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CCE proposed changes

The Council on Chiropractic Education (CCE) is the only agency recognized by the U.S. Secretary of Education for accreditation of Doctor of Chiropractic degree programs. They have recently proposed revisions to their current Standards for Accreditation, to take effect January 2012.

The proposed new draft of the CCE standards and policies can be found here CCE as a pdf, (see #5. July 23, 2010 - CCE Announcement CCE Draft #2 Standards and Policies).

However, this document is all inclusive and long and does not point out specific changes, it is a complete draft. Opponents of the proposed changes have identified and specified the changes that are most threatening to them. These are clearly outlined in this article in a chiropractic trade magazine: 2. You will note that the groups opposed are: Life-, Palmer-, Parker-, Sherman-colleges, the federation of straight chiropractors, and the like. Dr. Clum (past president of Life) has also comprehensively outlined the changes here: 3 It is notable that CMCC, NYCC, NUHS, and the like have supported the proposed changes. The final vote to adopt or reject these proposed changes has not yet occurred. For those who dont feel like reading, I have listed the changes that traditional chiro's are objecting to: The proposed controversial revisions are:

1. The removal of the term subluxation and any references to it.
2. The statement "without the use of drugs or surgery" has been eliminated from their description of the focus of chiropractic.
3. The CCE has redefined the term "chiropractic primary care physician" as to no longer apply uniquely to chiropractors.
4. The draft standards recognize the "Doctor of Chiropractic Medicine" degree to be equivalent to the Doctor of Chiropractic degree.

Puhlaa (talk) 20:29, 16 January 2011 (UTC)

Interesting! The comments on those links are also interesting to read. Keep us posted on what happens. The straights are up in arms, and that's a lot of people. -- Brangifer (talk) 22:32, 16 January 2011 (UTC)

CSF pressure

How much information is there about what chiropractic manipulations could do to CSF pressure? I found one paper on rats that suggested very little effect [1] but then again I don't know if there even are veterinary chiropractors... [I find this of special interest because I know that if I make the mistake of getting up only partway from a bed (so that the lower spine is supported but the upper is mobile) then trying to move laterally by twisting, it puts an uncomfortable pressure on my inner ears that can take half an hour to go away.] Wnt (talk) 19:46, 16 January 2011 (UTC)

There are numerous possible causes. Just avoid that maneuver. -- Brangifer (talk) 22:20, 16 January 2011 (UTC)

I don't know what that movement you are performing has to do with spinal manipulations, but if it puts uncomfortable pressure on your ears, I would avoid it. There are indeed veteriany chiropractors in some locations. DigitalC (talk) 01:05, 17 January 2011 (UTC)

Recent edit to lead

This edit did not summarise the body. The WP:LEAD is a summary of the body. The text in the lead is sourced per WP:V. "Efficacy and cost-effectiveness of maintenance care for various types of conditions are unknown."[2] QuackGuru (talk) 05:14, 21 January 2011 (UTC)

This edit did not comply with WP:LEAD because it did not summarise the body. QuackGuru (talk) 17:00, 23 January 2011 (UTC)

I agree with QuackGuru's deletion of material which didn't summarize the body of the article well. The material was not NPOV. It was worded so as to lead the reader towards a pro-chiropractic point of view.
Rather than "suggested" or "determined" I suggest using the word "stated" or "concluded". "Stated" is neutral: it simply reports that the study said that. "Suggested" suggests that the report expressed it in a tentative manner. The statement in the abstract doesn't look tentative to me. "Determined" is not NPOV because it means the statement is true. Actually the statement is the opinion expressed in a particular study.
I suggest replacing this sentence: "A systematic review determined[/stated/suggested] that the risk of death from manipulations to the neck by far outweighs the benefits." I think a better summary of the body is "Rarely, spinal manipulation can result in complications that can lead to permanent disability or death." The current sentence is based on a single study which was a review of case reports. ☺Coppertwig (talk) 17:56, 23 January 2011 (UTC)

I think your proposal is not a better summary of the body. The current sentence is not based on a single study. It is not a primary source. A personal disagreement with the source is not relevant on how to edit on Wikipedia. See WP:V. It is based on a systematic review. See WP:MEDRS. "Rarely, spinal manipulation can result in complications that can lead to permanent disability or death." does not summarise the body better. It is similar to the existing sentence that says "Spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or fatal complications in rare cases.[24][25]" The current sentence is better written and does a better job summarising the body. Your repetitive proposal is not about the risk-benefit, anyhow. I changed "determined" to "stated". QuackGuru (talk) 20:02, 23 January 2011 (UTC)

Recent Changes to lead (J Rheumatoid, neck pain, Spine 2008)

Recent [http://en.wikipedia.org/w/index.php?

title=Chiropractic&action=historysubmit&diff=409696703&oldid=409688418 edits] added:

1. Information about neck pain generally from J Rheumatology
2. A summary of the Spine 2008 finding (vad risk/chiropractic = vad risk/primary care)
3. Info that most chiropractors perform/prescribe common physical therapy exercises

I reverted because:

• The refs were [misformatted in brackets]

1. The J Rheumatology review was about neck pain generally not chiropractic
2. It included Spine 2008, without discussion.
3. The physical therapy exercise info was not referenced

Comments? Ocaasi (talk) 07:13, 24 January 2011 (UTC)

There is similar material in the body of the article. The text added to the lead did not summarise the body. QuackGuru (talk) 22:25, 24 January 2011 (UTC)

QG, why don't we summarize the Spine 2008 finding in the lead? It directly addresses relative risk rates between Chiropractic and primary care doctors. It's a systematic review. Why does Ernst-Death belong but not Spine 2008? Ocaasi (talk) 00:06, 25 January 2011 (UTC)

Good questions. DigitalC (talk) 17:09, 25 January 2011 (UTC)

Maybe I can phrase it differently. My question to myself after reading this was why am I asking you (QG) in the first place--but that's obvious since you are the editor who likely will object to such changes--and the objection you have cited/will cite is that the lead should summarize the body and that it would violate Weight to include Spine 2008. So let me be specific: If I assert that the lead is currently not summarizing key content from the article, because it excludes Spine 2008, and that it is currently against Weight, since it excludes one systematic review but not another, what would be your reasoning? Ocaasi (talk) 06:57, 26 January 2011 (UTC)

See WP:LEAD: "The lead section (also known as the introduction, lead, or lede) of a Wikipedia article is the section before the table of contents and the first heading. The lead serves both as an introduction to the article and as a summary of its most important aspects.

The lead should be able to stand alone as a concise overview of the article. It should define the topic, establish context, explain why the subject is interesting or notable, and summarize the most important points—including any prominent controversies. The emphasis given to material in the lead should roughly reflect its importance to the topic, according to reliable, published sources, and the notability of the article's subject should usually be established in the first few sentences."

See WP:MEDRS: "Wikipedia's articles, while not intended to provide medical advice, are nonetheless an important and widely used source of health information. Therefore, it is vital that the biomedical information in articles be based on reliable published sources and accurately reflect current medical knowledge.

Ideal sources for these aspects include general or systematic reviews in reputable medical journals; professional and academic books written by experts in a field and from a respected publisher; and medical guidelines or position statements from nationally or internationally reputable expert bodies."

"VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care." The preceding text is quoted from "Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study" Cassidy et al. (PMID 18204390).

There is similar information in the body using high-quality sources. "Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[136][160]"

The lead is a summary of the body. The summary of Safety is as follows. "Chiropractic care is generally safe when employed skillfully and appropriately.[23] "Spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or fatal complications in rare cases.[24][25]" The key content that summarises Risk-benefit is as follows. "A systematic review stated that the risk of death from manipulations to the neck outweighs the benefits.[26]"

This is a response to the question "Why Cassidy et al. (who is an expert in manipulation and stroke) not be given equal weight (at the very least) to Ernst?". As I understand it, the question is why the WP:LEAD does not give Cassidy et al. (PMID 18204390) and at least equal weight as Ernst 2010 (PMID 20642715). This general topic (at least to Ernst) was previously discussed and continues regarding the Ernst statement in the lead. Please review the archives for past discussions.

To summarise the issue: in Chiropractic#Safety, Haldeman et al. is used to support the claim "Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions".

Cassidy et al. is a primary study that is reviewed by Hurwitz et al. (PMID 18204386). Hurwitz et al. have this to say on the subject: "There are, however, a number of case reports and case series which show temporal associations between interventions and potentially serious complications (e.g., Martienssen and Nilsson, 1989; Haldeman, 1999). These temporal relationships do raise the question about the potential of side effects from most noninvasive interventions. This is a field that deserves considerable further study and, as part of its mandate, the Neck Pain Task Force studied the relationship between chiropractic treatment and vertebrobasilar artery (VBA) strokes (these findings are summarized below).

"In a population-based case-control study, Rothwell et al showed an increased risk of VBA dissection within a week of a chiropractic visit among persons under age 45 years (odds ratio = 5.03, 95% CI = 1.32, 43.87). As part of the Neck Pain Task Force mandate, Cassidy et al extended these findings using both a case-control and case-crossover research design (a research design in which cases serve as their own controls until the event). This study confirmed an increased risk of VBA, but found a similar increase in risk of this form of stroke after visiting a primary care physician for neck pain. These findings suggest that the increased risk of VBA stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from VBA dissection (in the prodromal stage) seeking care before their stroke. Thus, although cervical spine manipulation cannot be ruled out as a potential cause of some VBA strokes, any potential risk is very small." As per WP:MEDRS, it is better to use a reliable review when one is available, as is the case here. I think the Wikipedia summary of the situation matches the union of Hurwitz et al. and Haldeman et al. fairly closely. However, if you'd like to propose better wording based on the current reviews, please feel free. For example, it would be fine to start a new thread and make a specific proposal.

Again, the Cassidy et al. source is a primary study and we don't need to mention dubious sources directly. There are dozens of primary studies on all sides of the safety issue: reaching down and citing just the ones we like, which is what seems to be proposed here (it's not exactly clear), is a recipe for introducing editorial bias. Primary studies (and dated sources) are {dubious}. Unsourced statements require a {citation needed} or the text can be removed and discussed on the talk page. QuackGuru (talk) 19:23, 27 January 2011 (UTC)

1. I appreciate you going through that in detail. The policy references can probably be accomplished with a simple wikilink, but the rationale about which studies to cite and why is what I will respond to here.
2. Briefly, I like leads; I like WP:LEAD. I think the lead should summarize the body. My claim is that our lead does not, since it leaves out any mention of the significant, and possibly causally relevant overlap in VAD risk between manipulation and primary care.
3. I'm not disputing MEDRS. Spine 2008 is a 'Population-based, case-control and case-crossover study'. Ernst is a systematic review of case studies; I don't think it is obviously a more reliable source given its type of methodology, but that's a question for the MEDRS talk page. (I was calling Spine 2008 a systematic review, which may not have been correct). Regardless, Haldeman is a systematic review.
4. We have similar in the body yes, but not in the lead. In some form the following aspect should be included or summarized in the lead:
   • "The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care." (Cassidy, Spine 2008)
   • "Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions" (Haldeman)
   • "These findings suggest that the increased risk of VBA stroke associated with chiropractic and primary care physician visits is likely due to patients with headache and neck pain from VBA dissection (in the prodromal stage) seeking care before their stroke. Thus, although cervical spine manipulation cannot be ruled out as a potential cause of some VBA strokes, any potential risk is very small." (Hurwitz)
5. These are as important a finding as Ernst's (that the risk outweighs the benefits); I think they are directly relevant to understanding Ernst as well, by providing the relative context for risk rates.
6. I also think we need to mention the consensus that this area needs more research to establish the causality and scope of incidents. (Hurwitz: "This is a field that deserves considerable further study"; Neurologist 2008: "Further research, employing prospective cohort study designs, is indicated to uncover both the benefits and the harms associated with CMT."; Spine 2009: "There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.")
7. Cassidy may be a primary study (I don't think its methodology makes it clearly primary or secondary), but either way that doesn't mean it's dubious, only that it must be appropriately. Ocaasi (talk) 01:35, 28 January 2011 (UTC)

Almost every study or review says further research is needed. Telling the reader this is irrelevant and not the point of the sources. You are disputing MEDRS when you insist on using a primary study especially when there is other similar information in the article. Cassidy may be a primary study? It is a primary study according to the study and which means this study is against MEDRS. There is similar informatiuon in the body, anyhow. Adding low level details to the lead is not going to improve this artcle. The body says "Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.[161]" The more relevant point is the causality or causation with vertebrobasilar artery stroke. If we summarises this key content it would be too much detail in the lead. QuackGuru (talk) 04:00, 30 January 2011 (UTC)

Original research?

"The RCTs suggest that massage therapy, physiotherapy, relaxation and chiropractic spinal manipulative therapy might be equally effective as propranolol and topiramate in the prophylactic management of migraine. However, the evaluated RCTs had many methodological shortcomings. Therefore, any firm conclusion will require future, well-conducted RCTs on manual therapies for migraine."[3]

The source does not verify the claim stated. QuackGuru (talk) 22:45, 10 February 2011 (UTC)

The RCTs suggest..., but the Review, which is a review of the RCTs, states. Specifically, 'the systematic review states that research (RCTs) suggest...' I've updated the text to reflect the nuance, and refactored the heading to be less pointy. Ocaasi (talk) 22:49, 10 February 2011 (UTC)

The text says "The RCTs suggest...". I could of added an WP:INLINE template for the failed WP:V text but I decided to remove the WP:OR again. QuackGuru (talk) 23:33, 10 February 2011 (UTC)

Changes needed in the LEAD

The 4th paragraph of the LEAD currently includes the statement:

• "Collectively, systematic reviews of this research have not demonstrated that spinal manipulation is effective, with the possible exception of treatment of back pain.[4]"

This statement is sourced to a narrative review by Ernst in 2008. This is troublesome for 3 major reassons, first, the statement is sourced to a narrative review (does not meet MEDRS according to the standards being enforced in this article by QG); second, the body of the article presents systematic reviews that suggest some efficacy of manual therapies used by chiropractors with regard to back pain, neck pain, some headaches, lumbar radiculopathies, etc; Third, a very comprehensive systematic review of the literature was very recently published that states:

• "Spinal manipulation/mobilization is effective in adults for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; manipulation/mobilization is effective for several extremity joint conditions; and thoracic manipulation/mobilization is effective for acute/subacute neck pain. The evidence is inconclusive for cervical manipulation/mobilization alone for neck pain of any duration, and for manipulation/mobilization for mid back pain, sciatica, tension-type headache, coccydynia, temporomandibular joint disorders, fibromyalgia, premenstrual syndrome, and pneumonia in older adults. Spinal manipulation is not effective for asthma and dysmenorrhea when compared to sham manipulation, or for Stage 1 hypertension when added to an antihypertensive diet. In children, the evidence is inconclusive regarding the effectiveness for otitis media and enuresis, and it is not effective for infantile colic and asthma when compared to sham manipulation." [5].

