like many other medical treatments, is hard to test and has not been rigorously proven), then this (to my mind hypothetical) objection applies with equal force to the proposed alternate wording. In that case, why change the wording to something that is longer and more confusing?
Eubulides (talk) 08:39, 2 June 2008 (UTC)
Thank you for your reply, Eubulides.
Perhaps I see a distinction that you don't – in which case it should perhaps be easy to find wording we can both agree on.
The paragraph quoted from the source implies that chiropractic care has not been rigorously proven to be effective. However, as I see it, it does not state that. I believe the author deliberately refrained from stating that, because it would be a statement which would be hard to prove and which could go out-of-date if new studies are published. Regardless of the reason why it doesn't state it, since (IMO) it doesn't, we shouldn't (IMO) state it either.
To my mind, the source also leaves open the possible alternative interpretations of "Numerous chiropractic treatments, like numerous medical procedures, have not been rigorously proven to be effective" or, along with the previous sentence, "Much of chiropractic is difficult to prove effective ... numerous medical procedures have not been proven effective either." If I understand what you're saying, Eubulides, you mean that it's not completely clear whether all of chiropractic is intended to be included in "much of the healing arts".
To me, there is an important distinction between "it is difficult to establish conclusive findings," which implies but does not state that there is no rigorous proof, and "has not been rigorously proven," which states it outright and is a very strong, probably impossible-to-prove and therefore perhaps unscientific statement when applied to all of chiropractic care as opposed to being applied to an unspecified and therefore flexible set of medical procedures. A scientist can state that they have not seen proof of something and we can all conclude from that that there probably isn't proof, since the scientist probably keeps up with the literature; but a scientist is less likely to state confidently that no proof exists anywhere.
Just making a sentence a little longer and more confusing is a minor problem, to my mind, in comparison to the importance of adhering to WP:V and avoiding stating something which is not (IMO) stated in the source (as represented in that paragraph), and which you seem to be saying is not stated in the other, more reliable, sources either. However, the first three of the suggested alternative wordings below are shorter and arguably simpler than the current wording:
  • "Like many other medical procedures, chiropractic treatment is difficult to test." (short and simple.)
  • "As with numerous medical procedures, the effectiveness of chiropractic treatment is difficult to test."
  • "Like many other medical procedures, chiropractic treatment is difficult to rigorously prove effective."
  • "There are difficulties in trying to rigorously prove effectiveness for many health care treatments, including chiropractic treatment as well as numerous medical procedures."
  • "Numerous medical procedures have not been rigorously proven effective; this is also true of chiropractic treatments." (deliberately ambiguous – perhaps we shouldn't do that, though)
  • "Numerous medical procedures and chiropractic treatments have not been rigorously proven to be effective." (also deliberately ambiguous: does "numerous" apply to "chiropractic treatments"?)
Regards, ☺ Coppertwig (talk) 19:42, 3 June 2008 (UTC)

(outdent)

  • "Has not been rigorously proven," is a scientific statement and is quite common in scientific papers. Here are some examples of its use in high-quality scientific sources:
  • "Hyperglycemia has a key role in oxidative stress in diabetic nerve, whereas the contribution of other factors, such as endoneurial hypoxia, transition metal imbalance, and hyperlipidemia, has not been rigorously proven." (Obrosova 2002, PMID 12198815)
  • "The accuracy of the definition of the bottom of the nerve fiber ayer measurement has not been rigorously proven." (Jaffe & Caprioli 2004, PMID 14700659)
  • "Although it has been frequently proposed that AICD is a signalling molecule similar to the Notch intracellular domain, this has not been rigorously proven." (De Strooper 2007, PMID 17268505)
  • The source in question (DeVocht 2006, PMID 16523145) is two years old. It's fairly high level; I don't think it's much more out-of-date now than it was when it was published.
  • The source talks about "chiropractic treatment", not "chiropractic treatments". That is, it is not talking about particular treatments, but about chiropractic treatment as a whole.
  • The previous paragraph in the source says this about chronic headache: "Although not rigorously documented in large-scale, well-designed randomized control trials, as of 2001, there had been at least nine trials of various degrees of quality and size involving 683 patients with chronic headaches with reported clinical improvement." The source is saying that the literature on the effectiveness of chiropractic treatment (here, for chronic headache) has not rigorously documented effectiveness. This is what builds up to the "has not been rigorously proven" (for all chiropractic treatment) in the next paragraph.
  • How about this rewrite? It's derived by combining the 2nd and 5th of your proposals, along with changing the word "test" to the source's word "establish":
"As with many other medical procedures, the effectiveness of chiropractic treatment is difficult to establish and has not been rigorously proven."

Eubulides (talk) 21:04, 3 June 2008 (UTC)

I acknowledge that some scientific articles state that some things are not rigorously proven. However, in this discussion we don't have any article that states (IMO) that the effectiveness of chiropractic treatment in general has not been rigorously proven. It says something about rigorous documentation with regard to treatment of headaches in particular; and it says it in an "although" clause. If we need to reach down into "although" clauses of less-reliable sources, maybe the statement is getting undue weight. I oppose the sentence you propose, which states that the effectiveness of chiropractic treatment has not been rigorously proven. I suggest: "As with many other medical procedures, the effectiveness of chiropractic treatment is difficult to establish." Or, how about saying something more similar to what the source says: "The effectiveness of chiropractic treatment is difficult to establish; many medical procedures also lack rigorous proof of effectiveness." (I posted the preceding at 22:28, 3 June 2008. ☺ Coppertwig (talk) 00:33, 4 June 2008 (UTC))
  • These two suggested paraphrases suffer from the same issue (which I still don't see as being an important one) as the paraphase that is currently in Chiropractic. Neither suggested paraphrase logically follows from what the source formally states (even though they are both obvious paraphrases of what the source is saying). For example, both paraphrases say "The effectiveness of chiropractic treatment is difficult to establish", which is obviously supported by the source; but this is not a logical implication of what the source formally says. If the problem is that an obvious paraphase uses deduction that is formally unwarranted, then what makes these paraphrases acceptable but the paraphrase in Chiropractic unacceptable?
  • Let's put it a different way. The source says "numerous medical procedures have not been rigorously proven to be effective either". The only plausible way I can see to interpret that either is as follows: although chiropractic treatment has not been proven to be effective, numerous medical procedures have not been rigorously proven to be effective either. Is there any other plausible way to interpret that either? If not, then Chiropractic's current paraphrase is fine, no?
Eubulides (talk) 07:24, 4 June 2008 (UTC)
Good point, Eubulides, about my suggestions also being mere paraphrases. One answer to that is: if you see them as equally bad but I see the current sentence as worse, then why not just go with one of my suggestions? Another answer is: the paraphrases I suggest seem to me to be innocuous paraphrases, while the statement that there is no rigorous proof of effectiveness is a very strong statement which would require very careful sourcing.
Yes, I see plausible alternative interpretations of the "either" statement in the source. The best one seems to me to be this: "Opinions differ about the effectiveness of chiropractic treatment. Many people believe that the effectiveness of chiropractic treatment has not been rigorously proven; however, the effectiveness of many medical procedures has not been rigorously proven, either."
I suggest the following, which I think follows the source more closely: "As with some medical procedures, many of which also lack rigorous proof of efficacy, opinions differ as to the efficacy of chiropractic treatment." ☺ Coppertwig (talk) 10:06, 10 June 2008 (UTC)
I see your point, and your suggestion has merit, but it also has problems that mean it's a bit worse than what is in there now.
  • Most important, the source says "opinions differ" first, and then follows up with lack of rigorous proof as being a problem in settling the difference of opinion. But the suggested wording puts it the other way: it says there is a lack of rigorous proof, and therefore that opinions differ about efficacy, with the implication that this is the same as many other medical arts. But that is not what the source is saying. The source is saying that opinions about chiropractic treatment differ for whatever reason (philosophy, or turf-war, or whatever), and the difficulty of finding solid evidence hinders us from resolving the dispute.
  • I don't follow your interpretation of the word "either" in the source. The source does not say or imply that "Many people believe that the effectiveness of chiropractic treatment has not been rigorously proven". It says flatly "numerous medical procedures have not been rigorously proven to be effective" (followed by the word "either", which means chiropractic treatment is in the same boat). There is no implication that there's serious doubt about this flat claim. The "different views" the source mentions are different views about whether the treatment is efficacious (where there is not a consensus among experts), not about whether the the treatment's effectiveness has been rigorously proved (where the consensus is clear: it hasn't been rigorously proved).
  • The source talks about "much in the healing arts" and "numerous medical procedures", which clashes with the suggestion's "some medical procedures".
  • The source says "rigorously proven to be effective", which clashes slightly with the suggestion's "rigorous proof of efficacy". Effectiveness is not the same as efficacy, though they are related.
  • Given the continuing conflict we're having here, perhaps the simplest thing is to remove the sentence in question from Chiropractic. That's too bad, as I think it's important to mention that chiropractic treatment is in the same boat as many other medical procedures with respect to evidence. I'm confident DeVocht is making this point, but if the consensus is that he's not, then let's just remove the sentence entirely (until and unless we find some other source that is making the point).
Eubulides (talk) 19:43, 10 June 2008 (UTC)
I think this version addresses all of the points you raise above: "Opinions differ as to the effectiveness of chiropractic treatment; many medical procedures also lack rigorous proof of effectiveness." I thought you had said that several sources had made the point that medical procedures are in the same boat; I also think it's important to include this point. However, I'd rather just remove the sentence than leave it as is.
The source doesn't say that many people believe that effectiveness of chiropractic treatment has not been rigourously proven. It also doesn't say that everybody believes that. It just doesn't say explicitly anything about it. The word "either" is obviously alluding to something unstated: it could as easily be the unstated thing I suggest as the unstated thing currently in this article. I think the author refrained from stating that the effectiveness of chiropractic treatment has not been rigourously proven in order to avoid being challenged by people who believe that it has been, as well as to cover himself in case proof of effectiveness was just being published around the same time as that paper or would be published within a few years. ☺ Coppertwig (talk) 22:35, 10 June 2008 (UTC)
The source does not say that many people believe or disbelieve anything about rigor. It just says that many medical procedures haven't been rigorously proven (there's nothing about belief in that statement). I disagree that the "either" could just as easily cause us to interpret DeVocht as saying merely "Many people believe that the effectiveness of chiropractic treatment has not been rigorously proven"; he is saying that the effectiveness has not been rigorously proven, period. However, all that being said, the latest wording you proposed is adequate so I put it in after replacing an "effectiveness" with an "efficacy" (to match the source better) and adding an "other" (to avoid making the implication that chiropractic treatments are somehow not medical). Eubulides (talk) 23:25, 10 June 2008 (UTC)
That sentence that was just put in is still not worthy. The cited source doesn't back it's inclusion. It won't pass WP:SYN. This is what the source says. You can pick out the part that we have chosen to use:
  • "Although by far most chiropractic treatment is given for back pain, it seems able to affect a broader range of conditions as shown in the following few examples. Second to back pain, chiropractors probably are best known for treatment of chronic headaches. Although not rigorously documented in large-scale, well-designed randomized control trials, as of 2001, there had been at least nine trials of various degrees of quality and size involving 683 patients with chronic headaches with reported clinical improvement.2 In one study, subjects with chronic mechanical neck pain syndromes receiving spinal manipulation had an average increase in pressure pain threshold of 45% whereas a control group showed no change.48 There is some indication that chiropractic treatment may be helpful for some cases of temporomandibular disorders based on positive case reports 13,19,38 and the improvement of all nine patients in a small prospective case series.11 The edge light pupil cycle time, a reflex of the eye that is mediated through the autonomic nervous system, is influenced by high-velocity manipulation to the upper cervical spine.18 Mechanical stimulation of the spine of rats has an effect on blood pressure, heart rate, and the activity of sympathetic nerves.39 Some chiropractors report having successful treatment of otitis media such as in a case report by Saunders 40 that also includes reviews of a retrospective study of 46 children,16 a pilot study of 22 children,41 and two case series of five and 322 children.14,17
Nevertheless, there are different views concerning the efficacy of chiropractic treatment, which is not surprising. Unfortunately, it is difficult to establish definitive, unarguable, and conclusive findings regarding much in the healing arts despite the millions of papers that have been written about presumably scientifically sound studies. Because of this difficulty, numerous medical procedures have not been rigorously proven to be effective either.24,44 Expert opinions vary on virtually every aspect of health care...."
IOWs, the author prefaces his statement about "rigorously proven" with a long diatribe about the research that supports chiropractic and then argues that people still don't believe it. So he states the obvious 'that it is difficult to establish definitive, unarguable, and conclusive findings for "anything"'. And nothing in medicine is rigorously proven because of this. His point is that we have to loosen up and realize that there is value there. If we don't represent this sentence in this fashion, then we are misrepresenting the author's intention. We are using the sentence to represent chiropractic treatment negatively, which is not the intention of the author. It would be like us saying that Ernst says "chiropractic care adds quality of life". -- Dēmatt (chat) 02:32, 11 June 2008 (UTC)
  • It would be quite reasonable to quote Ernst on the strengths of chiropractic. Indeed, #Cost-effectiveness 2 cites Ernst to support the claim "A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain...".
  • More generally, it's a good thing, not a bad thing, to quote chiropractic critics on strengths of chiropractic, and to quote chiropractic supporters on weaknesses. A strength that is admitted even by critics is quite well supported, and conversely by weaknesses admitted even by supporters.
  • Research that supports chiropractic is already summarized in Chiropractic at length, supported by more-recent and far more-reliable sources than DeVocht. There is no point saying again here (simply because DeVocht says so) that research support exists for chiropractic treatment. The only reason to cite DeVocht here is because he makes the valid and important point (which the more-recent and far more-reliable sources do not) that it's hard to rigorously prove large chunks of medicine.
Eubulides (talk) 17:58, 11 June 2008 (UTC)
Thank you very much for making that change, Eubulides. I really appreciate it and think it's a big improvement. That paragraph now no longer seems to me to be a WP:V violation.
I agree with Eubulides that, when feasible, quoting critics on the strengths and supporters on the weaknesses is a good way to ensure that we're reporting solid facts.
In response to Dematt's point: I now notice that the first paragraph of "effectiveness" all seems rather negative: Since the first paragraph should serve as an introduction to the whole section, I think the paragraph could be improved by adding a few words meaning that there is in fact some evidence supporting the effectiveness of chiropractic treatment. For example, adding "Chiropractic treatment seems able to affect a broader range of conditions than back pain", based on the paragraph quoted by Dematt above. I'm trying to figure out where this could fit into the paragraph smoothly: I suggest putting it just before the last sentence, and joining it to the last sentence by inserting "but".☺ Coppertwig (talk) 23:42, 13 June 2008 (UTC)
  • Its 1st sentence is neutral: "The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment."
  • Its 2nd sentence defends chiropractic: "Opinions differ as to the efficacy of chiropractic treatment; many other medical procedures also lack rigorous proof of effectiveness."
  • Its 3rd sentence is both negative (it says chiropractic benefits from the placebo response) and positive (it defends chiropractic by saying all medical treatment does). Here's the sentence: "Chiropractic care, like all medical treatment, benefits from the placebo response."
  • Its 4th sentence states something negative about our knowledge, not about chiropractic: "The efficacy of maintenance care in chiropractic is unknown."
The proposed text "Chiropractic treatment seems able to affect a broader range of conditions than back pain" is not a good idea. That text is controversial and comes from a source (DeVocht 2006, PMID 16523145) that was partisan by design. That source was one side of a debate between two chiropractors: the other side of the debate was Homola 2006 (PMID 16446588). The two articles were published adjacently in the same volume of Clinical orthopaedics and related research. Both sides of this debate were chiropractors (so this was not a debate that covered the mainstream spectrum), but DeVocht was more pro-chiropractic than Homola was. In his debate piece, DeVocht does not attempt to be balanced. For example, his above-quoted discussion of chronic headache, otitis media (middle ear infection), and temporomandibular disorders gives only pro-chiropractic sources (and dated sources to boot) and does not at all reflect mainstream consensus. Eubulides (talk) 09:23, 14 June 2008 (UTC)
Again, Homola is not a Chiropractor, and has not been since 2000. To state that a 2006 debate between Homola and DeVocht was between two chiropractors is not true. DigitalC (talk) 05:25, 24 June 2008 (UTC)
Homola has a D.C. and meets every definition of chiropractor that is given in Chiropractor. Is your objection that Homola has retired? If so, that has very little bearing on this topic. Eubulides (talk) 07:02, 24 June 2008 (UTC)

(<<<outdent) In response to Eubulides' comment, I withdraw my proposal to add "Chiropractic treatment seems able to affect a broader range of conditions than back pain". ☺ Coppertwig (talk) 14:40, 14 June 2008 (UTC)

Improved version RfC

It is my opinion that this change was for the better. Please give your opinion on the matter. ScienceApologist (talk) 15:01, 14 May 2008 (UTC)