Thus, the LEAD needs to be changed to be more representative of the current state of the literature and not rely on a single narrative review to summarize the current research regarding efficacy. I propose that the current sentence:

• "Collectively, systematic reviews of this research have not demonstrated that spinal manipulation is effective, with the possible exception of treatment of back pain.[6]"

should be replaced with:

• "Collectively, research only supports the use of chiropractic manual therapies for the treatment of back pain, neck pain, some forms of headache and some extremity joint conditions"[7] Puhlaa (talk) 23:31, 14 February 2011 (UTC)

The source is reviewing other sources which say the same thing. We should use the newer source rather than using an older source. The UK report is not a systematic review. QuackGuru (talk) 17:06, 15 February 2011 (UTC)

That makes it either a systematic review, or a high-quality review of systematic reviews. Either one seems to be up on the MEDRS scale. Discussion at Wikproject Medicine: Wikipedia_talk:WikiProject_Medicine#MEDRS.3F

Further, the sentence under question is not currently sourced to a systematic review, it is a narrative review by Ernst.Puhlaa (talk) 18:04, 15 February 2011 (UTC)

The Ersnt source meets MEDRS. According to Puhlaa, the UK report is not a systematic review. QuackGuru (talk) 18:08, 15 February 2011 (UTC)

My removal of the description "systematic review" was to compromise with you in hopes of finding concensus for inclusion of the extensive study that is the UK evidence report. However, you seem unable to compromise, and rather use such attempts at compromise by other editors to support your POV. Please dont twist my attempts at compromise to support your POV.Puhlaa (talk) 19:54, 15 February 2011 (UTC)

QG, can you specifically explain why the 2008 Ernst review 'meets MEDRS' but the 2010 UK Report review does not? Ocaasi (talk) 18:11, 15 February 2011 (UTC)

According to you the Ersnt source is a review and the UK source is a report. Time to move on. QuackGuru (talk) 18:17, 15 February 2011 (UTC)

QG, please explain, as Ocaasi asked, why does Ernst narrative review meet MEDRS but the UK evidence report does not?Puhlaa (talk) 18:34, 15 February 2011 (UTC)

• The Ernst paper says: "A narrative review of selected articles from the published chiropractic literature was performed."[8]
• The UK evidence report says: "The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories."[9]

I think it is pretty clear which source belongs in the chiropractic article and which does not. Will you make the right choice QG? or will you let your POV get in the way?Puhlaa (talk) 18:42, 15 February 2011 (UTC)

I agree with Puhlaa. Has this been incorporated in the body of the article first? -- Brangifer (talk) 22:12, 15 February 2011 (UTC)

I have tried twice to add the info from this comprehensive review into the body of the article in the section entitled "Evidence Basis" under the subheading "effectiveness". However, QG has twice undone my attempts at adding it, claiming it does not meet MEDRS. Thus, I have not tried to re-add it a third time until there were other editors who agree it is a valuable addition and meets MEDRS. This is why it has been posted by Ocaasi at Wikipedia_talk:WikiProject_Medicine#MEDRS.3F.Puhlaa (talk) 22:25, 15 February 2011 (UTC)

Then QG is going to have to use more convincing arguments than what appear to be flat out untrue statements. He's going to have to convince us. So far I'm not impressed. -- Brangifer (talk) 22:38, 15 February 2011 (UTC)

Here's the ref from PubMed:

• Bronfort G, Haas M, et al, "Effectiveness of manual therapies: the UK evidence report", Chiropr Osteopat. 2010; 18: 3. February 25. doi: 10.1186/1746-1340-18-3. PMC 2841070
  "The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories."

This is about as solid as it gets. Put it in the body and update the lead. (If you get more ownership, stonewalling and IDHT behavior from QG, then contact me and we'll take action to stop his disruptive influence here.)

Note the change of journal title: Readers should note that in January 2011 the journal’s name changed to Chiropractic & Manual Therapies from Chiropractic & Osteopathy.[10]

This is the most scientifically legitimate of all chiropractic journals. Their research reports are generally quite trustworthy, with few exceptions, and this isn't one of those exceptions. -- Brangifer (talk) 22:34, 15 February 2011 (UTC)

Changes have now been made in 3 parts for ease of review. Please feel free to edit content or style as you feel necessary.Puhlaa (talk) 23:05, 15 February 2011 (UTC)

Excellent work. This can now be tweaked but shouldn't be reverted. There may well be need for slight changes in wording or formatting, but your work is substantially good. Congrats! -- Brangifer (talk) 01:11, 16 February 2011 (UTC)

The UK report meets the standards of MEDRS for being a secondary review, recent and relevant. As long as editors have reached a consensus that the journal where it was published meets RS standards for peer-review and editorial oversight, then there's no reason to exclude it. However, as it seems to contradict Ernst (at least partially), shouldn't we be applying WP:NPOV: "If different reliable sources make conflicting assertions about a matter, treat these assertions as opinions rather than facts, and do not present them as direct statements"? My understanding of that is the body of the text can state as facts whatever is agreed by both sources, but we should attribute to each source their opinions where they disagree. --RexxS (talk) 00:37, 16 February 2011 (UTC)

You are generally correct when this is applied to general sources and common opinions, but medical sources have a way of outdating and replacing each other. These aren't just ordinary opinions but evaluative judgments based on the research at hand. I think that's the difference. If it were the common expression of opinions not influenced by changing research, you'd be spot on. -- Brangifer (talk) 01:09, 16 February 2011 (UTC)

So you're saying that WP:NPOV doesn't apply to medical articles because each later finding replaces all previous ones? And there's no such thing as a "dispute between reliable sources" because medical consensus shifts with changing research? MEDRS says "Controversies or areas of uncertainty in medicine should be illustrated with reliable secondary sources describing the varying viewpoints." How do you square that up with your view? --RexxS (talk) 03:14, 16 February 2011 (UTC)

No, I'm not saying that. NPOV applies everywhere, and if up-to-date medical sources disagree, we reflect the controversy by presenting both views and their sources. At some point, when there is no longer disagreement or newer reviews include and update older ones, then we drop mentioning the older ones, unless they are significant as historical sources. OTOH, maybe you have a point here and we're dropping Ernst too quickly. (I have certainly been in the forefront for using him all along.) I wouldn't have anything against keeping Ernst if we can find a logical way of wording it. Would you like to propose some wording? -- Brangifer (talk) 03:42, 16 February 2011 (UTC)

Agreed with above, however, the Ernst article that was there did not meet MEDRS (it was a narrative review; see above), and his earlier work that reviewed the evidence for manual therapies more generally (systematic review of systematic reviews) was published in 2006 and only reviewed research up to 2005 [11]. Thus, it is not so much that they contradict, the UK report is just more current. The strong push for evidence (particularly due to what has occurred in the UK) has resulted in vast ammounts of research being conducted in the last few years. This likely explains why Ernsts reviews have different conclusions with regard to MSK conditions. The lack of evidence for the treatment of visceral conditions is consistent between Ernsts earlier reviews and the current UK report. In conclusion, I feel that here we are safe and consistent with NPOV to simply use the high quality and current review that has been added. Puhlaa (talk) 00:42, 16 February 2011 (UTC)

I wouldn't say Ernst doesn't meet MEDRS, but it's older and not as good as this latest review. This newer one seems to be more accurate. -- Brangifer (talk) 00:57, 16 February 2011 (UTC)

Hang on a moment, where's the guidance that says an older review is to be replaced? Ernst is RS and MEDRS and is a significant viewpoint which should be represented per WP:NPOV. We don't just pick a side in a disagreement by choosing whichever was published latest and disregard a two-year old secondary RS – and that is most certainly not an "outdated review". Let's not start using our own prejudices by assertions like "not as good as this latest review". By what standards is it not so good? Our own amateur analysis of the methodology? No, we determine the quality of a source by the reputation of the journal where it is published, as anything else is merely subjective and substitutes our own opinion for the processes of peer-review and editorial oversight. Anyone could just as easily argue that a review published in a partisan journal carries less weight than one published in Journal of Pain and Symptom Management. The correct procedure is as I outlined: examine all the relevant reliable secondary sources; represent all significant viewpoints; state undisputed facts; and attribute any disputes. It may be that you can cover all the viewpoints without citing all of the sources considered; but it is a fundamental breach of neutral writing to discard reliable sources without ensuring that what they have to say are covered. If you don't believe Ernst meets both MEDRS and RS, then take it to the WP:RS/N. --RexxS (talk) 03:14, 16 February 2011 (UTC)

Per my comment above I'm open to a proposal. BTW, lest there be a misunderstanding, I have stated above and will reaffirm here, that Ernst is MEDRS. No doubt about that. -- Brangifer (talk) 03:42, 16 February 2011 (UTC)

I'll also try to avoid misunderstanding if I can. I'm concerned that this article has been controversial for a long time and the only way to keep it "on the rails" is to scrupulously adhere to our policies and guidelines. I'm not so worried about any particular wording (that can be changed tomorrow), but I am worried about dropping a reliable secondary source from 2008 simply on the grounds that it is automatically outdated when a 2010 source is found. It's just not a good procedure to adopt without question, if you see what I mean. If you tell me that the editors here have considered the viewpoints of both Ernst and Bronfort per policy, and feel that each are represented adequately in the article, then I have no complaint. --RexxS (talk) 04:02, 16 February 2011 (UTC)

I have started a section for continuation of this matter:

• Talk:Chiropractic#Are we dropping the Ernst review too soon?

Brangifer (talk) 03:50, 16 February 2011 (UTC)

Neck pain/whiplash

(moved from above because it's a slightly different topic) -- Brangifer (talk) 01:02, 16 February 2011 (UTC)

This Cochrane review PMID 20510644 words it slightly differently. Doc James (talk · contribs · email) 23:22, 15 February 2011 (UTC)

The article you refer to states "Moderate quality evidence showed cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction at intermediate-term follow-up." I am uncertain how this is inconsistent with what the UK evidence report stated? Do you have any proposed revisions? I am happy to make changes or see changes made! Note, one of the authors of the article you refer to is the lead author of the UK evidence report. Puhlaa (talk) 23:28, 15 February 2011 (UTC)

All I am saying is we should also use this as support in the lead and maybe mention the comparison to mobilization. The UK report is a compliant ref. Doc James (talk · contribs · email) 23:53, 15 February 2011 (UTC)

I have added the systematic review to the neck pain/whiplash section in the body. I am uncertain how to incorporate it into the LEAD without initiating a discussion of specific modalities used by chiropractors to frame the comparison between mobs and manip. Any ideas?Puhlaa (talk) 00:33, 16 February 2011 (UTC)

I haven't had a chance to examine it yet, but it may not be necessary to mention it in the lead, unless it's a significant matter. We don't mention every detail in the lead, only significant ones. -- Brangifer (talk) 01:16, 16 February 2011 (UTC)

Verb tense

This phrase still bugs me:

innate intelligence, "a vitalistic notion that brings ridicule from mainstream science and medicine.[7]"

I don't dispute its verifiability or accuracy, but it is using the active present tense, which is not typically used in encyclopedias. Recommend three options:

1. a vitalistic notion which has brought ridicule from mainstream science and medicine - present perfect tnese
2. a vitalistic notion that continues to bring ridicule from mainstream science and medicine. - present continuous
3. a vitalistic notion that "brings ridicule from mainstream science and medicine." - quotation

Thoughts? Ocaasi (talk) 21:59, 15 February 2011 (UTC)

I think all three are better than the current text, however, I dont know that the source supports the second proposal. If I had to choose one I would go with the first option.Puhlaa (talk) 22:07, 15 February 2011 (UTC)

The third one isn't actually an exact quote, and I think the exact quote is better:

• a vitalistic notion that "brings ridicule from the scientific and health care communities and confusion within the chiropractic profession."

So just the more informative, comprehensive and exact quote, and use quote marks. -- Brangifer (talk) 22:19, 15 February 2011 (UTC)

Agreed with BR's proposal, I like the exact quote for this.Puhlaa (talk) 22:28, 15 February 2011 (UTC)

Done. All this close paraphrasing without actual quotations makes for awkward reading. Think this is a good fix. Ocaasi (talk) 22:38, 15 February 2011 (UTC)

Some editors take paraphrasing too far. We are allowed to use exact quotes in moderation. Can we mark this section as resolved? If so, then would "the hunter who shot the deer" please do it? -- Brangifer (talk) 22:41, 15 February 2011 (UTC)

I did it. One question, though. I don't like direct quotations without attribution, but then you run into ASF issues, which is why I just prefer grammatical paraphrasing. So this one is settled half-way for me, but I'm ok with it for now. Ocaasi (talk) 22:49, 15 February 2011 (UTC)

Any direct quotation needs to be referenced, preferably with an inline citation as close to the quote as possible. But there's no need to attribute as well it unless you want to stress the point that it is the author's opinion. When the matter is undisputed among reliable sources, it's sufficient to allow the reader to check the reference if they are actually interested in the author of the quote. --RexxS (talk) 00:47, 16 February 2011 (UTC)

Agree on all points. Very legitimate concerns, but I agree with RexxS. This case shouldn't need attribution. Otherwise I generally think ASF is used far too much by QG and believe that "when in doubt, attribute". -- Brangifer (talk) 01:14, 16 February 2011 (UTC)

Chiropractic treatment prompts shingles

I recall reading that chiropractic treatment can cause the varicella zoster virus to break out from its latent position in nerve cell bodies in the spinal nerve, where the chiropractic-released virus causes shingles. Mechanically speaking, this makes sense. The article probably should touch on this. -- Uzma Gamal (talk) 14:49, 23 February 2011 (UTC)

Do you have a source for that? -- Brangifer (talk) 18:26, 4 March 2011 (UTC)

Are we dropping the Ernst review too soon?

Above objections have been expressed about this matter. Any thoughts or proposals about the matter? -- Brangifer (talk) 03:48, 16 February 2011 (UTC)

This issue was always why Ernst was included not the UK report. I don't recall suggesting that we take out Ernst just because it was older. That would not be how we handle two qualifying sources. Instead, we can try to summarize their collective findings, or if that is too contentious, just list the points of agreement and then attribute (as RexxS suggested) where they disagree, per 'Describe the dispute'. The strength of Wikipedia is that it is as comprehensive as it is up to date; Ernst is not a bad source here, just not the only source. Ocaasi (talk) 13:05, 16 February 2011 (UTC)

I maintain that Ernst can be removed from the LEAD in favour of new research. I am uncertain how a LEAD (a short summary of the body) benefits from something like including the older review regarding effectiveness. Would we write,

"A 2008 review suggested that manual therapies used by chiropractors are not good for anything (Ernst 2008). A 2010 review found that manual therapies used by chiropractors are effective for low back pain, neck pain, some headaches and some extremity joint condiditons (Bronfort 2010)".

The controversy around chiropractic is being too far extended here when we try to apply it to the evidence for the effectiveness, as without pseudoscientific ideas like innate and subluxation chiropractic is just another manual therapy. Some chiros troubling belief in these stupid ideas does not make their manual therapy any less effective. I wonder, if we go look at the physiotherapy article (physio's use the same types of therapies I believe - manips, mobs, rehab exercise, etc) does it say they are not effective for anything? Does the LEAD there go through the progression of the evidence for effectiveness or does it summarize the current state of the literature on effectiveness? As always, I am willing to conform to the majority view of reasonable editors, but the above is my opinion on the issue. Puhlaa (talk) 13:42, 16 February 2011 (UTC)

It's still possible for narrative reviews to come to different conclusions regarding manipulative efficacy. If Ernst and the UK report are both worth including in the body, then I think either both or neither are suitable for inclusion in the lead. To only use the UK report in the lead would be to take a clear stance that the more recent review is more accurate, which may or may not be true. At the least, we would have to use language such as the most recent systematic review of effectiveness.... But why can't we synthesize (the acceptable kind) the results of the studies into a coherent lead: Recent systematic reviews agree that a, b, c, are effective; are split over whether d, e, f, are effective, consistently find no benefit for g,h, and i, and need more data for j, k, and l. Or something like that. Ocaasi (talk) 14:47, 16 February 2011 (UTC)

If an adequate way of doing this is proposed then I will support it. Your current proposal will not work because Ernst says SM is not effective for anything "Collectively, systematic reviews of this research have not demonstrated that spinal manipulation is effective, with the possible exception of treatment of back pain." (Ernst 2008). This is inconsistent with the most recent review (UK report currently included), and with the info found in the body which incudes systematic reviews suggesting there may be effectiveness for low back pain (Spine Journal, 2010)[12]; neck pain (Manual Therapy, 2010)[13]; migrain (J Headache Pain, 2011)[14]; shoulder pain (JMPT 2010)[15]; leg pain (JMPT 2009)[16]; lumbar radiculopathy (Phys Med Rehabil Clin N Am, 2011)[17]. Why keep Ernst when it is clearly inconsistent with the current state of the literature and a review is available that IS consistent?

It is interesting that no editors are jumping on this idea with regard to the discussion of stroke in the lead. No one is questioning why systematic reviews that question the causational link between cervical manipulation and stroke are not included in the lead, only in the body. Why is there such inconsistency? Only Ernst most recent 2010 review needs to be included with regard to stroke, but older reviews must be included with regard to efficacy? I aacknowledge that you have brought up this issue Ocaasi, but you are the only editor who has)Puhlaa (talk) 15:12, 16 February 2011 (UTC)

Puhlaa, you know my stance on the stroke situation. Namely, I think we are grossly under-representing its complexity in the lead as well. That is something I would like to fix. But mentioning Ernst was not only my idea. See the WikiProject Medicine thread, where RexxS and others emphasized the need to include Ernst as well. Ocaasi (talk) 15:36, 16 February 2011 (UTC)

Like I said, I wont revert if Ernst is included based on majority agreement, I just contend that it is inconsistent with how policy is applied in other articles and in other sections of this article. I will shut up now :) I gave my opinion...I will wait for the changes to be made (Ernst re-included) or others to weigh in :) Puhlaa (talk) 15:38, 16 February 2011 (UTC)

If it's any help, WP:LEAD recommends that only notable disputes need to be included in the lead. I'm really not qualified to make that judgement myself, but perhaps someone is aware of a source that examines the extent of the disagreement between the two views expressed? Anyway, I'd expect that the body of the text ought to at least mention that reliable sources are not unanimous on the effectiveness of chiropractic methods. If pressed, I'd suggest the body contained something along the lines of:

• "A 2010 systematic review concluded that manual therapies used by chiropractors are effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions,<cite Bronfort> although a 2008 critical evaluation only found evidence for the effectiveness of SM in treating back pain.<cite Ernst>"

which is about as dispassionate as I can write it. Others may be able to do better. The lead at present says:

• "Many studies of treatments used by chiropractors have been conducted, with conflicting results. Collectively, research has suggested that manual therapies commonly used by chiropractors are only effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions."

and I guess that is a fair overview of what we know. Does anyone want to see much more detail than that? I'd only suggest changing the last phrase to "some joint conditions in the extremities" as the current wording reads awkwardly to me. Hope that helps. --RexxS (talk) 16:51, 16 February 2011 (UTC)

I'm okay with both of those. I get a little tripped up on the word 'only', but it can wait. Ocaasi (talk) 17:47, 16 February 2011 (UTC)

I see there never was consensus to drop the Ernst review. Editors should report what the source says rather than deleting a MEDRS compliant source. QuackGuru (talk) 20:45, 6 March 2011 (UTC)

Puhlaa, your review of the sources is SYN. Sources often disagree. The Ernst source is relevantly new as of 2008. The 2010 report is not a systematic review and is a weaker source. I think for balance we can restore the Ersnt 2008 source. QuackGuru (talk) 04:31, 20 March 2011 (UTC)

The 2010 review is a newer and better source than the Ernst review.

• The Ernst paper says: "A narrative review of selected articles from the published chiropractic literature was performed. For the assessment of efficacy, safety, and cost, the evaluation relied on previously published systematic reviews"[18]
• The UK evidence report says: "The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories."[19]

Thus, while the Ernst narrative review only discusses systematic reviews published prior to 2008, the 2010 review discusses all systematic reviews, all guidelines, and all RCTs published prior to 2010, making it far more comprehensive. However, I agree that sources often disagree, and as per the comments of RexxS above and your comments, I will add the Ernst review back into the body of the article following his/her recommendation:

• "A 2010 systematic review concluded that manual therapies used by chiropractors are effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions,<cite Bronfort> although a 2008 critical evaluation only found evidence for the effectiveness of SM in treating back pain.<cite Ernst>"

The Lead already communicates the idea that sources disagree in a concise manner, as RexxS has suggested above:

• "The lead at present says: "Many studies of treatments used by chiropractors have been conducted, with conflicting results. Collectively, research has suggested that manual therapies commonly used by chiropractors are only effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions." and I guess that is a fair overview of what we know."

Thus, the lead concisely communicates that sources disagree on efficacy and the body will (now) explicitly describe that the Ernst source disagrees. I must point out that the conclusion of the Ernst narrative is inconsistent with multiple new systematic reviews by multiple different authors found in the article, and do not personally see the value in its inclusion in the efficacy section of the article at all. However, compromise is what makes wikipedia work, so I will add it promptly :) Puhlaa (talk) 15:52, 20 March 2011 (UTC)

The lead does not have the specifc disagreement because you deleted. For balance the exact text you deleted in the body and the lead should be restored but with the attribution. QuackGuru (talk) 17:05, 20 March 2011 (UTC)

I disagree and you have not provided any evidence to support your claim. Myself, and other editors seem to agree that the LEAD is balanced. The LEAD already states that some sources disagree and emphasizes that despite claims to the contrary by some chiros, research only supports SM for certain MSK conditions (back pain, neck pain, some extremity cond. and some headaches). The vast majority of systematic reviews sourced in the chiropractic article do not agree with the conclusions of Ernst's 2008 review (only back pain has any evidence), thus it is the minority view. Ernst's 2008 narrative review should not recieve equal weight in the LEAD, as this would constitute undue weight for his minority view. Not every review that looks at efficacy can be put in the LEAD, only the majority view gets explicit mention. If Ernst is included explicitly in the LEAD then the LEAD is not representative of the body, which has far more systematic reviews showing evidence for SM for many MSK conditions in addition to back pain. Should all the reviews examining efficacy of SM be included in the LEAD?

For example one source says:

• Ernst 2008 – review says with the possible exception of back pain, spinal manipulation has not been shown to be effective for any medical condition. [20]

However, multiple newer sources seem to imply different:

• Bronfort et al 2010 – review found manipulation/mobilization is effective for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; several extremity joint conditions; acute/subacute neck pain. [21]
• Dagenais et al 2010 - systematic review found that most studies suggest manipulation achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for back pain.[22]
• Chaibi et al 2011 - systematic review found evidence that manipulation might be as effective as some commonly used medications in the prevention of migraine headaches.[23]
• Hahne et al 2010 – systematic review found moderate quality evidence to support the use of spinal manipulation for the treatment of acute lumbar disc herniation with associated radiculopathy.[24]
• Leininger et al 2011 - systematic review found moderate quality evidence to support the use of spinal manipulation for the treatment of acute lumbar radiculopathy.[25]
• Gross et al 2010 - systematic review found low quality evidence that SM was more effective than a control for neck pain, and moderate quality evidence that cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction.[26]
• Pribicevic et al 2010 - systematic review found low level evidence supporting manipulation for treatment of shoulder pain.[27]
• Brantingham et al 2010 - systematic review found limited or fair evidence supporting manipulative therapy for leg conditions.[28]
• Shaw et al 2010 - systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash.[29]

If you have a source says that evidence is lacking for any NON-MSK condition at all, then this could be added explicitly to the lead. When examining the evidence for MSK conditions though, Ernst comments in his narrative review are a minority view, most sources imply otherwise. Puhlaa (talk) 17:59, 20 March 2011 (UTC)

Your 2011 Puhlaa WP:SYN review is not a source. Low level evidence or might be effective or low quality evidence is not convincingly effective. The qualifier for Ernst in the body is "A 2008 critical evaluation, anyhow. Let's get it right in the body and lead to improve the article per WP:NPOV. QuackGuru (talk) 18:54, 20 March 2011 (UTC)

This edit added text not found in the source and was not a summary of the source the way it was previously written. There is a policy called WP:OR that may help. QuackGuru (talk) 17:21, 20 March 2011 (UTC)

Text can be cut and pasted from the older version or a draft can started with the older version to merge both versions together to restore NPOV. QuackGuru (talk) 17:45, 20 March 2011 (UTC)

Your statement: “There is a policy called WP:OR that may help” is demeaning, you know I am aware of policy! Perhaps I will recommend that you take the good advice of 2/0 here QuackGuru where you are already being discussed for tendentious editing. I know your perspective and you know mine, Lets wait and see what other editors think shall we? You know I am always open to following consensus. This will avoid the progression to continued demeaning/sarcastic statements and your usual IDIDNTHEARTHAT approach, which will result in another ANI. Do you agree? Puhlaa (talk) 17:59, 20 March 2011 (UTC)

My perspective is to comply with policy and a balanced approach which includes a balanced WP:LEAD. I think you are not understanding policy (IDIDNTUNDERSTANDTHAT). If the source does not say it then don't add it to this article. Lets wait and see what other editors think shall we? You unilaterally deleted the Ernst source against consensus. Let's restore the original text now but with in-text attribution and move on. According to you the 2010 source is a report not a comprehensive review. I agree. The source says it is a report. The article should be updated. QuackGuru (talk) 18:54, 20 March 2011 (UTC)

Your preference is to have other editors blindly follow your opinion, and has little to do with policy collectively. I agree that you are good at picking which individual policy you can use to support you opinion, then re-state it over and over, without actually ever providing evidence or support for your opinion and without considering other policies that might not support your opinion. I have provided plenty of evidence to support my perspective. I have shown why the LEAD currently follows all policy, and why explicit inclusion of Ernst 2008 in the LEAD violates NPOV and WEIGHT. You have not shown how there is not consensus for the article as it currently exists. You have also not shown how inclusion of Ernst accurately summarizes the body, nor how it is consistent with WEIGHT or NPOV. The article did not follow NPOV or WEIGHT or LEAD prior to the changes that were made according to consensus, now it is much better. Lets leave it how it is now, as this was achieved through consensus, until there is more than your opinion supporting change. Puhlaa (talk) 20:12, 20 March 2011 (UTC)

See WP:MEDASSESS:

"Knowing the quality of the evidence helps editors distinguish between minority and majority viewpoints, determine due weight, and identify information that will be accepted as evidence-based medicine. In general, editors should rely upon high-quality evidence, such as systematic reviews, rather than lower-quality evidence, such as case reports, or non-evidence, (e.g., anecdotes or conventional wisdom).

The best evidence comes from meta-analyses of randomised controlled trials (RCTs), and from systematic reviews of bodies of literature of overall good quality and consistency addressing the specific recommendation. Narrative reviews can help establish the context of evidence quality. Roughly in descending order of quality, lower-quality evidence in medical research comes from individual RCTs, other controlled studies, quasi-experimental studies, and non-experimental studies such as comparative, correlation, and case control studies. Although expert committee reports or opinions, along with clinical experience of respected authorities, are weaker evidence than the scientific studies themselves, they often provide helpful overviews of evidence quality. Case reports, whether in the popular press or a peer-reviewed medical journal, are a form of anecdote and generally fall below the minimum requirements of reliable medical sources."

"Narrative reviews can help establish the context of evidence quality." It is not our job to question the experts like Ernst. The Ernst source clearly meets MEDRS.

"Table 3 gives an overview of the most up-to-date systematic reviews by indication. 137e144 These systematic reviews usually include trials of spinal manipulation regardless of who administered it. Thus, they are not exclusively an evaluation of chiropractic. Collectively, their results fail to demonstrate that spinal manipulation is effective. The only possible exception is back pain. For this condition, manipulation may be as effective (or ineffective) as standard therapy.137" (Ernst 2008)

• 137. Assendelft WJJ, Morton SC, Yu Emily I, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low-backpain. The Cochrane Database of Systematic Reviews 2004;(Issue 1)10.1002/14651858. Art No.: CD000447.pub2.
• 138. Gross AR, Hoving JL, Haines TA, et al. Manipulation and mobilisation for mechanical neck disorders (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd, 2004.
• 139. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, et al. Are manual therapies effective in reducing pain from tension-type headache?: a systematic review. Clin J Pain 2006;22:278e285.
• 140. Ernst E. Chiropractic spinal manipulation for neck painda systematic review. J Pain 2003;4: 417e442.
• 141. Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for primary and secondary dysmenorrhoea. The Cochrane Database of Systematic Reviews 2001;(Issue 4)10.1002/14651858. Art. No: CD002119.pub2.
• 142. Husereau D, Clifford T, Aker P, Leduc D, Mensinkai S. Spinal manipulation for infantile colic. Technology report no 42. Ottawa: Canadian Coordinating Office for Health Technology Assessment, 2003:ie36.
• 143. Balon JW, Mior SA. Chiropractic care in asthma and allergy. Ann Allergy Asthma Immunol 2004;93:S55eS60.
• 144. Reid SA, Rivett DA. Manuel therapy treatment of cervicogenic dizziness: a systematic review. Man Ther 2005;10:4e13.

The Ernst source was in the article for years until you deleted it from the body and the lead which never had support. Are we dropping the Ernst review too soon? Yes, it was too soon. The Ernst source does summarise the effective section with regard to systematic reviews. As previously explained, low level evidence or might be effective or low quality evidence is not effective. The Ernst source is in the body and it can also be summarised in the lead as before per LEAD and NPOV. Let's leave the Ernst text the way it was before you deleted it against LEAD (but with in-text atribution in the lead per WP:ASSERT). I think we should include both for inclusion in the lead. You personally think a report is more reliable than the 2008 Ernst review but we should include both. Ernst summarises systematic reviews. The 2010 report summarises many sources including lower-quality evidence. QuackGuru (talk) 23:10, 20 March 2011 (UTC)

As I stated above, but QG ignored The 2010 review is a newer and better source than the Ernst review.

• The Ernst paper says: "A narrative review of selected articles from the published chiropractic literature was performed. For the assessment of efficacy, safety, and cost, the evaluation relied on previously published systematic reviews"[30]
• The UK evidence report says: "The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories."[31]

Thus, while the Ernst narrative review only discusses systematic reviews published prior to 2008, the 2010 review discusses all systematic reviews, all guidelines, and all RCTs published prior to 2010, making it far more comprehensive.Further, Ernst 2008 is inconsistent with many newer systematic reviews (I listed them above) which show there is evidence for far more than back pain. Ernst 2008 is a minority view, and while I agree it can serve a purpose in the body, it cannot be given equal weight in thre LEAD. Puhlaa (talk) 23:19, 20 March 2011 (UTC)

You have not shown how the 2010 report (the comprehensive review is OR) is a better source than the Ernst review according to WP:MEDRS. According to you "Ernst comments in his narrative review are a minority view, most sources imply otherwise." Source that imply that chiropractic is effective does not mean it is effective. I previously explained this to you before but you continue to provide your own SYN review of the literature. The report summarises all sources which will include lower-quality evidence but Ersnt summarises systematic reviews. For NPOV both can be included per comments by other editors earlier in this thread. Both sources have different methodologies which will have different conclusions. QuackGuru (talk) 23:32, 20 March 2011 (UTC)

Ernst 2008 is a narrative review, thus lower level evidence than systematic reviews. I have provided multiple systematic reviews here, which is the highest level of evidence per MEDRS, whose conclusions are inconsistent with the conclusion of Ernst's narrative review. However, the conclusions of those systematic reviews are consistent with the conclusions of the 2010 review. Thus, not only is the 2010 source a better (see my post above) and newer source, it is also consistent with the vast majority of systematic reviews found in the body of the chiropractic article. Ernst 2008 cannot get equal weight in the LEAD when it is such a minority view. As I already mentioned, find a source that says SM is not effective for any NON-MSK condition and we can include it in the LEAD and it wil be a good summary of the body. However, for MSK conditions the 2010 source is a better summary of the body and NPOV is ensured by qualifying that there are inconsistencies in the literature and some chiro's claim to be effective for more than the MSK conditions listed in the LEAD. Puhlaa (talk) 23:52, 20 March 2011 (UTC)

You previously claimed "most sources imply otherwise". If the sources imply that it is effective how could it be effective with the possible exception for the low back.