The majority of these edits were contentious, still being discussed on this page, and still lack consensus. Accordingly, I have reverted. There were some decent housekeeping edits in the mix, but the bad outweighed the good in my opinion. -- Levine2112 discuss 17:45, 14 May 2008 (UTC)
I would not have made these edits at this time. That being said, the discussion in #Comments on Scientific investigation 3 seems to have petered out, with questions remaining for the dissenting editors but no replies from them recently. The edits that were already discussed are a big improvement over what was in Chiropractic. Surely they can be further improved, and we can discuss that here. Many edits were not previously discussed, though, and they are more problematic; please see #Several important changes were never discussed below for more about them. Eubulides (talk) 23:44, 14 May 2008 (UTC)
It has been discussed on this talk page previously that any contentious edits should be discussed on the page before being implented. In addition, rather than grouping large housekeeping edits and reference formatting with contentious edits, it is better to make a larger number of smaller changes.DigitalC (talk) 23:53, 14 May 2008 (UTC)
We are not bound by what has happened on this page in the past (see e.g. WP:BOLD, WP:IAR). The question is whether the edits were good. There is consensus that they are. ScienceApologist (talk) 19:34, 19 May 2008 (UTC)
  • It is true that we are not bound; still, standard practice, as noted at the top of this talk page, is to discuss controversial changes before making them, which was (alas) not done here.
  • Even if there was consensus that the big edit improved the article overall, that would not imply that consensus for each part of the big edit. None of the commenters backing the consensus have commented on detailed criticisms of the previously-undiscussed parts of the big edit. (These criticisms were not available to the commenters, precisely because the big edit was sprung on the regular editors without discussion.) So there is no real evidence for consensus for the previously-undiscussed parts of the big edit that have been criticized after the big edit was made.
Eubulides (talk) 20:47, 19 May 2008 (UTC)
  • Agree with ScienceApologist: Surveying these changes, they appear to be quite reasonable and backed by reliable sources. I agree with SA that these changes constitute an excellent start at reform of this page, which is sorely needed to create something encyclopedic that conforms to WP:NPOV.--Filll (talk) 18:04, 14 May 2008 (UTC)
  • I think it's better, more NPOV. I'm not sure that adding back practice styles is worthwhile (this article is way long already!) and I believe it's hard to pigeon-hole any individual chiropractor, but I approve of most changes, esp. re. Manga and worker's comp studies.--—CynRN (Talk) 19:07, 14 May 2008 (UTC)
  • I will take a look at the edits one by one and add the ones that haven't been disputed; I'll then come back here and summarize what's remaining. Eubulides (talk) 19:32, 14 May 2008 (UTC)
  • After I wrote the above comment, someone else added all the edits. So now I'm looking at them one by one and plan to take out the ones with the most problems. (If someone else doesn't revert again first.…). So far I've found mostly just citation problems, but I haven't got to the controversial stuff yet. Eubulides (talk) 20:13, 14 May 2008 (UTC)
  • I found a serious problem with the edits: many of them have never been discussed on this page, even though they are potentially controversial. For now I have reverted them; please see [[#[edit] Several important changes were never discussed]] below. Eubulides (talk) 23:44, 14 May 2008 (UTC)
  • I agree that the changes meet NPOV, are well sourced and helps the article to be able to go forward. My comment is from an outside opinion who watches the article and the talk page. --CrohnieGalTalk 19:39, 14 May 2008 (UTC)
  • There is growing consensus for the recent changes that are being discussed in this RFC. However, a couple of edits deleted some information that was part of the recent changes discussed in this RFC. Any minor tweaks can be made in mainspace. QuackGuru 01:07, 15 May 2008 (UTC)
  • I've restored the content under discussion. It appears fairly well-sourced. It deserves to be discussed rather than removed on a whim without properly addressing the quality of the references and their use. Let's all follow WP:TALK and WP:CON here. Thanks. --Ronz (talk) 01:42, 15 May 2008 (UTC)
There are serious problems with many parts of the edit. This should have been discussed before insertion, as per consensus above that any contentious edit would be previewed on the talk page before being taken to mainspace.DigitalC (talk) 04:16, 15 May 2008 (UTC)
I do not see any serious problems. I see a very thoughtfully written improved version. My recent edits were discussed in this RFC. Please respect the external advise. QuackGuru 04:38, 15 May 2008 (UTC)
There is broad consensus among external observers in this new RFC discussing the recent changes I made. These edits went against the advise from external third-party input of this RFC. QuackGuru 04:38, 15 May 2008 (UTC)
That edit had two parts. First, it installed the changes proposed in #Scientific investigation 3 and discussed extensively earlier. Second, as mentioned below, that edit installed several changes that were never discussed before installation. None of the external observers have commented specifically on the second (previously-undiscussed) class of changes. It is not clear that they approve of the previously-undiscussed changes. It is not even clear that the observers even noticed the previously-undiscussed changes. I didn't notice them without doing a line-by-line analysis of the edit, which took quite some time. Eubulides (talk) 06:09, 15 May 2008 (UTC)
The external observers are commenting at this RFC about this recent change. QuackGuru 06:25, 15 May 2008 (UTC)
The discussion here has been fruitful in this RFC for this recent change but this edit went against established third-party consensus. QuackGuru 06:39, 15 May 2008 (UTC)
I will follow up at #Several important changes were never discussed below. Eubulides (talk) 06:48, 15 May 2008 (UTC)

I saw this dispute while reading Vassayana's talk page. I don't know the subject, but I can see two things: first, probably many of the changes are good. Second, that while bold edits are good, they were subsequently edit warred in, [4](these for example) which is against the processes of WP. Therefore, there is a need for obtaining consensus on the changes before they are considered more than suggestions. ——Martinphi ☎ Ψ Φ—— 02:07, 16 May 2008 (UTC)

There was growing consensus for the recent changes but it appeared a certain editor attempted to flout consensus by edit warring.[5][6][7][8] QuackGuru 22:19, 19 May 2008 (UTC)
Or rather that certain editor was flouting the lack of consensus despite another certain editor touting that there was one. -- Levine2112 discuss 22:32, 20 May 2008 (UTC)
Martin, do you believe that the agreement seen by so many outside reviewers of the RfC that the content is good is not enough to establish that the content should be added? ScienceApologist (talk) 19:34, 19 May 2008 (UTC)
  • Concerned Comment The biggest problem I have with this version is that it is being billed as a consensus from the community, but they have not shared in the conversation or the work that has been put in to improve upon the very version they are looking at. There is more work to do, but if you call this a consensus version, it will be virtually impossible to make any more edits - even minor ones - as a particularly eccentric editor will likely take it as his duty to defend the "consensus view from outside editors". So while I can work with anything, nobody can work with the constant reversions to "the RfC version that many outside members have agreed to". So, unless you really like this version, I would rather you suggest that we continue to work together in the manner that WP was meant to work - where anyone can edit anytime and collaboration is the preferred method to accomplish consensus. Let the ones that are working this article decide what the 'best version' is. -- Dēmatt (chat) 00:58, 20 May 2008 (UTC)

Objective straights and reforms

Part of the change added material about objective straight and reform chiropractors, two groups which it's not clear still exist (we don't have good evidence that they exist, and we have weak evidence that they don't). As I recall this was last discussed at the end of the long section Talk:Chiropractic/Archive 18 #Problems with current Effectiveness draft, without a consensus about including the material in Chiropractic#Schools of thought and practice styles. I suggest moving this material to Chiropractic history or perhaps Chiropractic #History; I don't think it'd be controversial there. I removed this material for now, pending further discussion. Eubulides (talk) 20:54, 14 May 2008 (UTC)

I don't think the article needs the material about reform and objective straights, maybe not even in history. I don't think it's very notable.--—CynRN (Talk) 21:20, 14 May 2008 (UTC)
I'm not sure that removing the material was altogether appropriate. I agree that the issue may be one of historical relevance rather than modern day relevance, but I found the material to be informative, interesting, and well-sourced. ScienceApologist (talk) 22:09, 14 May 2008 (UTC)
I don't feel strongly either way. The subject of the reform group especially got discussed ad nauseum on the talk pages a few months ago with no real consensus. History would be the place if it is to be included.--—CynRN (Talk) 22:16, 14 May 2008 (UTC)
OK, for now I moved it to Chiropractic #History. Eubulides (talk) 22:25, 14 May 2008 (UTC)
I prefer the information under Internal conflicts be put at the end of the Schools of thought and practice styles section. QuackGuru 01:07, 15 May 2008 (UTC)
The internal conflicts section is relevant to the schools of thought and practice styles section. The internal conflicts has discussion about the varying thoughts, practices, and beliefs. QuackGuru 08:12, 15 May 2008 (UTC)
Sure, but almost everything in Chiropractic #History is relevant to some other section, and could be moved there. The point is that Chiropractic, by and large, is a discussion of chiropractic as it is today. Stuff that's no longer relevant should be put in Chiropractic #History to avoid cluttering up the rest of the sections with material that used to be true but is no longer true. That's how other historical material is treated, and this particular historical material should be no exception. Eubulides (talk) 02:06, May 15, 2008 (UTC)
I fear that statement reveals a misunderstanding (at least on this point) of Wikipedia. While I agree that purely historical and dated events (IOW no longer, unquestionably, and impossibly current in any manner) should be placed in the history section IF our sources also do so, this happens to be a different matter. Wikipedia articles should NOT limit themselves to the present picture of the subject. It would take alot of OR to achieve this with some things about chiropractic, since many DCs in practice TODAY believe, think, and act as described by what you term "historical" or what CorticoSpinal terms "progressive". Chiropractic today is a very broad spectrum of beliefs and practices, and we shouldn't limit mention of something we believe (or wish) is purely historical to the history section, since it is ALL current practice and belief many places. Ultra straight subluxationism and anti-subluxationism are all very current within the profession. They are all part of "progressive" chiropractic, depending upon one's own personal POV. The struggle for domination is far from over.
There is also a straw man at work here, which you (Eubulides) many not be aware of. Straw men can effectively be used to shoot down unpopular ideas. When this section was first written and later being developed further, the strawman of existence or nonexistence of groups and organizations was constantly being brought up as if it was an issue to this section. It is NOT an issue in this section. This section is about "schools of thought and practice styles". Let me illustrate. Luther is long since dead, but his "school of thought" still exists and is present in Protestantism, and we mention him, his thoughts, and the work of various protestant groups and denominations. Just so here. Even if the only organization that has been officially reform (the NACM) were to cease to exist (it happens to live a quiet existence, as always), it's school of thought is expressed by many chiropractors whose utterances reveal that they share "reform" thoughts and their practices as well. In this context it is OR to engage in speculations about the existence of an organization which is so unlike ordinary organizations that it has usually been relatively quiet and whose membership has been relatively secret. That question is totally irrelevant to this section.
What we need to focus on is: (1) Did that school of thought exist and (2) was it officially the position of one organization? Yes. Unquestionably. (3) Does that school of thought still exist? Unquestionably. That's all we need to know to include mention of the organization, its school of thought, and its role in the profession, past and present. In fact, a substantial portion of the proof of its influence and notability has been provided by its opposition. Notoriety is a pretty powerful form of notability which Wikipedia recognizes. If you want the strongest proof of something, get its enemies to provide it. The testimony of friends can't always be trusted, but the opposition of enemies can certainly be used as evidence. FYI, chiropractors wouldn't have access to VA hospitals today if it hadn't been for the influence of the representative of the NACM on the work committee where access was granted. That's a pretty powerful influence exerted by one little, minority, relatively secret, organization that has been very notably and vocally opposed by the whole profession. [9][10] Although that representative was initially attacked[11] quite viciously, that representative was actually thanked later for his role. Ultra straight organizations had actually opposed the idea. -- Fyslee / talk 04:38, 22 May 2008 (UTC)
Luther is dead, but the Lutheran church is very much alive: I can still call up the Lutheran church and someone will answer the phone. This is not the case for the NACM, by all reports. Let me take that analogy and run with it: Lutheranism only briefly mentions Pietism (in Lutheranism#See also), and this is appropriate. Pietism was formerly a very active branch of Lutheranism, but it's now dead as an organized group: you can't call any Pietist churches on the phone (the Pietists have an indisputable effect on current teachings of some Lutherans, but they're no longer active). In contrast, Lutheranism does mention the differences between reformism and confessionalism, an important and active distinction among Lutherans: one can currently call up the reformists and someone will answer the phone, and likewise for the confessionalists, and it's entirely appropriate to cover that as a current issue.
In that sense, I don't see any reliable evidence cited showing that reformers are still active. Their work may have influenced current thought (just as Pietists influenced current Lutheran thought), but outside the History section Chiropractic should cover current thought, not the historical influences. Eubulides (talk) 08:35, 22 May 2008 (UTC)
You're missing the point, which is that it doesn't make any difference if the organization is active or not. The school of thought and practice style (anti-subluxation) is very much alive. Those who express such views are reform chiropractors. -- Fyslee / talk 14:16, 22 May 2008 (UTC)
I agree with this. -- Dēmatt (chat) 13:10, 23 May 2008 (UTC)
If we can find reliable sources showing that anti-subluxation is very much alive now, then I agree that should be included in the school-of-thought section. But it should be called "anti-subluxation", not "reform", no? Eubulides (talk) 16:58, 22 May 2008 (UTC)
It's not anti-subluxation per se, but pro-mainstreaming (which means they think chiropractors must drop their garb). -- Dēmatt (chat) 13:12, 23 May 2008 (UTC)
OMG is "garb" not just the perfect word for it! We should write for living! -- Dēmatt (chat) 13:16, 23 May 2008 (UTC)


Unless something has changed since previous consensus existed that there was not sources to believe these groups still exist, they should ONLY be placed in the history section. I for one believe that reform chiropractors DO exist, they just don't use the name "reform chiropractors" - but alas, without the name, it is hard to find sources that back that up. In that sense, I guess they are just at the end of the ideological spectrum of mixers.DigitalC (talk) 00:21, 16 May 2008 (UTC)

Effectiveness and Cost-benefit sections

Both of these section were added without a consensus. They are still a lot of discussion about the wording and even about whether or not to add these sections at all. To me, this (and the addition of the Objective straight and Reform) were the most egregious of the mass edits and most in need of being removed. -- Levine2112 discuss 21:42, 14 May 2008 (UTC)

There's an RfC currently in the works. Most of the people commenting seem to think that the edits including these bits were good. You are free to explain exactly what your objections are, but I don't think removal at this time is appropriate. ScienceApologist (talk) 22:10, 14 May 2008 (UTC)
The RfC was about effectiveness, not about cost-benefit. The cost-benefit section was added without any discussion, which is not a good idea for a controversial article like this. Also, the effectiveness section that was added was not the effectiveness section that was proposed. For now, I reverted to what was proposed and copied the undiscussed stuff to the next subsection. Eubulides (talk) 23:44, 14 May 2008 (UTC)
The new RFC was linked to the recent edits. I see growing consensus to include the information from the comments in the new RFC. QuackGuru 01:07, 15 May 2008 (UTC)
Calling a consensus again when there is no such consensus?DigitalC (talk) 04:18, 15 May 2008 (UTC)
There is broad consensus among external observers in the new RFC which is to be respected. QuackGuru 04:26, 15 May 2008 (UTC)
Again, I disagree that the external observers have a consensus about (or even noticed) the previously-undiscussed changes in that edit. Eubulides (talk) 06:09, 15 May 2008 (UTC)

Several important changes were never discussed

The edit contains several important changes that were never discussed on the talk page. Some of them are quite likely controversial. Please discuss changes like these before putting them in. For now I removed the undiscussed changes and list them below for further comment. Eubulides (talk) 23:33, 14 May 2008 (UTC)

  • The following text was added to the discussion of the British Medical Association:
'In 1997, the BMA has identified chiropractic health care that can be regarded as "discrete clinical disciplines" because it has "established foundations of training and have the potential for greatest use alongside orthodox medical care."[56]'
  • The new Cost-benefit section was never discussed. I enclose it below, for further discussion. Please put comments in #Comments on Cost-benefit 1 below.

Eubulides (talk) 23:33, 14 May 2008 (UTC)

The RFC was about all of my recent edits. QuackGuru 01:07, 15 May 2008 (UTC)
The external observers commented about the overall edit, most of which had been discussed earlier. There's no evidence that the observers noticed, much less approved of, the changes that were slipped into that edit without any previous discussion. The only comments they made were about the changes that had been discussed earlier. It is contrary to common practice on this page to install major, potentially-controversial changes without any discussion on the talk page. Please discuss these changes in the relevant sections of this talk page, now that the sections have been created. Eubulides (talk) 06:48, 15 May 2008 (UTC)
The external observers were commenting on this recent change. We have discussion from third-party input. Uninvolved Wikipedians did discuss my recent change in the new RFC. QuackGuru 07:08, 15 May 2008 (UTC)
Most of what you are calling "my recent change" consisted of material that had been previously discussed. The uninvolved Wikipedians commented on the entire edit, and could easily have been fooled (by the way earlier discussion occurred) into thinking that the edit was installing what had been discussed. None of the comments by the uninvolved Wikipedians indicate that they read, understood, or agreed with the not-previously-discussed part of the change. It is poor practice to take a proposed edit which has had a lot of discussion, to make unannounced and important changes to it, and to install the changed edit without bothering to notify people that the edit involves undiscussed changes. I cannot emphasize this enough. Major changes need to be discussed first, before installing them; that is the standard procedure on this page, and it's standard procedure for good reason. Eubulides (talk) 09:15, 15 May 2008 (UTC)
There is absolutely NO indication that any of the RfC respondents were fooled. This is pure obstructionism. I will assume good faith and simply ask you to abide by the new consensus that the additions are good and needed in the article. There is no policy or guideline that says someone has to discuss first. One can discuss after the changes are made. That is being done here. The current consensus is to keep the changes. Please also stop making up rules for editing. Your cooperation is appreciated. Thanks. ScienceApologist (talk) 14:39, 15 May 2008 (UTC)
  • There is no evidence that the RfC respondents read or understood the not-previously-discussed changes. None of the RfC respondents have responded to the substance of the subsequent criticism of the not-previously-discussed changes; this appears in many sections on the talk page, including #Comments on Cost-benefit 1, #Sorry to stop by in the middle of a POV war, and #Objective straights and reforms.
  • So it is not true that "the current consensus is to keep the changes"; there may have been a consensus at the point the previously-undiscussed changes were made, but now that problems have been pointed out with those changes, the consensus, if there was one, is no longer present.
  • Your revert to an old state ignored discussion that occurred after the "new consensus" (see, for example, #Sorry to stop by in the middle of a POV war). This discussion resulted in several improvements in wording in citation to the material, improvements that have not been disputed, and thus your revert lost this useful information. Please do not ignore later discussion, and please do not blindly revert and inadvertently remove later improvements.
Eubulides (talk) 16:14, 15 May 2008 (UTC)
  • One other thing: I am not "making up rules for editing". The top of this talk page says "This is a controversial topic that may be under dispute. Please read this page and discuss substantial changes here before making them." This is a good rule, and should in general be followed. It was not followed for the previously-undiscussed changes. It is bad procedure to install changes into a controversial article without discussing them first. Eubulides (talk) 16:17, 15 May 2008 (UTC)
One thing is for sure, there is clearly no consensus to add these edits. It is truly a mystery why these editors are claiming that there is a consensus when so many editors disagree with these edits. -- Levine2112 discuss 19:32, 15 May 2008 (UTC)
Consensus is established above. ScienceApologist (talk) 17:11, 18 May 2008 (UTC)
I don't think so, SA. The question of validity still has not been addressed; i.e. why are Eubulides et QuackGuru trying to push an WP:SYN of SMT and pass it off as effectiveness of chiropractic. What is the effectiveness of medicine, dentistry and maybe more appropriately, physical therapy? If you can provide a sound rationale that would be helpful. CorticoSpinal (talk) 19:21, 18 May 2008 (UTC)
You are confused about what consensus is. Please read up on Wikipedia policies and guidelines. ScienceApologist (talk) 19:25, 19 May 2008 (UTC)
  • Concerned Comment The biggest problem I have with this version is that it is being billed as a consensus from the community, but they have not shared in the conversation or the work that has been put in to improve upon the very version they are looking at. There is more work to do, but if you call this a consensus version, it will be virtually impossible to make any more edits - even minor ones - as a particularly eccentric editor will likely take it as his duty to defend the "consensus view from outside editors". So while I can work with anything, nobody can work with the constant reversions to "the RfC version that many outside members have agreed to". So, unless you really like that version, I would rather you suggest that we continue to work together in the manner that WP was meant to work - where anyone can edit anytime and collaboration is the preferred method to accomplish consensus. Let the ones that are working this article decide what the 'best version' is. -- Dēmatt (chat) 00:58, 20 May 2008 (UTC)