• Bronfort et al 2010 – report found manipulation/mobilization is effective for: acute, subacute, and chronic low back pain; migraine and cervicogenic headache; cervicogenic dizziness; several extremity joint conditions; acute/subacute neck pain. [32] Not a systematic review but a report from a chiropractic journal.
• Dagenais et al 2010 - systematic review found that most studies suggest manipulation achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for back pain.[33] Most most studies suggest manipulation... That does not mean it is effective.
• Chaibi et al 2011 - systematic review found evidence that manipulation might be as effective as some commonly used medications in the prevention of migraine headaches.[34] The claim might be as effective does not mean it is effective.
• Hahne et al 2010 – systematic review found moderate quality evidence to support the use of spinal manipulation for the treatment of acute lumbar disc herniation with associated radiculopathy.[35] It is only moderate quality evidence to support spinal manipulation of the acute lumbar disc herniation with associated radiculopathy.
• Leininger et al 2011 - systematic review found moderate quality evidence to support the use of spinal manipulation for the treatment of acute lumbar radiculopathy.[36] The source found only moderate quality evidence.
• Gross et al 2010 - systematic review found low quality evidence that SM was more effective than a control for neck pain, and moderate quality evidence that cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction.[37] The source found low quality evidence that SM was more effective than a control for neck pain.
• Pribicevic et al 2010 - systematic review found low level evidence supporting manipulation for treatment of shoulder pain.[38] The source found low level evidence.
• Brantingham et al 2010 - systematic review found limited or fair evidence supporting manipulative therapy for leg conditions.[39] The source found limited or fair evidence.
• Shaw et al 2010 - systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash.[40] The source found low level evidence. QuackGuru (talk) 00:15, 21 March 2011 (UTC)

Thank you for ackowledging that there are many new systematic reviews examining SM in the article. Now you just need to acknowledge that good evidence, weak evidence, some evidence, lots of evidence are all different than no evidence. The original text in the article said "collectively, research has not found SM to be effective for any condition with the possible exception of back pain." This is clearly not what the research says today. Collectively, the research seems to say that there is some evidence for many MSK conditions and good evidence for back pain. I admit, in 2008 the Ernst narrative might have been accurate and consistent with the literature, but as of 2011, systematic reviews are saying much different. Is the goal to summarize old research or current research? The 2010 source summarizes more new research than Ernst 2008 and is also more consistent with even newer systematic reviews pubished since the 2010 source. The Ernst 2008 (older) outcome is given weight in the body, but is not a good summary of the body as you have admitted above by re-listing several systematic reviews that show there is evidence for conditions besides back pain. However, I am still ok with the LEAD as it is qualifying that some sources have inconsistent conclusions. Puhlaa (talk) 00:29, 21 March 2011 (UTC)

As I tried to explain to you before both sources use different methodologies to come to different conclusions. I don't see any changes in the newer systematic reviews. For chronic low-back pain there is high quality evidence.[41] You have not found a source that supports SMT is effective with the possible exception being back pain. You have not found a source that supports your personal conclusion that Ernst is wrong or dated. The Ernst 2008 outcome should be given equal or more weight in the lead, because it is a concise summary of the systematic reviews. The standard for evidence is more than implying it is effective. QuackGuru (talk) 00:53, 21 March 2011 (UTC)

I am not sure that it is up to you to say what constitutes the standard for evidence, especially not here. Here, MEDRS says what sources carry what level of evidence, and what should recieve more weight. Policy also decides what the LEAD should include. In general, systematic reviews carry more weight than narrative reviews, newer reviews often replace older reviews, and weight is determined by the prominence of the conclusion considered across the sum of all the sources. Here we have one 2008 narrative review by Ernst that summarizes sytematic reviews older than 2008 and says that SM is only effective for back pain (possibly). Then we have multiple 2010 & 2011 systematic reviews that conclude anywhere from low to high quality evidence for the use of SM to treat a number of MSK conditions. Finally, we have a 2010 review (narrative-? general-? systematic-?) that summarizes systematic reviews, guidelines and RCTs older than 2010 and that says evidence supports back, neck, extremity and some headache Tx with SM. The Ernst 2008 source is the oldest source of all these, and is not consistent with any of the newer sources. Perhaps you didnt understand that, according to policy, this means Ernst 2008 gets less weight, if any, in the LEAD. If you want to include Ernst 2008 then we need to include the newer systematic reviews as well so that the reader is not misled to believe that 1 source says no evidence except for back pain and 1 source says evidence for more than back pain. It is actally 1 source says only back pain, 1 source says more than back pain and a multitude of the highest quality sources (according to MEDRS) say there is evidence (some low, some moderate, some high) to support more than back pain. It is better to be concise in the LEAD. As it stands, the LEAD suggests there is some debate among research, but only explicitly presents the source most consistent with the vast majority of systematic reviews found in the body. According to MEDRS, newer reviews should include data found in older reviews, if they dont then the older reviews should be considered dubious. The newer systematic reviews must be considering older data that Ernst 2008 examined, or is Ernst 2008 dubious? If it is dubious, maybe it should not be in the body of the wikipedia article either? I dont consider Ernst 2008 dubious, do you? I think it is just older, and now there is newer research. Puhlaa (talk) 01:20, 21 March 2011 (UTC)

You claim I am not sure that it is up to you to say what constitutes the standard for evidence. The evidence you provided was not high-quality evidence. The report came to a different conclusion becuase it has a different methodology and evidence guidelines.

You claim there are multiple 2010 & 2011 systematic reviews that conclude anywhere from low to high quality evidence for the use of SM to treat a number of MSK conditions. Which systematic review shows there was high quality evidence for SMT other than back pain. This source is a report not a comprehensive systematic review. The Ernst review is consistent with the systematic reviews presented. I think your argument is dubious. Low level evidence does not equal effectiveness. Please show high-quality evidence. Any evidence does not mean it is effective. If it is not up to us to decide the level of evidence then the Ernst source should be restored for balance. The LEAD suggests there is some debate among research, but does not include the Ernst source that is consistent with the systematic reviews. QuackGuru (talk) 01:42, 21 March 2011 (UTC)

You claim that the 2010 review came to a different conclusion becuase it has a different methodology and evidence guidelines. The difference is that it examined a far more comprehensive pool of research, as it evaluated guidelines and new RCTs up to 2010 in addition to systematic reviews up to 2010 to make its conclusions, whereas Ernst 2008 examined only systematic reviews prior to 2008.

You are right, it is not up to us to decide the level of evidence. Systematic reviews are the highest level of evidence according to MEDRS. We have seen that there are systematic reviews in the body that conclude that research exists to support the efficacy of SM for more MSK conditions than back pain. Whether it is high or low quality is irrelevant, it is still more than none as Ernst 2008 claims. Perhaps you didnt understand that the 2010 review is more consistent with these systematic reviews than the Ernst 2008 narrative? Did you understand that the 2010 review is more comprehensive and newer than the 2008 Ernst narrative? You claim that Ernst 2008 should get equal weight, or even more weight in the LEAD than the 2010 review when Ernst 2008 is older, less comprehensive and inconsistent with systematic reviews found in the body. Do you agree that newer, more comprehensive sources that are consistent with systematic reviews found in the body of the wikipedia article should get more weight in the LEAD? Or, do you still think that an older, less comprehensive narrative that is inconsistent with systematic reviews in the body should get more weight? Lets go back to our earlier agreement to allow some other editors to weigh in, as I have grown tired of repeating myself in so many ways trying to help you understand. Puhlaa (talk) 02:02, 21 March 2011 (UTC)

That is your personal opinion that the Ernst source is less comprehensive and inconsistent with systematic reviews. I could not find where in MEDRS that says a concise review of systematic reviews is a weaker source. The Ersnt source is not dated according to MEDRS. The source is not older than five years old. A narrative review of systematic reviews is a good source to keep in the article in accodance with WP:MEDRS. I asked "Please show high-quality evidence. Any evidence does not mean it is effective." You claim the Ernst source is inconsistent but I think it is not up to you to decide the level of evidence. Even when you tried to show newer systematic reviews claim chiropractic is effective for other treatments other than back pain you were unable to provide the evidence that newer systematic reviews show chiropractic is effective. The 2010 source is a 'report to review the literature. I'm not sure why the article claims it is a comprehensive review when the source says it is a report.

See Wikipedia:Identifying reliable sources (medicine)#Use up-to-date evidence:

"Look for reviews published in the last five years or so, preferably in the last two or three years. The range of reviews you examine should be wide enough to catch at least one full review cycle, containing newer reviews written and published in the light of older ones and of more-recent primary studies."

"Within this range, assessing them may be difficult. While the most-recent reviews include later research results, do not automatically give more weight to the review that happens to have been published most recently, as this is recentism." QuackGuru (talk) 21:58, 21 March 2011 (UTC)

Osteopathy

Why no mention of the obvious and, to the public, very similat therapy Osteopathy? — Preceding unsigned comment added by 207.245.198.135 (talk • contribs) 2011-02-22, 17:15

There currently exists in the article the sentence: "Chiropractic overlaps with several other manual-therapy professions, including massage therapy, osteopathy, physical therapy, and sports medicine." Further, in the LEAD, chiropractic is described as: "The main chiropractic treatment technique involves manual therapy, including ...". The description of manual therapy implies the similarity with other manual therapy professions, and the linked article on manual therapy further makes this comparison. There may be room for expansion of the sentence in the LEAD to explicitly state the similarity to other manual therapies, but I dont know that this is necessary.Puhlaa (talk) 20:13, 24 February 2011 (UTC)

Recent edit says Disorders = subluxations

Lets not use wikipedia to push what WE think "defines" chiropractic! The World Federtaion of Chiropractic (WFC) is made up of the national associations of chiropractors in 85 countries. The WFC represents them and the chiropractic profession in the international community. The WFC defines chiropractic as:

"A health profession concerned with the diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, and the effects of these disorders on the function of the nervous system and general health. There is an emphasis on manual treatments including spinal adjustment and other joint and soft-tissue manipulation."

My two cents: While "subluxation" was traditionally a term used by chiropractors to describe the spinal dysfunctions they treat, it is not consistent with "current chiropractic", nor is it what "defines" the profession. After 3 years in chiropractic college I have not heard subluxation once with regard to diagnosis or treatment! The only time I have heard the term used is in chiropractic history class. The same can be said by my colleagues at NYCC, NUHS, WSCC, etc. There are few schools still instructing the use of this term as it is inconsistent with its greater usage in "conventional medicine" and causes confusion. Besides, if chiropractic were to be defined by any single thing, it would be spinal manipulation. — Preceding unsigned comment added by Puhlaa (talk • contribs) 23:18, 3 March 2011 (UTC)

Puhlaa, I can agree with your last sentence, and that should actually be added (let's remember to do it), but otherwise your school and the scientific reform, anti-vertebral subluxation position is still a minority position, so much so that the National Association for Chiropractic Medicine actually gave up their reform efforts and closed shop. Reform has been well-nigh impossible to push through. As a science based chiro student you know this and I'm surprised. I suspect you only surround yourself with other likeminded chiros and are oblivious to what's still going on in the rest of the profession. The ICA and WCA are still very much alive and active, but the NACM is gone. The subluxationists have won.

Most (all!) middle aged and older practicing chiropractors were educated under the subluxation paradigm and will not allow a non-subluxation based new chiro to work for them, and most new graduates are still from straight schools, at least in the USA, which produces most chiros.

I don't know what the situation is in Canada, but in the USA chiropractic is legally defined by the vertebral subluxation and only subluxation treatment is reimbursed, which puts the profession in a real dilemma. If they don't treat subluxations, Medicare won't pay. It's the legal and philosophical foundation of the profession, so even those modern chiros who would like to change things can't do it. That would break the law that defines the profession.

You lead out with an ironic accusation: "Lets not use wikipedia to push what WE think "defines" chiropractic!" Not only would WP:Kettle apply, but I'd say it's the other way around. You're trying to force the article to describe the profession the way you WISH it were, but you're wrong. (Another Canadian chiro...who is banned... tried to do the same thing.) The profession is much more than Canada. Again, I sympathize with your plight, but that's life. The profession isn't out of the forest of pseudoscience quite yet. There are clearings in the forest that enclose pockets of scientific fresh air, and you operate in one, but that's not the whole forest. The rest of the forest is still filled with plenty of dank, damp, rotting pseudoscience fumes. Too many chiros are educated in subluxationism, and they won't give up, and USA Medicare and state laws prevent even those who'd like to change things from doing so. It's written in black and white in the laws defining what chiropractors are allowed to do, and what they are required to do, each and every treatment. This situation was all created so that chiropractors couldn't get prosecuted for practicing medicine without a license, and so they could get reimbursed.

In the UK the GCC recently dissed the subluxation, but the BCA has fought back and the GCC has backed down and modified their position, so subluxationism is still alive and well in the UK, just as it is in the USA. Reform is being resisted by the rank and file. Too bad.

BTW, you've worded the heading misleadingly. That was in my edit summary. Otherwise, to sum this up, the article isn't about what we might wish chiropractic were (we both wish it would drop the old VSC nonsense), it's about what it is, both new and old, good and bad. My edit made it clear what the reality is. I'm willing to tweak it if you have some suggestions for improvement, but wholesale reverting isn't called for since my edit made the initial introductory sentences more accurate. As it was it described my profession of Physical Therapy (!), without mentioning what was unique to chiropractic. That came too far down in the lead, and I fixed that. Readers should know immediately what makes chiropractic unique and special. It shouldn't be buried way down there because some science based chiropractic editors are embarrassed by the fact. That's POV editing and that's not allowed here. This isn't a brochure describing some ideal image according to a newer and future paradigm that is only in place in a few spots.

Now, let's look at that edit in the subsection below and see if it can be improved. -- Brangifer (talk) 08:33, 4 March 2011 (UTC)

Tweaking the first sentence of the lead

First tweak by Brangifer

I made an edit (underlined below) which got reverted:

• "Chiropractic is a health care discipline and profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especiallyprimarily through treatment of vertebral subluxations of the spine, under the hypothesis that these disorderssubluxations affect general health via the nervous system."

What is wrong with that? Before it was the definition of Physical Therapy. Now it describes chiropractic as it is in most places, and as it is legally required to be in the USA.

Let's also remember to incorporate the idea in your good comment above:

"if chiropractic were to be defined by any single thing, it would be spinal manipulation."

That too is true, but what is being adjusted is the vertebral subluxation: "manual manipulation of the spine to correct a subluxation". That's by law in the USA. Both words are present:

• "The Social Security Act limits Medicare coverage for chiropractic services to "treatment by means of manual manipulation of the spine to correct a subluxation demonstrated by x-ray to exist." Because chiropractic theory regarding illness differed so greatly from mainstream medicine, the x-ray requirement was written into the benefit as an attempt to "control program costs by insuring that a subluxation actually exists." The consensus, from the chiropractic community as well as representatives of the health care field, is that the x-ray requirement has not served this purpose." [42]

In 2000 the x-ray requirement was dropped, but the wording is still the same. Note that it must be "manual". All the instrument adjusting is actually not billable, but in practice it is billed and paid. To bill Medicare for a treatment, IF the chiropractor carefully follows the law, the treatment session must include a "manual" manipulation of the "spine", using a "subluxation" diagnosis, regardless of what's wrong with the patient. American law requires chiros to practice straight chiropractic. That's a far cry from what you've been doing at CMCC, but CMCC graduates are still practicing subluxation-based chiropractic all over the world. Even if the new ones weren't trained that way, they can rarely get an internship where they are not required to begin practicing this way, and they quickly get turned into subluxation-based chiros to survive.

THAT'S the reality which this article must describe. If we followed policy here and included the contents of the Chiropractic controversy and criticism article in this main article, it would be more evident what the reality of the situation really is, but the subject matter in that article can only exist at Wikipedia because it is hidden away from the public "over there". That's because of some very obstinate subluxation-based (and then a banned anti subluxation-based) editors we've had here who controlled this article. Each for very different motives chose the same solution - hide the embarrassing facts. -- Brangifer (talk) 08:44, 4 March 2011 (UTC)

Second tweak by Ocaasi

Why don't we emphasize the complexity, tradition, and variance in the definition. As an encyclopedia, we shouldn't "pick" which definition is accurate; we should take seriously that we can summarize the dispute among sources. For example:

Chiropractic is a health care discipline and profession that emphasizes diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system, traditionally through management of vertebral subluxations--misalignments of the spine--under the hypothesis that they affect general health via the nervous system. The most common method of treatment is direct spinal manipulation, although chiropractors also..."

Whatcha think? Ocaasi (talk) 18:13, 4 March 2011 (UTC)

Bingo! That's PRECISELY the direction we should be going, and which policy requires. While using definitions from RS isn't forbidden and is often a good thing, a Wikipedia lead as a whole summarizes the whole article, and the first sentence(s) should provide a definitional description, but still based on the whole article, not some external quote of an existing definition not based on our NPOV/covering-all-significant-POV article content. That's why Wikipedia definitions end up being better than definitions from any other source. Those definitions are usually founded in a specific promotional agenda, and the WFC definition is such a definition. It's a promotional, wishful thinking, marketing tool.