Cost-benefit 1

The benefits of chiropractic care seem to outweigh the involved risk.[57] The cost-effectiveness of SMT has not been demonstrated beyond a reasonable doubt.[36] However, spinal manipulation for the lower back appears to be relatively cost-effective.[58] Of the various interventions available, the most cost-effectiveness treatment for lower back pain could not be determined from the limited research available.[59] The data indicates that SM therapy typically represents an additional cost to conventional treatment.[60] Due to SM's popularity, higher quality research into the risk-benefit is recommended.[61] Preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care after an initial therapy.[62] When compared with treatment options such as physiotherapeutic exercise, the risk-benefit balance does not favor SM.[63] The small risk associated with manipulation of the cervical spine could be avoided with the use of nonthrust passive mobilization movements.[64] There is no evidence that SM is superior to other treatment options available for patients with low back pain.[65] In occupational low back pain, shorter chiropractor care had a benefit for reducing work-disability recurrence and longer chiropractic care did not show a benefit for preventing work-disability recurrence when analyzing tha data from workers' compensation claims data.[66] SM helps to reduce time lost due to workplace back pain, and thus employer savings.[67]

Comments on Cost-benefit 1

(Please put comments here.) Eubulides (talk) 23:33, 14 May 2008 (UTC)

  • First comment is that any SM should be changed to SMT. I changed the first thinking it was a typo. This is going to run into similar problems as effectiveness, where the sources are talking about the cost-effectiveness of SMT, not the cost-effectiveness of chiropractic.DigitalC (talk) 00:02, 15 May 2008 (UTC)
  • If There is no evidence that SM is superior to other treatment options available for patients with low back pain.is to be included, it should be changed to There is no evidence that SMT is either superior or inferior to other treatment options available for patients with low back pain. In accordance with the following quote from the conclusion of the article "Neither did we find evidence that these therapies are superior to spinal manipulative therapy.". However, this source is not EVEN on cost effectiveness of SMT, it is on effectiveness of SMT, and as such should not be in this section.
  • after an initial therapy. is grammatically incorrect. After initial therapy, or after an intiial treatment would be grammatically correct.
  • When compared with treatment options such as physiotherapeutic exercise, the risk-benefit balance does not favor SM. Again, this falls into the trap of assuming that this is Cost-benefit of SMT, and not Cost-benefit of Chiropractic. Chiropractors use physiotherapeutic exercise as a treatment.
  • The small risk associated with manipulation of the cervical spine could be avoided with the use of nonthrust passive mobilization movements. This one is a POV statement, and I will have to search for a source the backs that it is POV. From my understanding the risk is the same for any grade of mobilization. DigitalC (talk) 00:49, 15 May 2008 (UTC)
Actually, the research suggests that manipulation and mobilization carry the same risk. In fact, the same risk as performing a cervical range of motion exam. So not only is it POV, it's not accurate. Is there a reference for it? -- Dēmatt (chat) 03:43, 15 May 2008 (UTC)
Yes, it is referenced, but I agree with you that research suggests that any movement of the cervical spine carries the same risk.DigitalC (talk) 04:10, 15 May 2008 (UTC)

I am pretty much against the majority of the content which Quackguru added. . . moreover I am petrubed by the manner in which it was added. Discussion about Reformers should be removed. . . along with the contentious efficacy and research section.TheDoctorIsIn (talk) 01:03, 15 May 2008 (UTC)

I feel there are severe limitation still in this version although there is undoubtedly some good to it too. We can work with this and make it much better and more relevant, however. The validity some of the information presented here is highly suspect and there are major omissions still. For example, scientific research into chiropractic has been done by chiropractors, believe it or not, since the 1920's. I thought we are supposed to be discussing scientific investigation of chiropractic care, not SMT. They're not the same. What about the NIH study? That was a landmark one in 1976. The New Zealand study in 1979? The Meade study, the Rand study, etc? These are all SPECIFIC to CHIROPRACTIC CARE. Just because they're old doesn't mean that their invalid. The Crick and Watson paper (1955) after all, is holding up well. Also, there has been some pretty bad cherry picking that is either a violation of WP:POINT or WP:COATRACK. If our allopathic editors want to play that game, we can have a tit for tat war with inserting trivial facts that present the OTHER POV. For example, the addition of the "Canadian DCs don't know how to research" is a bit over the top. This study was done in the province of ALBERTA representing less than 15% of Cdn DCs most of whom graduated when the EBM era hadn't arrived. There are more examples, but I must go back to work. Too bad these edits had been railroaded in, and supported blindly by the usual suspects. Also, Fill -- your comment was in poor taste. If you think the Citizendium article with it's lead (with a direct quote taken from 1966) applies here, you're not up with the times. Also, the medical community here is editing against the evidence which I find distressing. Lastly, Ernst is being used throughout this article to negate, trump or override the sound opinion of EXPERTS in SMT and EFFECTIVE and CHIROPRACTIC CARE. This practice must stop. CorticoSpinal (talk) 16:58, 15 May 2008 (UTC)
  • The current version emphasizes scientific investigation of chiropractic care. This inevitably means heavy coverage of SMT, since SMT is a core component of that care.
  • If an old study is truly landmark it can be expected to affect current reviews. If not, then we shouldn't be mentioning it ourselves. We should rely on expert opinion as to what is important and what is not. We should not be making those calls ourselves, when the expert opinion is already available.
  • No, and SmithBlue told you this already. If the purpose of the review is not congruent with the given topic, the review is not valid and should not be used. DCs would consider Manga to be landmark, MDs not so much. So we are to rely on MD reviews? CorticoSpinal (talk) 22:18, 16 May 2008 (UTC)
  • SmithBlue's argument, while valid, is not a get-out-of-jail-free card that will let an editor ignore a review whenever they please. It requires a good reason that the review is not congruent with the given topic. No reason has been advanced for any of the reviews cited in Chiropractic, so in no case has there been any justification for ignoring expert reviews and reaching down into the reviewed sources. Eubulides (talk) 07:35, 19 May 2008 (UTC)
  • I agree that reaching down and inserting trivial facts from primary studies is not the way to go. If that exists in Chiropractic now, we should fix it.
  • The "Canadian DCs" stuff has been removed (for now; until someone reverts it again, I suppose). That stuff is contentious and was not discussed before inserting. I agree that it is potentially controversial and deserves careful review first.
  • Many (most?) cites to Ernst are not to things that override expert chiropractors. The exceptions are marked as such (e.g., "a critical review"). At least, that's the intent; if there are problems in this area then let's please discuss fixes.
19:18, 15 May 2008 (UTC)
  • Ernst is pushed on every single CAM article and although his opinion is certainly notable (that's NEVER been debated) the weight, tone and influence of his words, especially in chiropractic has been a huge problem since he was pushed onto the scene in Feb 08. Mainstream doesn't even agree with his views on SMT, this is illustrated with the American College of Physicians recommending SMT for LBP whereas Ernst still says its "dangerous" with "no proven beyond a resonable doubt" and "adds costs". Essentially, all his statements are in direct conflict with bulk the mainstream literature. His star is fading as he continues his witch hunt and if he's reading this I think he's a massive douche bag and the quality of his papers re: chiropractic care are by far the most biased, unbalanced, unobjective and misleading ones out there. He should take a cue from Kaptchuk (1998) who can raise concerns but present both sides. CorticoSpinal (talk) 22:18, 16 May 2008 (UTC)
  • There is certainly a difference of opinion in mainstream medicine about the effectiveness of SMT. The American College of Physicians does not "recommend" SMT for LBP; it lists it as a "likely effective" therapy, along with massage therapy, acupuncture, willow bark extract, and devil's claw.[12] There is substantial disagreement among low back pain guidelines, with some of them agreeing more with Ernst and some agreeing more with chiropractors (see Murphy et al. 2006, PMID 16949948). It is highly misleading to cite just one group in this area and to pretend that it is the final word, and Chiropractic should fairly represent all sides, including both the skeptics and the proponents of chiropractic. Eubulides (talk) 07:35, 19 May 2008 (UTC)

Manipulation of the cervical spine (MCS) is used in the treatment of people with neck pain and muscle-tension headache. The purposes of this article are to review previously reported cases in which injuries were attributed to MCS, to identify cases of injury involving treatment by physical therapists, and to describe the risks and benefits of MCS. One hundred seventy-seven published cases of injury reported in 116 articles were reviewed. The cases were published between 1925 and 1997. The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases. Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists. Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements). The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed.

Here is the abstract from the Di Fabio RP ref. The risk can be avoided with the use of mobilization (nonthrust passive movements). Thanks. QuackGuru 04:23, 15 May 2008 (UTC)

As above, yes you have a source for it. However, it is POV, in that other sources state that the risk is the same for manipulation, mobilzation, range of motion examination, and shoulder-checking while driving.DigitalC (talk) 05:15, 15 May 2008 (UTC)
Please provide a list of other sources. QuackGuru 05:21, 15 May 2008 (UTC)
Please see Anderson-Peacock E, Blouin JS, Bryans R; et al. (2005). "Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash" (PDF). J Can Chiropr Assoc. 49 (3): 158–209. PMC 1839918. PMID 17549134. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
 • we deem that where it is the mere movement of neck tissues that causes a risk factor to be an absolute contraindication to an HVLA thrust, manipulation that is not HVLA or mobilization are equally contraindicated by this factor, see also Rome P.L. “Perspectives: An Overview of Comparative Considerations of Cerebrovascular Accidents”, Chiropractic Journal of Australia 1999; 29(3): 87-102, as well as Terrett A.G. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation. Des Moines, Iowa: National Chiropractic Mutual Insurance Company, 2001. DigitalC (talk) 05:38, 15 May 2008 (UTC)
The word however was added to a sentence. I do not see any reason for this. QuackGuru 07:52, 15 May 2008 (UTC)
"However" is a connecting adverb meaning "nevertheless, in spite of that, etc". "However" used correctly in a sentence will suggest that that sentence disagrees in sense somewhat with the preceeding sentence(s). In this case, it was used to tie two sentences together to improve flow, so that it wasn't so choppy.DigitalC (talk) 00:39, 19 May 2008 (UTC)

I have not yet had time for a detailed review of #Cost-benefit 1 (I've been tied up with the aftermath of the recent Effectiveness changes) but here is a quick first reaction:

  • It's much improved from #Cost-benefit 0, but still needs quite a bit of work.
  • It refers directly to many primary studies. It should focus instead on what recent reviews say, e.g., van der Roer et al. 2005 (PMID 15949783), Canter et al. 2006 (PMID 17173105), Cherkin et al. 2003 (PMID 12779300). Primary sources should be used only with good reason (e.g., if they're too new to be reviewed and are obviously important). Eubulides (talk) 09:00, 15 May 2008 (UTC)
  • Isn't Assendelft et al. 2003 (PMID 12779297) superseded by Assendelft et al. 2004 (PMID 14973958). Why cite the obsolescent source?
  • Let's stay away sources older than 5 years old. They're too dated. If a subject hasn't been reviewed in the past 5 years, then it's probably not worth summarizing here.
This makes no sense. Historically chiropractic care has been shown to be cost effective, why ignore the data? There's a reason why DCs SPECIFICALLY have been invited to participate in integrative models of care. Result? Less costs again. CorticoSpinal (talk) 17:03, 15 May 2008 (UTC)
Again, there is no intent to ignore old data. If old data is still important, it should appear in a recent review. If it doesn't appear, that's good evidence that it wasn't that important after all, at least according to published expert reviewers. Eubulides (talk) 19:18, 15 May 2008 (UTC)
Again, you are missing the point regarding the validity of some of the reviews. Let me paraphrase, again, what SmithBlue and myself have been telling you for quite some time now: if the purpose of the review is not congruent with the topic at hand, then it is not valid. There are severe logical flaws in your reasoning and you've used the same excuse for 4 months to keep out extremely reliable and valid "primary" studies that are far more valid and academically robust than some of the reviews supported by yourself. A refusal to include studies which meets WP:RS, WP:V and are from indexed peer-reviewed journals will forever prevent from making this article NPOV. CorticoSpinal (talk) 23:18, 16 May 2008 (UTC)
No argument has been put forth that the reviews in question are incongruent with the topic at hand. On the contrary, the reviews are quite congruent with the topic of effectiveness. There is no good reason to disregard reliable reviews and to substitute our own opinion about the the reviewed studies. Eubulides (talk) 07:35, 19 May 2008 (UTC)
  • The text flows poorly. Contradictory sentences are run together without any explanation. The text needs to tell a consistent story and hang together; currently it doesn't do that well at all.

Eubulides (talk) 09:00, 15 May 2008 (UTC)

And yet, attempts to make it flow better are met with objection.DigitalC (talk) 00:02, 16 May 2008 (UTC)
I have updated the cost-benefit section. It flows very well now. QuackGuru 15:43, 23 May 2008 (UTC)

Cost-Benefit of Chiropractic Care 2a: Work in Progress

The benefits of chiropractic care seem to outweigh the involved risk.[68] A 2007 retrospective analysis of 70,274 member-months in a 7-year period within an IPA, comparing medical management to chiropractic management, demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance. This clearly demonstrates that chiropractic nonsurgical nonpharmaceutical approaches generates reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone. [69] For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs . This effect was greater on a per-episode basis than on a per-patient basis. [70] Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction. Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain. [71] A 4-year retrospective claims data analysis comparing more than 700,000 health plan members within a managed care environment found that members had lower annual total health care expenditures, utilized x-rays and MRIs less, had less back surgeries, and for patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399). The authors concluded: "Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care." [72] In occupational low back pain, shorter chiropractor care had a benefit for reducing work-disability recurrence and longer chiropractic care did not show a benefit for preventing work-disability recurrence when analyzing tha data from workers' compensation claims data.[73] In 2004, Workmans Compensation evaluated the effectiveness and cost-effectiveness of chiropractic care for acute low back injuries and demonstrated that chiropractic care was superior to physical therapy in reducing pain, inproving perceived disability, and lost work time (9 days for chiropractic care in comparison to 20 days for physiotherapy). [74]. This is in general agreement with previous Workmans Compensation analyses' which chiropractic care is equal or superior to standard medical care. [citation needed] A 1999 Medicare study revealed that "The results strongly suggest that chiropractic care significantly reduces per beneficiary costs to the Medicare program. The results also suggest that Chiropractic services could play a role in reducing costs of Medicare reform and/or a new prescription drug benefit."[75] A demonstration project regarding an expansion of coverage of chiropractic services was launched in 2005. Under this demonstration project, chiropractors will be allowed to bill medical, radiology, clinical lab and certain therapy services related to the treatment of neuromusculoskeletal conditions. [76]

Comments of Cost-effectiveness 2a

Before I get hounded, this is a very quick draft; it is by no means complete and I will integrate the best of QGs draft into when I have a bit more time. There are tons of workmans comp studies to include but the bulk of them say chiropractic care (for NMS disorders) is cost effective and patients prefer it to standard medical care (don't know if PT is included in this or not, we should find out so we don't lump in PT care with med if appropriate). The preliminary results of the just completed Chiropractic Medicare Demonstration project in the US shows this trend continues, but I'm willing to simply state there's been a cost-effectiveness and effectiveness project done by the DoD, Medicare and DVA in the US to determine the merits of integrating chiropractic care into managed, governmental programs. St-Mikes deserves a mention too; I think its the first hospital in North America to have permanent inclusion of DCs on staff who are fully integrated (i.e. full time employee status). I'm not quite sure of the situation in the US; although I do know there is a small, but increasing # of DCs who have hospital privileges. The trend is that this is increasing too. CorticoSpinal (talk) 22:53, 16 May 2008 (UTC)