Your suggestion is very good. Let's work on it as it has great potential. -- Brangifer (talk) 19:01, 4 March 2011 (UTC)

My first tweak would be to leave out the explanation of VS, as that describes a real, orthopedic "subluxation", not the chiropractic VS, which is a fictional entity unlike the mainstream definition of "subluxation", although the chiropractic VS includes real subluxations. Even the WHO notes the difference. By using those words, we're actually making it sound like chiropractors are always treating real subluxations, when that is rarely the case, and when sensible chiropractors encounter them, they will often send the patient directly to the emergency room. We should also link to spinal adjustment, not to manipulation, since that's what makes chiropractic unique. The difference isn't physical, but philosophical. -- Brangifer (talk) 19:01, 4 March 2011 (UTC)

My second idea would be to add to or modify the "mechanical disorders of the musculoskeletal system" wording, since the reason for manipulating the spine is either for treating back pain, or, when performed by straight chiropractors, for treating ALL diseases in the body, not just the musculoskeletal system. They are interested in treating the whole body, which they believe can be done by tweaking the spine.

We just need to make sure the description includes all facets of chiropractic as practiced today, both the minority, more science-based kind, and the majority straight kind. Regardless of the fact that a number of chiropractic schools are phasing out the use of the word "subluxation", they are still teaching the same form of treatment, but using other words, and pretty much all the existing middle aged and older chiropractors are actually subluxation-based and force even their science-based interns to practice that way, thus undoing their education. That's reality, and we must describe it, not some future ideal as envisioned by modern reform chiros and critics of chiropractic. -- Brangifer (talk) 19:01, 4 March 2011 (UTC)

Third tweak by Brangifer

Here's a tweak of Ocaasi's version:

Chiropractic is a health care discipline and profession that emphasizes diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system, traditionally through management spinal adjustment of vertebral subluxations--misalignments of the spine--under the hypothesis that they affect general health via the nervous system. Straight chiropractors use spinal adjustments to treat all diseases, including visceral conditions. The most common method of treatment is direct spinal adjustment, although Chiropractors also use other methods..."

How about that? Please suggest tweaks. -- Brangifer (talk) 19:16, 4 March 2011 (UTC)

Fourth tweak by Ocaasi

• I like getting rid of 'management' which was a weak word. "Spinal adjustment" is probably a tad redundant, since we're talking about subuluxations--I think just 'adjustment' would suffice.
• I think we should define subluxation in the lead. You might take issue with 'misalignments' since it suggests they exist but I think we need a simple explanation... Maybe 'theorized misalignments' or something...
• Hesitant to use the term Straight until we've given an overview of the field and differences among practitioners.
• I'd like Puhlaa's input for rounding out the not-traditionally side of things, since we give an indication that treating subluxations certainly used to be the primary method, and may still be, but haven't filled in the holes about what alternative treatments there are, and how prominent they have become. Ocaasi (talk) 19:34, 4 March 2011 (UTC) So my best so far would be:

Chiropractic is a health care discipline and profession that emphasizes diagnosis, treatment, and prevention of mechanical disorders of the musculoskeletal system, traditionally through adjustment of vertebral subluxations--theorized misalignments of the spine--under the hypothesis that they affect general health via the nervous system. The most common method of treatment is direct spinal adjustment, exclusively so for classically trained or Straight chiropractors who adhere to the subluxation model as the cause of all disease. Non-Straight Chiropractors, or Mixers, also use other methods including [... ... ...]. Something about modern, scientifically based practices...

Just throwing some out there. Ocaasi (talk) 19:46, 4 March 2011 (UTC)

Excellent! This is getting to be quite good. -- Brangifer (talk) 01:12, 5 March 2011 (UTC)

A couple points. First, although there may still be a few dogmatic nuts around, most chiropractors do not believe that subluxation is a misalaignment of the vertebrae. This was one of Palmers original therories, and was tossed out along time ago. I would encourage you to read this short paper on the evolution of the chiropractic subluxation by Howard Vernon [43]. Thus, including this statement in the definition is troublesome, it belongs in the history of subluxation section in the body. Second, your definition uses traditional and straight, one should be used consistently. I prefer traditional, as the straight/mixer thing is becoming obsolete because only one school in the world teaches true straight chiropractic anymore - Sherman - hands only, spine only. It has become more of a traditional/dogmatic group vs a modern/evidence-based group. Third, there is a mistake in your definition of traditional/straight chiropractors as they dont believe subluxation causes all disease, they believe it causes dis-ease (lack of ease or improper body function). They believe only a body not functioning properly (dis-eased) gets disease. It is confusing, but very few chiros will say they can cure disease, they cure dis-ease and the body then cures the disease (clear as mud?). I even agree with this to a small extent, as a person not functioning optimal (weak immune system, no sleep, in pain, etc.) will get sick easier than someone who is functioning optimally. Modern chiros just dont agree that spinal manipulation is the #1 way to prevent dis-ease to prevent disease :) PS. why is there a seperate article for adjustment and spinal manipulation? This is ridiculous! They should be merged, or spinal adjustment article just deleted. Adjustment is spinal manipulation, just with some dogma thrown in the mix. Was this done by a traditional chiro trying to emphasize the dogma in his practice?

Lastly (for now), It seems that your new definition contains all the info that already exists in the first paragraph of the LEAD, just in a diferent order? If you are just wanting to emphasize the pseudoscience (which is what it appears), then just move the last sentence of the fist paragraph from the article "Traditional chiropractic assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body's function and its innate intelligence,[6] a vitalistic notion that "brings ridicule from the scientific and health care communities and confusion within the chiropractic profession."[7]" And place it as the second sentence instead. Thus, the opening paragraph would be:

• Chiropractic is a health care discipline and profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine, under the hypothesis that these disorders affect general health via the nervous system.[1] Traditional chiropractic assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body's function and its innate intelligence,[6] a vitalistic notion that "brings ridicule from the scientific and health care communities and confusion within the chiropractic profession."[7] Chiropractic is generally categorized as complementary and alternative medicine (CAM),[2] a characterization that many chiropractors reject.[3] Although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry or podiatry.[4] The main chiropractic treatment technique involves manual therapy, including manipulation of the spine, other joints, and soft tissues; treatment also includes exercises and health and lifestyle counseling.[5]

Puhlaa (talk) 19:00, 5 March 2011 (UTC)

Objections by Puhlaa

Sorry to be a stick-in-the-mud, but at the moment I am still somewhat disappointed that two veteran editors would be trying to synthesize (WP:OR?) a new definition of chiropractic to open the LEAD when there is already a definition in the LEAD that meets WP:V. BR, you accuse me of WP:kettle for saying that the current LEAD (that meets WP:V) should remain instead of your WP:OR definition? Please explain? Have you both sat back and thought about if it is consistent with wikipedia policy to synthesize a new definition of chiropractic just so that you can include a couple dogmatic words that YOU think defines the profession? A good explanation for what you are doing is NOT because the LEAD must summarize the body, as subluxations have already been introduced in the LEAD ("For most of its existence it has battled with mainstream medicine, sustained by pseudoscientific ideas such as subluxation and innate intelligence").

IMO, If you are not happy with the current definition found in the LEAD, then an alternate definition that meets WP:V and pleases all editors should be used rather than a critic and a layperson trying to synthesize a new definition that suits their view of the profession. BR, if you are not happy with the current definition in the LEAD (which is from the world federation of chiropractic, a body that represents 85 national chiropractic associations including the ACA and the CCA), perhaps one of the following established definitions that meets WP:OR will work:

• Medicare [44]: "Chiropractic Medicine - employs manipulation and adjustment of specific areas of the body (often of the spine) to prevent and treat disease and nerve function."
• The National Center for CAM (NCCAM) [45]: "Chiropractic is a health care profession that focuses on the relationship between the body's structure—mainly the spine—and its functioning. Although practitioners may use a variety of treatment approaches, they primarily perform adjustments (manipulations) to the spine or other parts of the body with the goal of correcting alignment problems, alleviating pain, improving function, and supporting the body's natural ability to heal itself."
• The Association of Chiropractic Colleges [46]: "Chiropractic focuses on the relationship between the body's main structures – the skeleton, the muscles and the nerves – and the patient's health. Chiropractors believe that health can be improved and preserved by making adjustments to these structures, particularly to the spinal column. They do not prescribe drugs or perform surgical procedures, although they do refer patients for these services if they are medically indicated."

If you are insistent on including the word subluxation because for some reason you think this "defines" chiropractic, then what about the definition from

• The World Health Organization: "A health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health. There is an emphasis on manual techniques, including joint adjustment and/or manipulation with a particular focus on subluxations."

If none of these, then somone is going to have to explain to me why a newly synthesized definition is better than an established definition by one of the above well established bodies. Please include in the explanation how this meets wikipedia policy. If that happens (as I might be completely wrong about all this) then I will assist in producing a brand new definition of chiropractic with the two of you that includes the words that YOU say define chiropractic. Puhlaa (talk) 00:46, 5 March 2011 (UTC)

Two quick points. One, I'm not that veteran, though I take your concern seriously.

Two, we're not trying to "write" a definition whole-cloth, but to synthesize a definition (a bad word, but only OR if it's not back-up-able by sources) considering that there are some differences of emphasis or outright approach among Chiropractic organizations and practitioners. The reason I am inclined to this approach is that definitions are concrete things but which one do you pick? So we write 'our own' but it's more a nod to summary than synthesis, I believe. Some editors have less tolerance for this kind of thing and see it as clearly outside of policy (and certainly OR misuses can happen under the flag of 'summary'); meanwhile, BR and I, along with some other editors feel that we are in a unique position to necessarily and even optimally summarize competing, subtly varying, or just differently worded approaches. Therein lies a difference of approach, but as long as it comes out with a definition that all parties reasonably agree on, and which covers major aspects presented in most sources, in a way which is accessible to the reader... I personally don't care where we got it.

So let's get to the issue--what is wrong with the proposed drafts? How would you 'define' the field properly, to take into account both the breadth, tradition, complexity, deviations, and change?

A quick note, I thought 'traditionally' made the reference to subluxation much less 'dogmatic'. I have no problem with a variety of approaches here, as long as we cover all of the bases, one of which--and not a trivial one at that--is the Straight/historical side of subluxation. However we present that is ok with me, and maybe it doesn't belong in the first sentence... but the second or third? Ocaasi (talk) 01:00, 5 March 2011 (UTC)

Puhlaa, you're definitely not a stick-in-the-mud! Your input is valued and we were waiting for it. I think we can hammer this out together into a consensus version. There is no rush.

The first thing to do is make it clear that we're doing what is required at Wikipedia, and it's not OR. We are summarizing the article, but summarizing the parts (which are indeed sourced) which can be used to make a definition/description that is based on the article contents, not an unbalanced or promotional definition from somewhere else. Like I said above, it's not wrong to use such definitions as content, but if they aren't based on our article's contents, we need to make our own Wikipedia definition/description which more accurately describes the profession. Our definition must also be an accurate description of all of chiropractic, not just of a part or future ideal. Go back above and read what I and Ocaasi have written as our justifications for doing this. Such summarization isn't even close to OR since it's based on sourced content. No new ideas are created in the process.

This doesn't prevent us from ALSO creating a section for various definitions, and that might be informative to readers and show how they vary. I wouldn't be averse to doing that at all. The danger of POV editing in that process is very real, because who's to decide which definitions to use? Cherry picking definitions is touchy business(!), but together we could probably agree on a handful to use. We just need to deal with the fact that definitions and descriptions from other sources don't do the subject justice since they are often conflicting, only written from one POV, or are promotional in nature, such as the WFC definition. That definition is so broad that it actually defines Physical Therapy(!), ignoring many aspects of the subject and actual practice. The part that is uniquely chiropractic comes too far down in the lead. -- Brangifer (talk) 01:48, 5 March 2011 (UTC)

The ACC paradigm definition of the profession and of VS is important to note here:

• "Chiropractic is concerned with the preservation and restoration of health, and focuses particular attention on the subluxation. A subluxation is a complex of functional and/or structural and/or pathological articular changes that compromise neural integrity and may influence organ system function and general health. A subluxation is evaluated, diagnosed, and managed through the use of chiropractic procedures based on the best available rational and empirical evidence." - "Technique systems in chiropractic"

Brangifer (talk) 02:01, 5 March 2011 (UTC)

Also, in keeping with Puhlaa's good point about the primacy of the adjustment, here's another good one:

• "SPINAL MANIPULATION: THE CORE CHIROPRACTIC ACT
  Adjusting with the hands—the signature chiropractic gesture—is the unifying activity that allows chiropractic to transcend its internal discord and create a coherent profession. Overriding disputes within the profession, the core question for all chiropractors remains unchanged and agreed on: how should the hands move the vertebrae? Beneath doctrinal disparity and clinical diversity, chiropractic has an internal cohesion that is more than a defensive reaction to a critical world. Chiropractors believe that the correction of spinal abnormality—the adjustment of vertebrae—is a critical healing act." [47]

Brangifer (talk) 03:44, 5 March 2011 (UTC)

Edit request from Mg87DC, 7 March 2011

{{edit semi-protected}} I would like to have the following added to the "Cost-effectiveness" section of this wiki page.

A 2010 research article found that beneficiaries had a 40% lower overall cost for treatment of low back pain when they initiated care with a DC than those who initiated care with an MD.

my cited source is as follows.

Cost of Care for Common Back Pain Conditions Initiated With Chiropractic Doctor vs Medical Doctor/Doctor of Osteopathy as First Physician: Experience of One Tennessee-Based General Health Insurer Richard L. Liliedahl, Michael D. Finch, David V. Axene, Christine M. Goertz Journal of Manipulative and Physiological Therapeutics_dev November 2010 (Vol. 33, Issue 9, Pages 640-643)

http://www.jmptonline.org/article/S0161-4754%2810%2900216-2/abstract Mg87DC (talk) 22:34, 7 March 2011 (UTC)

The source is not reliable. See WP:MEDRS. QuackGuru (talk) 18:16, 8 March 2011 (UTC)

The source is reliable and the study well done. However, we will have to wait until this study has been reviewed by a secondary source before it gets any mention in the chiropractic article on wikipedia, as this is consistent with the standards this article is being held to.Puhlaa (talk) 19:27, 8 March 2011 (UTC)

I cannot agree that the source is reliable, although the study appears well done. Does that journal have a good reference index? — Arthur Rubin (talk) 19:34, 8 March 2011 (UTC)

The journal is peer-reviewed and indexed on Medline, Index Medicus and Current Contents/Clinical Medicine. Further, the editorial board is made up of DCs, PhDs, PTs and MDs [48]. QG only objects because it is a "chiropractic journal", however, by this flawed and biased logic, no journal that was subject-specific could be reliable. Chiropractic articles are logically published in chiropractic journals just as pharmaceutical articles are published in pharmaceutical journals. As long as they are peer-reviewed, indexed and have a respectable editorial board then there can be no logical objection by wikipedia editors. However, this discussion is pointless at the moment as the article does not meet the current convention of only secondary sources being used in the chiropractic article.Puhlaa (talk) 19:54, 8 March 2011 (UTC)

According to Wikipedia's MEDRS, the source is not reliable when we have high-quality sources on the topic. QuackGuru (talk) 20:14, 8 March 2011 (UTC)

Could you please clarify what you mean (Puhlaa) that only secondary sources are being used in the (this) chiropractic article and why that is? This will help me to better evaluate research that is appropriate for this site. Mg87DC (talk) 21:08, 8 March 2011 (UTC)

Mg87DC, The chiropractic article is a controversial one, and there are strong emotions involved on both sides of the controversy. This is evidenced by the 'locked' state of the chiropractic article (vandalism control). In order to ensure that no 'side' of the controversy has more 'weight' carried in the article than is owed by the current level of scientific evidence, we seem to have to enforce ultra strict adherence to wikipedia policies. One important policy is WP:MEDRS, which gives a system of hierarchy to scientific articles. I have pasted a brief excerpt below, but the entire article might be worth a read to you if you want to contribute (which I hope you do).Puhlaa (talk) 21:54, 8 March 2011 (UTC)

• Knowing the quality of the evidence helps editors distinguish between minority and majority viewpoints, determine due weight, and identify information that will be accepted as evidence-based medicine. In general, editors should rely upon high-quality evidence, such as systematic reviews, rather than lower-quality evidence, such as case reports, or non-evidence, such as anecdotes or conventional wisdom.
• The best evidence comes from meta-analyses of randomized controlled trials (RCTs) and systematic reviews of bodies of literature of overall good quality and consistency addressing the specific recommendation. Narrative reviews can help establish the context of evidence quality. Roughly in descending order of quality, lower-quality evidence in medical research comes from individual RCTs, other controlled studies, quasi-experimental studies, and non-experimental studies such as comparative, correlation, and case control studies. Although expert committee reports or opinions, along with clinical experience of respected authorities, are weaker evidence than the scientific studies themselves, they often provide helpful overviews of evidence's quality. Case reports, whether in the popular press or a peer reviewed medical journal, are a form of anecdote and generally fall below the minimum requirements of reliable medical sources.

Since this issue is clearly being discussed, I'm untranscluding the edit request while y'all continue to debate the issue. Qwyrxian (talk) 06:21, 11 March 2011 (UTC)

While the journal may be peer-reviewed, the article is not so good. Self-referral of patients to different treatment modalities is always problematic unless a variety of confounding variables are controlled. In any event the effect is not 40% but rather 20% when the severity of the presenting problem is controlled. Perhaps someone who has read the entire article can comment on how issues such as houshold income, ethnicity, education levels, etc were controlled. I am not against including the article as long as the method and problems of the method are also presented.Desoto10 (talk) 23:42, 12 March 2011 (UTC)

The issues of household income, ethnicity, education levels as controls are not as important in this analysis because they have no known weight on the subject of Low Back Pain. However age, sex, and pharmacy claims are of greater importance to the efficacy of the study and are included in the Symmetry Pharmacy Risk Groups, which was used to help generate the results. It helps to remember that this article is not evaluating patient costs but costs incurred by the health insurance company, which is important because those numbers help to determine health care premiums. This research article gives a large sample population of 85,402 which is large enough to give an accurate general analysis but lacks in being able to determine how education levels influence the cost of Low Back Pain care. The major limitation of this article is that, while a huge sample population was used, the evaluation only used one providor, Blue Cross Blue Shield. As in any good research article, it generates more questions than it answers. Case and point "When controlled for ethnicity and household income do the costs change?", similarly a more interesting question may be to dig further into comparative research regarding the method of injury and cost analysis. Hope this helps! Mg87DC (talk) 17:48, 14 March 2011 (UTC)

Edit request from Mg87DC, 14 March 2011

{{edit semi-protected}} Please edit this sentence (first sentence of Straight-Mixers section). My reasoning being that straights and mixers are not separate professions but separate philosophies. Also the the use of the word 'masquerading' is derogatory, implying impersonation or deception.

Please change: Chiropractic is often described as two professions masquerading as one.

Replace with: Chiropractic is often described by two philosophies, straights and mixers, that differ on their approach to the treatment and understanding of vertebral subluxations.

Another edit I would like to request. Is of the last line of the second paragraph in the philosophy section.

Please Change: "Chiropractors study the biomechanics, structure and function of the spine, along with what they say are its effects on the musculoskeletal and nervous systems and its role in health and disease.[32]"

Replace with: Chiropractors study the biomechanics, structure and function, of the spine along with its effects on the musculoskeletal and nervous systems and its role in health and disease.[32]

My reason being that the words "along with what they say" is an unnecessary addition and not reflective of the source material.

Mg87DC (talk) 16:47, 14 March 2011 (UTC)

The masquerading bit is a direct quote from the reference:

"Chiropractic has frequently been described as being two professions masquerading as one, and those two professions have attempted to live under one roof." Perhaps it should be in quotations.Desoto10 (talk) 00:33, 16 March 2011 (UTC)

My edit for this 'quote' was intended to remove the negative connotation that chiropractic 'masquerades', or in other words is deceptive regarding its two philosophies. Sentences like these are generally from biased sources of professional skeptics 'masquerading' as reliable sources. See? My edits to this page are aimed at removing the bias while keeping the information the same. I believe that my edit removes the bias and maintained the information of the sentence that there are two separate branches to chiropractic in regards to philosophy (the subject of the section). My edit also removes the need for a direct quote by summarizing the meaning of the quote, it also makes for a smoother entrance into the discussion of straights and mixers. If this edit cannot be made then a new unbiased source must be found. Mg87DC (talk) 04:03, 16 March 2011 (UTC)

First, I dont think we can re-summarize the sourced text because an editor thinks the sources authors were too negative. Secondly, I like that a strongly negative connotation was associated with this sentence. This sentence was not from a biased skeptic, but from a group of evidence-based chiros who want the profession to leave the dark ages behind. A huge complaint of chiropractic is that as a patient, or as an MD referring their patient, you dont know if you are going to get 1) a modern, evidence-based chiropractor that will trreat the problem as efficiently as possible using therapies with known effectiveness, or 2) a traditional, philosophy-based chiropractor that will simply adjust the upper cervical spine of a patient with lateral epicondylitis because the elbow cant heal if the innate isnt flowing. Clearly there are two seperate professions here, and unfortunately they continue to pretend they are the same to the public. This seems like a masquerade to me.Puhlaa (talk) 19:20, 16 March 2011 (UTC)

I agree that your other request is somewhat valid--the referenced source (ACA History) does not say that chiropractors "study" anything. The ref states that they "attend to" these things. We need a better, unbiased source for this in any case. I believe the point of that sentence is that chiropracters work on the spine in order to improve health. The medical consensus seems to be that the "improvement of health" is restricted to improving lower back pain via spinal manipulation and not via a metaphysical mechanism which some chiropracters invoke (ie., innate heling).Desoto10 (talk) 00:48, 16 March 2011 (UTC)

you missed the point of the edit. When the original author of the page or whoever edited that sentence added "along with what they say". which adds bias to the statement by implying that the spine may not have an effect on the musculoskeletal system. (which it does, last time I checked the spine was part of a persons skeleton). Yes the medical consensus is that chiropractic is effective for pain relief of low back pain, when employed by a DC or DO. Innate healing has little to do with the effectiveness of treatment but more the hypothesis behind why chiropractic works physiologically. Regardless of belief in "Innate", spinal manipulation reduces low back pain. Example, if you cut your finger, why does it heal? *because homeostasis must be maintained and fibrin fills in the gap while inflammation slows down the blood flow and fights off bacteria, etc* Innate intelligence supposedly is the 'reason' that the body starts that healing process, it is the intelligence of your body to heal itself. for your finger to heal and scab over you didn't need to take an asprin and it wasn't because of the band aid, but the ability to maintain homeostasis.... I guess if you got rid of the words "Innate Intelligence" chiropractic might sound like "Chiropractors believe in the bodies ability to maintain homeostasis". Sorry for the rant by the way. If I clouded anything up please tell me! Mg87DC (talk) 04:03, 16 March 2011 (UTC)

Mg87DC, few people will argue with the bodies "innate" ability to heal itself....the debate comes when Chiros claim they can affect the bodies "innate" abilities simply by manipulating the spine. There is still no research-based evidence that spinal dysfunction interferes with the bodies normal homeostasis, nor that simply manipuating a dysfunctional spine restores that homeostasis. What we do know is that a dysfunctional spine can cause back pain and sometimes extremity pain, and manipulating the spine can relieve that pain. Thus, perhaps the sentence could be modified to:

"Chiropractors examine the biomechanics, structure and function, of the spine along with its effects on the musculoskeletal and nervous systems and what they believe to be its role in health and disease."

This change recognizes that there is no question that the spine affects the musculoskeletal system, and even the nervous system (via central sensitization), however attributes to chiropractors the idea that this can all affect general health. Puhlaa (talk) 10:28, 16 March 2011 (UTC)

I agree with Puhlaa. To Mg87DC, no, I got the point, but probably did not express myself clearly. First, I point out that the reference does not claim that chiropractors "study" anything but rather "attend to". This is not what our article says currently and that, at least, should be changed. In addition, as Puhlaa mentions, it must be made clear that the medical consensus is that spinal manipulation can help to relieve lower back pain only and, other than that, has no effects on "health". Improvement in general health via spinal manipulation is a claim by chiropractors and is not backed by scientific theory or evidence and, therefore, must be qualified as a claim by that group.Desoto10 (talk) 18:28, 16 March 2011 (UTC)

Mg87DC, for your first request I think removing "masquerading" would introduce bias, not alleviate it, since it is a direct quote from the source. For the second request, it looks like you have made a change already, and it looks fine to me. Leaving "masquerading" looks like it might be consensus, so please replace the edit request template with {{tlf|edit semi-protected}} if there's nothing further. Thanks, — Bility (talk) 22:50, 17 March 2011 (UTC)

Edit request from 90.203.158.224, 24 March 2011

{{edit semi-protected}} Please change A systematic review found that the risk of death from manipulations to the neck outweighs the benefits.[28] to In the past there has been a link between cervical manipulations and the occurrence of stroke [28] however, according to Cassidy et al 2009 the increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. Cassidy et al found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care. Cassidy et al. (2008). Risk of Vertebrobasilar Stroke and Chiropractic Care Results of a Population-Based Case-Control and Case-Crossover Study. European Spine journal. 17 (Supplement 1), 176-183. Pleas change this because the original statement is incorrect, if the risk of injury is the same as seeing your PCP then how does that outweigh the benefits?, surely that means along the same line of thinking that the risk of seeing you PCP outweighs the benefits of the treatment that they provide... stupid isnt it? There is evidence of cervical manipulation helping migraines, cervicogenic headaches, cervical facet syndrome and more... The editors of this page should also note the Edzard Ernst is known for his poorly constructed biased studies and manipulation of words against the chiropractic profession. Studies by this man are therefore considered to have poor reliability, read the study by him yourself, he references 27 incidences over the past century, if the same was applied to any other profession where a incident of death occurred at some point somewhere in the world then he would be able to make up the same stupid connections and conclusions and go on to twist words to embelish a biased viewpoint. 90.203.158.224 (talk) 16:22, 24 March 2011 (UTC)

"In the past there has been a link between cervical manipulations and the occurrence of stroke[28]"

This part of the proposal is vague and does not summarise any source.

"however, according to Cassidy et al 2009 the increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke."

The word "however" is WP:OR and similar text can be found in the body under sources [141][169]. "Several case reports show temporal associations between interventions and potentially serious complications. Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[141][169]"

"Spinal manipulation is frequently associated with mild to moderate adverse effects and with serious or fatal complications in rare cases.[26][27]"

The lead does explain the risk of fatal complications are rare. There is balance in the lead.

The lead says "A systematic review found that the risk of death from manipulations to the neck outweighs the benefits.[28]" CONCLUSION: "Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit."[49] The text is fairly accurate (even with the "by far" part removed from the lead).

Bias studies meet NPOV policy. See WP:NPOV: "As a general rule, do not remove sourced information from the encyclopedia solely on the grounds that it seems biased." See WP:V, WP:RS and WP:MEDRS for the reliability of sources. QuackGuru (talk) 17:46, 25 March 2011 (UTC)

QuackGuru, are you the same person as 90.203.158.224? What exactly do you want changed? It seems that you're comparing apples with oranges. Your requests do not really seem wholly logical. Banaticus (talk) 14:18, 26 March 2011 (UTC)

 Not done Did no one bother to read the template box? it says This template may only be used when followed by a specific description of the request, that is, specify what text should be removed and a verbatim copy of the text that should replace it. "Please change X" is not acceptable and will be rejected; the request must be of the form "please change X to Y"  Ronhjones  ^(Talk) 18:39, 29 March 2011 (UTC)

I think that we should reopen debate on this article by Ernst. After having read the study, and comments from Ernst regarding the systematic review which are seen on this page "Chiropractors have criticized this conclusion, claiming that the author did not evaluate the potential benefits of spinal manipulation.[174] Edzard Ernst stated "This detail was not the subject of my review. I do, however, refer to such evaluations and should add that a report recently commissioned by the General Chiropractic Council did not support many of the outlandish claims made by many chiropractors across the world."[174]" This admittance that benefits of spinal and or cervical manipulation were not evaluated for this report seems to me that the conclusion stated is unsubstantiated. This whole argument can be dismissed when the risk of a stroke from a neck manipulation is compared to the alternative medical treatment, NSAIDS or some other pain reliever, in which the risk of stroke or death is much higher from overdose or gastrointestinal bleeding. J Manipulative Physiol Ther 1995 (Oct); 18 (8): 530–536. And for those who want to jump on the date of the article, the data used in the Ernst review was much older and thus more unreliable. And systematic reviews main weakness is the bias of the author. It seems that there is still strong opposition to the Ernst article. And I maintain a skeptics view that it is possible that Ernst, Stephen Barrette and others are still fossils from an era where Medicine and Medical doctors were the unquestionable experts for medical advice, and that the departure from that over the past 50years eats at their egos (I know it would mine). While I'm still being skeptical, does anyone feel that many of these systematic reviews could be funded by the AMA and Big Pharma? Because of the fact that chiropractic is cheaper and just as effective for treatment of NMS pain, in which back pain is a $90 billion expenditure for Americans, $31 Billion is for outpatient visits, and $20 billion is for the drugs to treat that pain, and chiropractic is the largest conservative care option to take that money away from Big Pharma and MD's. ****

In a side Note. This whole chiropractic page is becoming very difficult to read and is confusing to read. Many articles appear several times and state the same thing. Also this article could just be titled Controversy in Chiropractic. Or a Skeptics view to Chiropractic.**** — Preceding unsigned comment added by Mg87DC (talk • contribs) 21:29, 11 April 2011 (UTC)

Regardless of the accuracy of the Ernst statement in the face of conflicting evidence, the statement doesn't belong in the lede. It creates undue weight positioned there. 68.122.51.169 (talk) 07:47, 20 April 2011 (UTC)

disease/dis-ease

Some recent edits to correct the dis-ease typo, which is not a typo.

I think we need to:

• put this in italics or
• put this in quotes or
• add a paraphrase/explnation or
• add a citation for the term or
• some combination of these

Not just so other editors don't fix the typo, but since dis-ease is a chiropractic term of art--jargon--and WP:JARGON is bad for readers. So we should explain how the term is used. Ocaasi ^c 19:48, 18 April 2011 (UTC)

Which ever of your above suggestions you like most is fine with me Ocaasi, I agree that it is important to add clarity here. I am not really familiar with the "dogmatic" chiropractic literature, the best source I could find at the moment to help was: Charles A. Lantz (1995) A Review of the Evolution of Chiropractic Concepts of Subluxation. Topics in Clincial Chiropractic;2(2):1-10 This source defines dis-ease as "dissonance or disharmony". Puhlaa (talk) 22:05, 18 April 2011 (UTC)

Upon further reading, I now think we should just leave it as "disease". I was unable to find chiropractic literature, besides the article above, that consistently used "dis-ease" instead of "disease". The one I found above does not source its definition, and it could thus be the authors interpretation? The addition of a hyphen doesnt seem to be an issue in the literature, so it seems more appropriate (and less confusing) to just use the direct term here rather than a dogmatic term that has not been defined very well. What do you think? Puhlaa (talk) 18:10, 5 May 2011 (UTC)

Suggested revision

I am recommending a change to the last sentence of the lead paragraph. Currently the lead paragraph concludes with:

• Traditional chiropractic assumes that a vertebral subluxation or spinal joint dysfunction interferes with the body's function and its innate intelligence,[7] a vitalistic notion that "brings ridicule from the scientific and health care communities and confusion within the chiropractic profession."[8]

However "joint dysfunction" and its effect on overall "function" (currently included in the pseudoscience sentence) is not disputed, for example, improved range of motion is an accepted outcome of joint manipulation by all professions who use it, and research clearly supports this. Including these ideas in the sentence dilutes and blurs the discussion of pseudoscience in chiropractic. What is pseudoscientific is the "vitalistic" idea of "subluxation" and "innate intelligence". I would thus like to remove the mention of "joint dysfunction" and "function" from the last sentence in the lead paragraph, making the sentence read:

• Traditional chiropractic assumes that a vertebral subluxation interferes with the bodies innate intelligence,[7] a vitalistic notion that "brings ridicule from the scientific and health care communities and confusion within the chiropractic profession.[8]

I would like to add a new final sentence that reads:

• Many of today’s chiropractors focus on musculoskeletal problems of the spine,[50] and want to seperate themselves from the traditional vitalism of innate intelligence.[51]

Puhlaa (talk) 17:30, 5 May 2011 (UTC)

While I haven't checked the sourcing/verifiability, the wording sounds good to me. DigitalC (talk) 19:16, 12 May 2011 (UTC)

If the text sounds good does not mean it complies with the lead. The lead must summarise the body. The quote in the lead is poor writing. Wikipedia articles must not be made up of quotes. See WP:LEAD. QuackGuru (talk) 19:02, 19 May 2011 (UTC)

Your statement makes no sense QG. If you took time to read the above you will note that the original text in the lead was already a quotation. This pre-existing quote has simply been augmented now by well-written text that more accurately summarizes the body as well as more accurately describes the profession. You never seemed to mind the quotation being there until now.....You will have to manufacture some other complaint to try and roadblock another good change. Puhlaa (talk) 19:14, 19 May 2011 (UTC)

"brings ridicule from the scientific and health care communities and confusion within the chiropractic profession.[8] Wikipedia articles are not based on quotes.