This draft relies on primary studies when it should rely on reliable reviews. For cost-effectiveness we have enough high-quality reviews that there's no need to reach down into primary studies ourselves. Chiropractic's current cost-benefit section is bad enough, but at least it cites some reviews relatively fairly; this proposed 2a replacement is far worse in that regard. Eubulides (talk) 07:35, 19 May 2008 (UTC)
Well, it certainly appears thorough. I'll have to check the sources as Eubilides suggests, but it's a start. BTW, I haven't quite found my way around this talk page, so if there is something that is no longer of any use, how about archiving it so I don't strike up another conversation about something that is already settled. -- Dēmatt (chat) 19:41, 20 May 2008 (UTC)
  • It's the "appears thorough" that worries me. By citing primary sources in addition to the secondary reviews, it's making the evidence appear stronger than it is, or it is arguing with the reviews (I don't know which, as I haven't had time to read all that stuff). Either way, it should be fixed, preferably by dropping citations to the primary sources (I don't see why they're needed, but again I haven't read the sources yet).
  • Currently we're relying on auto-archiving; the page is getting a tad big to navigate through (or archive) by hand.
Eubulides (talk) 22:16, 20 May 2008 (UTC)
So, you haven't investigated the sources but object to them? Stop trying to omit valid studies that aren't covered by reviews. Geez, how many times in 4 months can you use the same argument, over and over again with many different editors disagreeing with the way you interpret MEDRS? CorticoSpinal (talk) 18:28, 21 May 2008 (UTC)
Has anybody actually read the sources? So far, I see no evidence that anybody has. As far as I can tell, this cost-effectiveness draft was generated by someone who read only the abstracts. Someone (and it will probably be me, sigh) will have to actually read the sources. I am skeptical that there will be any need to cite the primary sources, because I expect that review will cover the material in question. Eubulides (talk) 20:13, 21 May 2008 (UTC)
I've read the sources used in the draft. The claims are supported by the literature. Many of the papers are interdisciplinary collaboration, between DCs and MDs. So, a lot of bias goes out the window there. If we can find reviews that addresses all the points made above then obviously we can choose a review, however I doubt that one review will cover all the specific points. Tertiary sources such as governmental studies could be used as well. CorticoSpinal (talk) 23:23, 21 May 2008 (UTC)

By "reading the sources" I do not mean just reading the abstracts. I mean reading the entire papers. I still don't see any evidence that anybody has actually read the sources. Eubulides (talk) 08:35, 22 May 2008 (UTC)

I haven't read all the sources either, but I have now read the draft, and it is far inferior to what's in Chiropractic#Cost-benefit, a section that itself is not that strong. We'd be better off starting from the existing section than from this draft. Here are some specific comments. Some of these comments also apply to Chiropractic#Cost-benefit (as some of the text is in common).

  • The most important complaint is that this section consists entirely of cites to primary studies. It should rely on reliable reviews where these are available. It should lead with the results from reviews, and should fill in with primary studies only when necessary. Currently it does just the opposite: it leads with primary studies, and emphasizes their results, and doesn't report reviews. This is backwards from what WP:MEDRS recommends, and means that there is all-too-great opportunity for our bias to leak into the text.
  • "The benefits of chiropractic care seem to outweigh the involved risk." This is just a primary study, and should not be the lead sentence in the section. Also, the cited source does not talk about chiropractic care in general, just about chiropractic care for neck pain. Also, this relies on a single primary study and should say so. A better summary would be "A 2007 Dutch study found that the benefits of chiropractic care for neck pain seems to outweigh the involved risk." but this summary should not be used to lead the section. Eubulides (talk) 08:35, 22 May 2008 (UTC)
  • "A 2007 retrospective analysis of 70,274 member-months in a 7-year period within an IPA, comparing medical management to chiropractic management, demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance. This clearly demonstrates that chiropractic nonsurgical nonpharmaceutical approaches generates reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone." Again, this is a primary study and should not be emphasized so strongly, at the start. The second "clearly demonstrates" sentence is POV and is not supported by the source. The source's conclusion makes it clear that these results are for one IPA and may or may not generalize to others. The first sentence is way too long, given that it's summarizing just one primary study. The study is just about costs, not cost-benefit, and as such is of limited use in this section. I suggest creating a new section Cost for material like this.
  • "For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs . This effect was greater on a per-episode basis than on a per-patient basis." Again, this is just one primary study. This is a direct and extended quote from the abstract, without quote marks, and as such is too close to being a copyright violation for comfort. The study is just about cost, not cost-benefit, so it'd be more appropriate for a Cost section.
  • "Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction. Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain." Again, this is simply quoting the abstract from a single primary study; we can't do that. Somehow the quote managed to skip around the fact that this study found that chiropractic care costs were higher. This study is rarely cited elsewhere (I checked Google Scholar) and is suspect for that reason.
  • "A 4-year retrospective claims data analysis comparing more than 700,000 health plan members within a managed care environment found that members had lower annual total health care expenditures, utilized x-rays and MRIs less, had less back surgeries, and for patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399). The authors concluded: "Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care." This is a higher-quality primary study, but there's way too much here for Chiropractic. Again, this is a copyright violation. Again, this is just a primary study; we should be focusing on the reviews.
  • "In occupational low back pain, shorter chiropractor care had a benefit for reducing work-disability recurrence and longer chiropractic care did not show a benefit for preventing work-disability recurrence when analyzing tha data from workers' compensation claims data." Again, this is just citing a single primary study; here there is a bit more excuse for citing it (it's too recent to be reviewed) but the wording could be shortened quite a bit without harming this dicussion.
  • The remaining text is supported by lower quality studies (some not peer-reviewed, some older) and I won't bother to review it here now.
  • In short, this is a real step down in quality from what is in Chiropractic now. At least the current version cites three reviews and summarizes their results. This draft ignores the reviews. There is a great deal of possible bias inherent in going out and reviewing primary sources ourselves. We should resist that temptation by relying on reliable reviews whenever possible, as is largely the case here.

Eubulides (talk) 08:35, 22 May 2008 (UTC)

Your concerns of bias do not ring true. It is YOUR source, a secondary source nonetheless that has been demonstrated to be very biased and have severe design flaws. None of the primary studies cited have this deficiency. In other words, the review that is currently included is not valid and has been refuted but it being given a free ride despite the fact it's been rebutted. It's not a quality paper. You should resist the temptation of citing crap reviews that conform to your personal POV and goes against mainstream consensus. Yes, that's correct, Ernst's conclusions on SMT and chiropractic care goes against mainstream consensus. Which makes his opinion fringe. And his studies are flawed, so now we are citing flawed, fringe material as fact with 0 qualifiers. Is this the kind of "NPOVing" you want to bring to the article? CorticoSpinal (talk) 23:43, 26 May 2008 (UTC)
Wikipedia is not the place to conduct research reviews on our own, overriding reviews already published by experts in the field. Multiple reviews are cited in Chiropractic #Cost-benefit; they are not all by Ernst. Other reliable review sources are welcome, as per the usual WP:MEDRS guidelines. Reaching down into primary studies is dubious; Chiropractic #Cost-benefit already does way too much of this (and this should be fixed). Rewriting it to remove all mention of reviews, which is what is being proposed here, would be a step that is way, way in the wrong direction. Eubulides (talk) 08:08, 27 May 2008 (UTC)