My statement is based on WP:LEAD. You have not explained how the text is a summary of the body. We have many peer-reviewed sources in the body. QuackGuru (talk) 20:15, 19 May 2011 (UTC)

Please stop ignoring what has been posted above. Please read the above and Hear that the quote was already in the lead and you never complained before. The changes discussed here do not alter the quote that you were ok with up till now. If you are unhappy with the quote you can start a new thread to discuss changing the quoted text that has been there a long time.

The body explains how there are different "groups" within chiropractic, ie: straights/mixers; traditional/modern; belief-based/evidence based. Further, the body discusses how subluxation and innate causes division within the profession. Further, the body discusses scope of practice. The text added to the lead introduces this division, as well as accurately describes the current profession with regard to scope and philosophy. Please dont pretend to not understand this any further.

Only one source has been added, the other is already used in the article. If a source had not been given then you would have whined about WP:V. If you still think that there are already too many sources in this article, perhaps we should start to remove those that are low-quality vanity press like "trick or treatment" to make room for higher-quality peer-reviewed sources that are being included now? Puhlaa (talk) 20:56, 19 May 2011 (UTC)

Snippet

This slipped into the Philosophy section. It doesn't look right:

Chiropractic care is an outgrowth of belief in the concept that your body has a natural and powerful ability to heal itself, your body's structure -bones, joints and muscles- and capacity for healthy function are closely intertwined and that Chiropractic treatment helps balance your body's structure and function and promotes self-healing.[52]

Ocaasi ^c 05:22, 24 April 2011 (UTC)

While the source is good enough, it's a very short copyvio that doesn't really add much, and the last statement that is purely promotional and unproven fluff: "helps balance....promotes self-healing". I don't really see a need for it as this is dealt with elsewhere much better. -- Brangifer (talk) 05:59, 24 April 2011 (UTC)

I thought we could rephrase it. Maybe

Chiropractic is rooted in the belief that the body has a natural ability to heal itself, and that Chiropractic treatment can balance and improve structure and function in the bones, joints and muscles, promoting that capacity for self-healing. [53]

Something like that, but with a citation template not an external link. Ocaasi ^c 06:04, 24 April 2011 (UTC)

Definitely better since there is no evidence that the claim is true. BTW, we already discuss vitalism in this article, so be careful you're not duplicating information. -- Brangifer (talk) 06:11, 24 April 2011 (UTC)

How about, "Chiropractic is an outgrowth of belief in the concept that the body has a natural ability to heal itself, and that Chiropractic treatment can balance and improve structure and function of the body's bones, joints and muscles to promote self-healing."

On a side note, speaking of duplicating information, this whole page is full of it. example from the controversy section "Unsubstantiated claims about the effectiveness of chiropractic have continued to be made by individual chiropractors and chiropractic associations. The core concept of chiropractic, vertebral subluxation, is not based on sound science, and the concepts of subluxations and innate intelligence have been characterised as pseudoscientific.[184] and the utilization/satisfaction section."Unsubstantiated claims about the efficacy of chiropractic have continued to be made by individual chiropractors and chiropractic associations.[17". Yet in the past few months the page has really come around to be more informative, less "keep the fear alive" and easier to read. Cheers 99.69.85.100 (talk) 20:30, 23 May 2011 (UTC)

vertebral subluxation

This concept is no longer a "core concept" in chiropractic, in fact the U.K. Chiropractic council clearly rejects this concept (see vertebral subluxation). I deleted "core concept" and replaced with "core concept of certain branches of chiropractic". It can't be a core concept if it is rejected by one of the most prominent head associations. --MATThematical (talk) 18:31, 19 May 2011 (UTC)

Sounds good to me. I agree that it is no longer a "core" concpet, except for a minority group of chiropractors clinging to tradition instead of science. We might replace "core concept of certain branches of chiropractic" with "core concept of traditional chiropractic", but either way...... Puhlaa (talk) 18:35, 19 May 2011 (UTC)

Please provide WP:V for the change from the source being used. QuackGuru (talk) 18:56, 19 May 2011 (UTC)

We can use:[54]. I have added some of the relevent text below.Puhlaa (talk) 19:22, 19 May 2011 (UTC)

See WP:SUMMARY for the section. QuackGuru (talk) 20:17, 19 May 2011 (UTC)

Not sure what you are referring to with WP:Summary (an article that talks about how pages can grow really long and need to be summarized). Here is the source that officially that shows the General Chiropractic Council (GCC) has come out against subluxation [55] --MATThematical (talk) 22:58, 19 May 2011 (UTC)

The section Chiropractic#Controversy is a summary of the controversy article. I request V for the recent change. QuackGuru (talk) 17:23, 20 May 2011 (UTC)

The fact is without the change its a summary that contains the statement A, when the actual article says not A (the actual wikipedia article itself says that the GCC rejects vertebral subluxation). The word traditional needs to be placed (perhaps instead of different branches). I provided WP:V that the General Chiropractic Council (GCC) no longer accepts vertebral subluxation. Considering this source is more recent than the current source used, it suggests that the sentence prior to the edit is factually inaccurate. If it is not currently a core belief, and there is WP:V that it is not, then it should not be stated. So here are the options remove the first part of the sentence, and just start the paragraph with vertebral subluxation, replace the branches clause with traditional, or just leave it as it is. I would suggest the second choice, there doesn't seem to be any WP:V that talk about different branches.--MATThematical (talk) 17:58, 20 May 2011 (UTC)

Puhlaa and MaTThematical, I disagree. It's still a core concept. You're basically making an OR change based on ONE (disputed) instance in a minority area of the profession:

• The UK is a relatively small part of the profession. The USA is by far the largest and most influential. We can't use exceptions (Canada and the UK) to dictate for the majority position.

I dont think it is OR, but I do understand the point you are making.Puhlaa (talk) 20:13, 25 May 2011 (UTC)

• The UK chiropractors and their organizations reacted violently and complained about the original GCC statement (the one you're referring to), so much so that the GCC revised the statement and issued a newer, softer, one! They actually were forced to backpedal. The GCC's original position statement was correct (IMO), but they softened it because the professional organizations in the UK didn't like it. In practice UK chiropractors still practice as if the subluxation was a major core concept, much like their American counterparts. Many have changed their terminology and don't use the word itself, but they are just using other words and practicing in exactly the same way. The same for Canada. When you see an actual radical change of practice, THEN you'll know a real change has happened. That change would be much less use of spinal manipulation, in fact only in a minority of cases, much like Physical Therapy practice.

• The most important fact here, which makes the OR quite apparent, is that the position statements by the ACC and WFC are still in effect. They have not renounced the subluxation and the GCC doesn't speak for the UK chiropractic organizations. They still object to the original GCC statement.

Sorry, but we can't use OR or apply exceptions in the corners of the profession to the whole profession. The exceptions can be noted if well documented. That's all we can do. The subluxation is still a core concept. The VS article is lacking some information regarding the controversy in the UK and needs to be updated. -- Brangifer (talk) 18:01, 20 May 2011 (UTC)

Thanks for the clarification. Just to clear its not an example of OR though, its an example of a disagreement over the word core. The GCC is a major body, and the word core is a soft word that really has no meaning. I think the sentence is more meaningful if it starts with vertebral subluxation. The current reference, a book from 1954 can't defend the statement that it is currently a core belief. Either we need a better reference or we should just start the sentence with "vertebral subluxation". I agree with you though, if we define core in the way that you do, I would say that vertebral subluxation is a core belief, but the current reference does not say that it is currently a core belief (it can't because it is over 55 years old). --MATThematical (talk) 18:15, 20 May 2011 (UTC)

"The UK is a relatively small part of the profession. The USA is by far the largest and most influential. We can't use exceptions (Canada and the UK) to dictate for the majority position." We also can't violate WP:WORLDVIEW by ignoring the differences in Canada and the UK. DigitalC (talk) 15:46, 29 May 2011 (UTC)

So basically give me a WP:V reference that it is currently the most important core concept in Chiropractic, and the sentence as it is now written can stay. If that is not possible give a reference that it is currently a core concept in Chiropractic, and then we will leave the sentence as is except change "the" to "a" in the first part. Otherwise we should just delete the first clause. --MATThematical (talk) 18:20, 20 May 2011 (UTC)

A chiropractic draft page can be started to fix the mess. There is too much confusion and OR remaining in the article. QuackGuru (talk) 18:26, 20 May 2011 (UTC)

Text added by Puhlaa (see above):

• Against the Notion of "Innate Intelligence"

Palmer's notion of innate intelligence (see the subsection on "Magnetic Healing" under "Chiropractic's Origin") was in dispute from the beginning. Many of his first disciples, destined themselves to be influential teachers of chiropractic, never adopted it......The first chair of what became the Council for Chiropractic Accreditation, Claude O. Watkins (1909-1977), called for scientific research and the abandonment of all cultist and vitalist principles, starting with that of the innate. Today, a substantial number of chiropractors are anxious to sever all remaining ties to the vitalism of innate intelligence. For these practitioners, the notion of the innate serves only to maintain chiropractic as a fringe profession28 and to delay its "transition into legitimate professional education, with serious scholarship, research, and service."

• Against the Notion of Subluxation

Palmer's followers were also quick to amend the notion of subluxation. For Palmer, the term referred to the static misalignment of a single vertebra.....Support for the original notion of subluxation was also reduced by continuous biomedical criticism that points away from, and finally discounts, bone alignment as the cause of back pain. The criticism of an anatomist who concluded after a series of experiments that it is nearly impossible for vertebral displacement to impinge on a spinal nerve at the intervertebral foramen has also weakened allegiance to the concept. Many chiropractors no longer refer to simple subluxation but to a "vertebral subluxation complex," with an expanded meaning of mechanical impediments beyond bone displacement that can include mobility, posture, blood flow, muscle tone, and the condition of the nerves themselves. Some want to abandon the term altogether because it "threatens to strangle the discipline." Others speak of manipulable spinal lesions, chiropractic lesions, or vertebral blockage.

Puhlaa (talk) 19:22, 19 May 2011 (UTC)

Summary violation

"and the concepts of subluxations and innate intelligence have been characterised as pseudoscientific.[184]" QuackGuru (talk) 18:20, 20 May 2011 (UTC)

I am sorry, I do not understand what the violation is? Is it the use of a quotation? — Preceding unsigned comment added by Puhlaa (talk • contribs) 20:15, 25 May 2011 (UTC)

The text is not a summary of the other article and the text fails V. QuackGuru (talk) 23:54, 28 May 2011 (UTC)

Reviewing Chiropractic Risks

In the article cited in Internal Journal of Clinical Practice (2010) by Ernst, there seem to be assumptions made regarding the mortality of the 26 deaths and linking them directly to chiropractic manipulation. Reading further into the study, one will find out that the time of death was not immediately following the manipulation or soon thereafter, In fact of the 26 deaths, more than half of them (14) had either unknown times of death or deaths at a much later time, as many as 58 days, following the manipulation. To attribute the death to manipulation without examining all known factors such as presence of arteriopathy (genetic weakening of the arterial wall), other medications that may have caused complications such as clots or excessive bleeding, or the method of manipulation (the force and direction of the adjustment) leads to many unanswered questions regarding the method of this study. It also seems difficult to extrapolate the conclusions drawn from the study.

Like any other physician, chiropractors or osteopaths should perform necessary orthopedic tests, including vertebral basilar artery insufficiency screenings. Along with the patient history and past medical records, a physician can draw a confident impression of the risks for VBAI indications. Although not without risk, it minimizes a patient's possibility to adverse reactions. It should also be understood that no one type of physician who performs manipulation has a higher or lower incidence of risk according to their profession. As a potential patient however, it is important that you seek a competent practitioner with the proper training as much experience as you can find. —Preceding unsigned comment added by Drcharleshecht (talk • contribs) 20:37, 22 May 2011 (UTC)

Since when is there a reliable VBA insuffieciency screening? [citation needed]. Also, all of this is WP:OR. DigitalC (talk) 16:17, 25 May 2011 (UTC)

While I agree with some of the points being made by Drcharleshecht, I also agree with DigitalC's overarching comment that it is OR. I also agree that VBA insufficiency screening is unreliable and is no-longer recommended in best-practice guidelines (for chiropractors anyways). We are now taught to thoroughly screen for general risks of stroke (smoking, BCP, hypertension, etc) and use these to categorize the level of risk of serious adverse events for a patient. There is also alot of emphasis put on identifying subtle signs of stroke-in-progress (eg: signs of DAN and cranial nerve screens).Puhlaa (talk) 20:27, 25 May 2011 (UTC)

Puhlaa and DigitalC are totally correct. The same applies for Physical Therapists. The tests aren't reliable. Just because someone passes them doesn't mean they can't get an injury or stroke. The tests only give a false sense of security that puts the patient at risk. -- Brangifer (talk) 16:39, 27 May 2011 (UTC)

Real orthopaedic subluxations versus imaginary chiropractic subluxations

An interesting article from Focus on Alternative and Complementary Therapies, an official journal of the Royal Pharmaceutical Society:

• Homola, S. "Real orthopaedic subluxations versus imaginary chiropractic subluxations". Focus on Alternative and Complementary Therapies, Volume 15, Issue 4, pages 284–287, December 2010. Article first published online: 25 NOV 2010. DOI: 10.1111/j.2042-7166.2010.01053.x Royal Pharmaceutical Society

Brangifer (talk) 16:26, 29 May 2011 (UTC)

Issues with this article

For a start, I find it too US-centric. Other editors have already pointed out that various "core beliefs" are rejected in the UK. Also, I think that undue weight is being given to issues such as those listed under Public health regarding Fluoridation. It is as if someone wanted the reader to make the mental link of "well, if they are against so and so, they must be nuts, etc". This is my first reading of the article and have not followed it in the past. I just thought I should start a healthy dialogue about it. --Phagopsych (talk) 11:34, 25 June 2011 (UTC)

Phagopsych, First, I agree that the article is very US-focused, and that the majority of chiropractors in the UK, Canada, Switzerland and Denmark are very different from the majority of chiros in the US. However, this emphasis on US chiros is very much related to the fact that there are about 50,000 chiropractors in the U.S. and only about 10,000 in Canada, UK, Switzerland and Denmark combined. There are 2 potential ways to improve this I guess; we could ensure that each section in the article has a brief discussion about what is different in other countries, or, we could start a new section in the article that specifically examined the national variation amongst chiropractic. Second, I agree that issues regarding fluoridation does not really distinguish chiropractors anymore, this discussion could be changed, shortened, or just removed IMO. Puhlaa (talk) 15:41, 25 June 2011 (UTC)

Two good points. I like the idea of taking a paragraph to note regional differences. Do we have sources on this? Also, we should mention that Chiropractors supporting anti-fluoridation efforts and other alternative causes (notably anti-vaccination) is part of the field's historical and fringe milieu, and we should note the areas of Chiropractic in which those old beliefs are being taken to task. Again, any sources? Ocaasi ^{t | c} 18:24, 25 June 2011 (UTC)

Vertebral artery dissection mass original research editing against core Wikipedia policies

Discussion is related to improving this article.