References

  1. ^ a b c d e f g Villanueva-Russell Y (2005). "Evidence-based medicine and its implications for the profession of chiropractic". Soc Sci Med. 60 (3): 545–61. doi:10.1016/j.socscimed.2004.05.017. PMID 15550303.
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  9. ^ Quality of SMT studies:
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  16. ^ a b Vernon H, Humphreys BK (2007). "Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews" (PDF). Eura Medicophys. 43 (1): 91–118. PMID 17369783.
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  19. ^ Haneline MT (2005). "Chiropractic manipulation and acute neck pain: a review of the evidence". J Manipulative Physiol Ther. 28 (7): 520–5. doi:10.1016/j.jmpt.2005.07.010. PMID 16182027.
  20. ^ Bronfort G, Nilsson N, Haas M; et al. (2004). "Non-invasive physical treatments for chronic/recurrent headache". Cochrane Database Syst Rev (3): CD001878. doi:10.1002/14651858.CD001878.pub2. PMID 15266458. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
  21. ^ Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA (2006). "Are manual therapies effective in reducing pain from tension-type headache?: a systematic review". Clin J Pain. 22 (3): 278–85. doi:10.1097/01.ajp.0000173017.64741.86. PMID 16514329.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  23. ^ McHardy A, Hoskins W, Pollard H, Onley R, Windsham R (2008). "Chiropractic treatment of upper extremity conditions: a systematic review". J Manipulative Physiol Ther. 31 (2): 146–59. doi:10.1016/j.jmpt.2007.12.004. PMID 18328941.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  24. ^ Hoskins W, McHardy A, Pollard H, Windsham R, Onley R (2006). "Chiropractic treatment of lower extremity conditions: a literature review". J Manipulative Physiol Ther. 29 (8): 658–71. doi:10.1016/j.jmpt.2006.08.004. PMID 17045100.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  28. ^ Glazener CM, Evans JH, Cheuk DK (2005). "Complementary and miscellaneous interventions for nocturnal enuresis in children". Cochrane Database Syst Rev (2): CD005230. doi:10.1002/14651858.CD005230. PMID 15846744.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  31. ^ Kaptchuk TJ (2002). "The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance?" (PDF). Ann Intern Med. 136 (11): 817–25. PMID 12044130.
  32. ^ Meeker WC, Haldeman S (2002). "Chiropractic: in response" (PDF). Ann Intern Med. 137 (8): 702.
  33. ^ DeVocht JW (2006). "History and overview of theories and methods of chiropractic: a counterpoint". Clin Orthop Relat Res. 444: 243–9. doi:10.1097/01.blo.0000203460.89887.8d. PMID 16523145.
  34. ^ Kaptchuk TJ (2002). "The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance?" (PDF). Ann Intern Med. 136 (11): 817–25. PMID 12044130.
  35. ^ Leboeuf-Yde C, Hestbaek L (2008). "Maintenance care in chiropractic - what do we know?" (PDF). Chiropr Osteopat. 16 (1): 3. doi:10.1186/1746-1340-16-3. PMC 2396648. PMID 18466623.{{cite journal}}: CS1 maint: unflagged free DOI (link)
  36. ^ a b c Ernst E (2008). "Chiropractic: a critical evaluation". J Pain Symptom Manage. 35 (5): 544–62. doi:10.1016/j.jpainsymman.2007.07.004. PMID 18280103.
  37. ^ Haneline MT (2005). "Chiropractic manipulation and acute neck pain: a review of the evidence". J Manipulative Physiol Ther. 28 (7): 520–5. doi:10.1016/j.jmpt.2005.07.010. PMID 16182027.
  38. ^ McHardy A, Hoskins W, Pollard H, Onley R, Windsham R (2008). "Chiropractic treatment of upper extremity conditions: a systematic review". J Manipulative Physiol Ther. 31 (2): 146–59. doi:10.1016/j.jmpt.2007.12.004. PMID 18328941.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  39. ^ Hoskins W, McHardy A, Pollard H, Windsham R, Onley R (2006). "Chiropractic treatment of lower extremity conditions: a literature review". J Manipulative Physiol Ther. 29 (8): 658–71. doi:10.1016/j.jmpt.2006.08.004. PMID 17045100.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  40. ^ Everett CR, Patel RK (2007). "A systematic literature review of nonsurgical treatment in adult scoliosis". Spine. 32 (19 Suppl): S130–4. doi:10.1097/BRS.0b013e318134ea88. PMID 17728680.
  41. ^ Biondi DM (2005). "Physical treatments for headache: a structured review". Headache. 45 (6): 738–46. doi:10.1111/j.1526-4610.2005.05141.x. PMID 15953306.
  42. ^ Kingston H (2007). "Effectiveness of chiropractic treatment for infantile colic". Paediatr Nurs. 19 (8): 26. doi:10.7748/paed2007.10.19.8.26.c8646. PMID 17970361.
  43. ^ Glazener CM, Evans JH, Cheuk DK (2005). "Complementary and miscellaneous interventions for nocturnal enuresis in children". Cochrane Database Syst Rev (2): CD005230. doi:10.1002/14651858.CD005230. PMID 15846744.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  44. ^ Sarac AJ, Gur A (2006). "Complementary and alternative medical therapies in fibromyalgia". Curr Pharm Des. 12 (1): 47–57. PMID 16454724.
  45. ^ Evans, W. (2003). "Chiropractic Care: Attempting A Risk-benefit Analysis". American Journal of Public Health. 93 (4): 522–3, author reply 523. PMC 1447775. PMID 12660182. Retrieved 2008-05-20.
  46. ^ Bronfort, G. (2006). "Review conclusions by Ernst and Canter regarding spinal manipulation refuted". Chiropractic & Osteopathy. 14 (1): 14. doi:10.1186/1746-1340-14-14. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: unflagged free DOI (link)
  47. ^ Hurwitz, E.L. (2002). "Chiropractic care: a flawed risk-benefit analysis?". Am J Public Health. 92 (10): 1603–4. PMC 1447777. PMID 12660183. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  48. ^ Morley, J. (2001). "Ernst Fails to Address Key Charges". The Journal of Alternative & Complementary Medicine. 7 (2): 127–128. doi:10.1089/107555301750164145. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  49. ^ "Profession Responds Quickly to Negative U.K. Study on Spinal Manipulation". Retrieved 2008-05-20.
  50. ^ DeVocht JW (2006). "History and overview of theories and methods of chiropractic: a counterpoint". Clin Orthop Relat Res. 444: 243–9. doi:10.1097/01.blo.0000203460.89887.8d. PMID 16523145.
  51. ^ Kaptchuk TJ (2002). "The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance?" (PDF). Ann Intern Med. 136 (11): 817–25. PMID 12044130.
  52. ^ Meeker WC, Haldeman S (2002). "Chiropractic: in response" (PDF). Ann Intern Med. 137 (8): 702.
  53. ^ Kaptchuk TJ (2002). "The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance?" (PDF). Ann Intern Med. 136 (11): 817–25. PMID 12044130.
  54. ^ Meeker WC, Haldeman S (2002). "Chiropractic: in response" (PDF). Ann Intern Med. 137 (8): 702.
  55. ^ DeVocht JW (2006). "History and overview of theories and methods of chiropractic: a counterpoint". Clin Orthop Relat Res. 444: 243–9. doi:10.1097/01.blo.0000203460.89887.8d. PMID 16523145.
  56. ^ Chapman-Smith DA (1997). "Legislative approaches to the regulation of the chiropractic profession". Med Law. 16 (3): 437–49. PMID 9409129.
  57. ^ Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW (2007). "The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study". J Manipulative Physiol Ther. 30 (6): 408–18. doi:10.1016/j.jmpt.2007.04.013. PMID 17693331.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  58. ^ Haas M, Sharma R, Stano M (2005). "Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain". J Manipulative Physiol Ther. 28 (8): 555–63. doi:10.1016/j.jmpt.2005.08.006. PMID 16226622.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  61. ^ Rothwell DM, Bondy SJ, Williams JI (2001). "Chiropractic manipulation and stroke: a population-based case-control study". Stroke. 32 (5): 1054–60. PMID 11340209.{{cite journal}}: CS1 maint: multiple names: authors list (link)
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  63. ^ Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMC 1420782. PMID 16574972.
  64. ^ Di Fabio RP (1999). "Manipulation of the Cervical Spine Risks and Benefits". Phys Ther. 79 (1): 50–65. PMID 9920191.
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  66. ^ Wasiak R, Kim J, Pransky GS (2007). "The association between timing and duration of chiropractic care in work-related low back pain and work-disability outcomes". J Occup Environ Med. 49 (10): 1124–34. doi:10.1097/JOM.0b013e31814b2e74. PMID 18000417.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  67. ^ Frank J, Sinclair S, Hogg-Johnson S, Shannon H, Bombardier C, Beaton D, Cole D (1998). "Preventing disability from work-related low-back pain. New evidence gives new hope--if we can just get all the players onside". CMAJ. 158 (12): 1625–31. PMC 1229415. PMID 9645178.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  68. ^ Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW (2007). "The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study". J Manipulative Physiol Ther. 30 (6): 408–18. doi:10.1016/j.jmpt.2007.04.013. PMID 17693331.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  69. ^ "Clinical Utilization and Cost Outcomes from an Integrative Medicine Independent Physician Association:". J Manipulative Physiol Ther. (4) (30): 263–9. May 2007. doi:10.1016/j.jmpt.2007.03.004. PMID 17509435. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  70. ^ "Effects of a Managed Chiropractic Benefit on the Use of Specific Diagnostic and Therapeutic Procedures in the Treatment of Low Back and Neck Pain". J Manipulative Physiol Ther. 8 (Oct, 28): 564–9. 2005. doi:10.1016/j.jmpt.2005.08.010. PMID 16226623. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  71. ^ "Cost-effectiveness of Medical and Chiropractic Care for Acute and Chronic Low Back Pain". J Manipulative Physiol Ther. 8 (Oct 28): 555–563. 2005. doi:10.1016/j.jmpt.2005.08.006. PMID 16226622. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  72. ^ "Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs". Arch Intern Med. 164 (18) (Oct 11): 1885–1892. 2004. doi:10.1001/archinte.164.18.1985. PMID 15477432. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
  73. ^ Wasiak R, Kim J, Pransky GS (2007). "The association between timing and duration of chiropractic care in work-related low back pain and work-disability outcomes". J Occup Environ Med. 49 (10): 1124–34. doi:10.1097/JOM.0b013e31814b2e74. PMID 18000417.{{cite journal}}: CS1 maint: multiple names: authors list (link)
  74. ^ [1]
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