Do you support mass original research? This part of the proposal is to rewrite a vague/unsourced sentence in Traumatic. The main problem is the current vague sentence. Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection. Proposal to improve the incoherent vague sentence. The causality between chiropractic, particularly neck manipulation, and vertebral artery dissection is probable. Current paragraph in Traumatic. Chiropractic and other forms of neck manipulation have been linked[original research?] to vertebral artery dissection. In hospital-based studies this was the underlying cause for 16–28% of cases, but[original research?] it has been suggested[original research?] that the true figure may be higher and that there is significant under-reporting. Reports of the association are of weak to moderately strong quality, but[original research?] many of the reports have methodological flaws. The association between chiropractic neck manipulation and vertebral artery dissection is disputed by proponents of these treatment modalities.[original research?] I request WP:V for the text that seems to be inaccurate or is original research. I propose the following text to remove the rest of the WP:OR, taken out of context opinion. Proposal to improve current paragraph with this rewrite. The causality between chiropractic, particularly neck manipulation, and vertebral artery dissection is probable. In hospital-based studies this was the underlying cause for 16–28% of cases. The true figures for vascular accidents is higher because there is substantial underreporting. Reports of the association are of weak to moderately strong quality, and many of the reports have methodological flaws. Discussion. See WP:MEDRS: Ideal sources for these aspects include general or systematic reviews in reputable medical journals; professional and academic books written by experts in a field and from a respected publisher; and medical guidelines or position statements from nationally or internationally reputable expert bodies. See WP:WEIGHT: Neutrality requires that each article or other page in the mainspace fairly represents all significant viewpoints that have been published by reliable sources, in proportion to the prominence of each viewpoint. Giving due weight and avoiding giving undue weight means that articles should not give minority views as much of or as detailed a description as more widely held views. This MEDRS compliant source does discuss vertebral arterial dissection associated with manipulation of the spine throughout the systematic review. If this is an issue of WP:WEIGHT then we must give the recent systematic review due weight. "What’s known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death." "What’s new The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished." "Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g. 1,2). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism(2)." "This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death (1,2,26,30)." "Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial." E Ernst (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice. 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715. It is speculation/original research that chiropractic and other forms of neck manipulation have been 'linked' to VAD. The text does not pass V. This specific proposal is to replace the vague, 'unsourced' sentence with the 'sourced' evidence. I have previously requested verification but no editor was able to provide. WP:V. See Wikipedia:Fringe theories/Noticeboard/Archive 23#Vertebral artery dissection. It is indeed speculation/original research that neck manipulation has been 'linked' to VAD. Research examining the causality has been recently published in 2010 using a systematic review in accordance with WP:MEDRS. The VAD article currently does not satisfy NPOV, FRINGE, MEDRS, and V and does need to be changed. The current source being used at VAD is about adverse affects with spinal maniplaution in general. The Ernst 2007 source is not specifically about the relationship with VAD. We should not use a source not specific to the topic when there is a better and newer source avaliable from the same author. The proposal is sourced to the Ersnt 2010 that is clearly specific to the topic at hand. The taken out of context WP:OR sentence is: "The association between chiropractic neck manipulation and vertebral artery dissection is disputed by proponents of these treatment modalities." This sentence is a fringe minority view and does not represent the current source being used. The mainstream view states that the assocation between VAD and spinal manipulation is likely according to the 2010 recent systematic review (PMID 20642715). Do editors agree the OR from the other article should not make its way to this article? Does any editor want the OR removed from the other article? From the previous discussions it seems editors prefer WP:IAR rather than sourced text. QuackGuru (talk) 21:05, 28 June 2011 (UTC) This is the talk page for discussing improvements to the Chiropractic article. This is not the appropriate location to discuss improvements to other articles. DigitalC (talk) 03:55, 1 July 2011 (UTC) This is really very odd. Why would you use this talkpage as a forum to discuss another article? We have discussed this issue to death on Talk:Vertebral artery dissection. The current flow of the paragraph places all the different reports in context. Some concessions were made in the process (e.g. whether underreporting should be mentioned at all), and the current version seems to be supported by consensus. Any attempt to change the current version needs to be based on new information, not a rehash of the same arguments. JFW | T@lk 06:12, 1 July 2011 (UTC) Editors must not attempt to support OR rather than sourced text. The current version is unsupported by the source. See WP:OR. QuackGuru (talk) 20:39, 1 July 2011 (UTC) Do editors agree the OR against core policy must not be added to this article. Editors at the other article are unable to provide V. QuackGuru (talk) 02:16, 2 July 2011 (UTC) A 2010 systematic review found "Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely." E Ernst (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice. 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715. Is there a notable controversy to include in this or the vertebral artery dissection article? QuackGuru (talk) 02:25, 2 July 2011 (UTC)

QG, Please stop violating WP:TALK or I will have to report your tendentious behaviour. This dicussion clearly does not belong on this talk page. DigitalC (talk) 19:13, 2 July 2011 (UTC)

Do you agree you won't bring the mass OR to this page. Okay? QuackGuru (talk) 22:43, 3 July 2011 (UTC)

Lead - long run on quote?

I have reverted QuackGuru's bold edit. The edit summary claimed he was tidying a "long run on quote", but instead he changed a shortened paraphrase to a longer direct quote, which only makes the entire sentence longer. I don't think this improves the lead, and I don't see that the direct quote is in any way better than the paraphrase. DigitalC (talk) 00:00, 7 July 2011 (UTC)

DigitalC, are you sure? I thought that QG's change was a pretty good summary and was also shorter. Did I read it wrong?Puhlaa (talk) 00:03, 7 July 2011 (UTC)

Something is either wrong with me, or my WP. I fully support the change indicated. DigitalC (talk) 01:37, 7 July 2011 (UTC)

LEAD violation and duplication

There is duplication in the LEAD and the text is a LEAD violation. QuackGuru (talk) 01:23, 23 June 2011 (UTC)

Chiropractic treatment technique primarily involves manual therapy, including manipulation of the spine and other joints, as well as soft tissue therapies; treatment also commonly includes exercise and health and lifestyle counselling.[6] Traditional chiropractic assumes that a vertebral subluxation interferes with the body's innate intelligence,[7] a vitalistic notion that "brings ridicule from the scientific and health care communities and confusion within the chiropractic profession."[8] Many of today’s chiropractors focus on musculoskeletal problems of the spine,[1] and want to separate themselves from the traditional vitality of innate intelligence.[9]

I do not agree that it is duplication. The sentence in each case is not the same, only a single word is the same between the two sentences (ie, spine). The word 'spine' is expected to appear frequently in an article on chiropractic. The topic of the text in each case is different, thus the context is different in each case.Puhlaa (talk) 02:54, 23 June 2011 (UTC)

The text is similar and the new text is against LEAD. QuackGuru (talk) 21:01, 28 June 2011 (UTC)

QG, your continued attempts at stonewalling are getting tiresome...I hope you wont force me to report it? You have attempted to stonewall this change using V, which was refuted, then MEDRS, which was refuted, then NPOV, which was refuted, now you are saying it violates LEAD? Please explain how the text violates LEAD. Puhlaa (talk) 04:04, 5 July 2011 (UTC)

Do you think the source is a high-quality peer-reviewed source and a summary of the body? QuackGuru (talk) 04:06, 5 July 2011 (UTC)

Yes, the text summarizes the body. The body very thoroughly differentiates the different viewpoints within chiropractic. Yes, the source is good quality...the RAND corporation is well-known, impartial and does quality research. MEDRS does not limit us to peer-reviewed sources, and this source is arguably a secondary source that summarizes the history and current state of the profession from an impartial perspective. In addition, MEDRS describes “ideal sources for biomedical material”, this sentence is not biomedical material, it is a description of a profession. Moreover, “Controversies or areas of uncertainty in medicine should be illustrated with reliable secondary sources describing the varying viewpoints.” The sentence before the one in question describes only one perspective within chiropractic, where is the mention of the other chiropractic perspectives? Do you think this paragraph meets NPOV when it only mentions the pseudoscientific chiropractors? Do you agree that we need to give mention to the rest of the profession who are MSK specialists and reject pseudoscience? Do you agree that we need to include this text, which meets WP:V so that the article can meet WP:NPOV? Puhlaa (talk) 04:23, 5 July 2011 (UTC)

No, the text does not summarise the body and you have not shown that it does. We have peer-reviewed sources in the body. There is no reason to reach down into poor sources. If there is a problem you must use better sources (PMID 9818801). QuackGuru (talk) 04:30, 5 July 2011 (UTC)

It is odd that you claim the text does not summarize the body? However, I have re-examined the LEAD, I agree now that the sentence in question is unnecessary. DigitalC has 'broken-off' the mention of chiros that are critical of vitalism; this sentence differentiates the 2 perspectives within the profession and has a stronger source. I will delete the sentence.....is this to your satisfaction?Puhlaa (talk) 04:48, 5 July 2011 (UTC)

There is still a lot more problems with the LEAD. QuackGuru (talk) 18:25, 5 July 2011 (UTC)

You wrote "It is odd that you claim the text does not summarize the body?" When the source is not used in the body it can't be a summary. QuackGuru (talk) 02:14, 8 July 2011 (UTC)

Relevant systematic review per WP:MEDRS

A 2010 systematic review found "Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely."

E Ernst (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice. 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715.

Is there a notable controversy to include in this article? We can summarise the text here per MEDRS. QuackGuru (talk) 01:08, 3 July 2011 (UTC)

In the VAD article it mentions the controversy. We can do the same here with this source. There is no specific objection. QuackGuru (talk) 18:35, 7 July 2011 (UTC)

It is already mentioned in the article, and we should not violate WP:UNDUE by mentioning it twice. You also mispresent the situation at VAD, where there is no consensus for the inclusion of manipulation as a cause of VAD. DigitalC (talk) 03:37, 8 July 2011 (UTC)

Failed V

The text "and want to separate themselves from the traditional vitality of innate intelligence.[9]"

The source "Today, a substantial number of chiropractors are anxious to sever all remaining ties to the vitalism of innate intelligence. For these practitioners, the notion of the innate serves only to maintain chiropractic as a fringe profession28 and to delay its "transition into legitimate professional education, with serious scholarship, research, and service."29(p41)". QuackGuru (talk) 21:59, 3 July 2011 (UTC)

Seems to pass WP:V to me. DigitalC (talk) 22:21, 3 July 2011 (UTC)

Agree with DigitalC, the text passes WP:V.Puhlaa (talk) 20:09, 4 July 2011 (UTC)

The word "and" is SYN and "want to separate themselves from the traditional vitality of innate intelligence.[9]" was taken out of context. QuackGuru (talk) 18:27, 5 July 2011 (UTC)

I am not sure why you are posting this now, as this supposed SYN violation had already been fixed. The article currently reads "A large number of chiropractors want to separate themselves from the traditional vitalistic concept of innate intelligence." DigitalC (talk) 00:38, 6 July 2011 (UTC)

Is this the quote the sentence in the article is trying to paraphrase? Clearly this quote does not contradict the wiki sentence, but if that quote was the sole quote used to justify the sentence I actually would agree with QuackGuru. The wiki sentence doesn't do a good job of reflecting that particular quote. --MATThematical (talk) 16:44, 7 July 2011 (UTC)

The text "and want to separate themselves from the traditional vitality of innate intelligence.[9]" Previous OR.

The text now is "A large number of chiropractors want to separate themselves from the traditional vitalistic concept of innate intelligence." Rewrite.

There was OR in the lead but the text was rewritten. QuackGuru (talk) 02:25, 8 July 2011 (UTC)

Duplication in Safety

The Safety section currently reads: ..."Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.[173] The published medical literature contains reports of 26 deaths since 1934 following chiropractic manipulations and many more seem to remain unpublished. The causality between neck manipulation beyond the normal range of motion and vascular accidents is probable." As there are two sentences in there, close together, discussing causation/causality I removed the latter sentence. This was reverted by QuackGuru. Is there consensus to have this information presented twice in the Safety section? DigitalC (talk) 00:08, 7 July 2011 (UTC)

I see no reason to include this information twice in the safety section. The first mention of causation vs. association reads much better and is more informative than the latter sentence that you previously removed and QG subsequently reverted. I support removal of the second mention of causality. Puhlaa (talk) 00:26, 7 July 2011 (UTC)

There is cervical manipulation too. QuackGuru (talk) 18:32, 7 July 2011 (UTC)

mixers

mixers make up the majority of chiropractic practices, yet are no where to be found in the introduction. This should be briefly mentioned in the introduction. --MATThematical (talk) 16:35, 7 July 2011 (UTC)

"It has two main groups: "straights", now the minority..." This is enough the lead. QuackGuru (talk) 18:33, 7 July 2011 (UTC)

you are right. However I would propose the second paragraph read a little differently (currently the paraphrase from source [9] is a bit OR)

This is how it currently reads

D.D. Palmer founded chiropractic in the 1890s, and his son B.J. Palmer helped to expand it in the early 20th century.[10] It has two main groups: "straights", now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider vertebral subluxations to be the cause of all disease; "mixers" are more open to mainstream and alternative medical techniques such as exercise, massage, nutritional supplements, and acupuncture.[9] Chiropractic is well established in the U.S., Canada and Australia[11] and is the third largest health profession, behind medicine and dentistry.[12] Most who seek chiropractic care do so for low back pain.[13]

This is how I propose it reads

D.D. Palmer founded chiropractic in the 1890s, and his son B.J. Palmer helped to expand it in the early 20th century.[10] It has two main groups: "mixers", forming the majority of chiropractors, believe that subluxation is only one of many causes of disease, and therefore are more open to mainstream scientific tenants and conventional medical techniques, such as corrective exercises, massage, and ice therapy.[9] "Straights", now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider vertebral subluxations to be the cause of all disease. Chiropractic is well established in the U.S., Canada and Australia[11] and is the third largest health profession, behind medicine and dentistry.[12] Most who seek chiropractic care do so for low back pain.[13]

Organizationally, I think mixers should come first since they are in the majority (but perhaps the order is currently chronological in that straights came firs?). Also, according to [9] mixers are more open to conventional medicine, but only some are more open to other alternative medicine, and thus in my opinion could be highlighted outside of the lead. The way the current paragraph is written it makes it seem that conventional medicine and other alternative medicine are equally accepted by mixers, but [9] suggests that things like acupuncture are not as commonly endorsed by mixers as mainstream physical therapy techniques. Here is the quote from [9] that I am referring to

"'Mixers' tend to be more open to conventional medicine and to mainstream scientific tenets. For today's majority mixers, subluxation is one of many causes of disease.45 This translates into a greater use of therapies other than spinal manipulation. The National Board of Chiropractic Examiners46 indicates that most chiropractors use conventional physical therapy techniques, such as corrective exercise, ice packs, bracing, bed rest, moist heat, and massage. Nutritional supplements are the next leading nonmanipulative therapy in mixer practice, and depending on state laws, some chiropractors provide acupuncture, homeopathy, herbal remedies, and even biofeedback.47" --MATThematical (talk)

The section in the body is Chiropractic#Straights and mixers. I think the lead should be straights first and mixers second. I am confused by the proposal when the order is changed. QuackGuru (talk) 02:03, 8 July 2011 (UTC)

OK then this is the proposal with the order unchanged (2nd paragraph of the intro), if you find this less confusing.

It has two main groups: "straights", now the minority, emphasize vitalism, innate intelligence and spinal adjustments, and consider vertebral subluxations to be the cause of all disease; "mixers", the majority, are more open to mainstream scientific tenants and conventional medical techniques, such as corrective exercises, massage, and ice therapy.[9]

I still think its a bizarre to highlight the less popular group first in the intro, but that's not a big deal in comparison to the OR in the paragraph. Basically the stuff putting other alternative medicine on the same footing as mainstream medicine, in terms of acceptance among mixers, is completely OR (at least [9] implies mixers practice normal physical therapy techniques frequently but only "some" practice or recommend other forms of alternative medicine.) I think the talk about acupuncture and homeopathy can go in the Chiropractic#Straights and mixers section. --MATThematical (talk) 03:28, 8 July 2011 (UTC)

Agreed MATThematical. This section is confusing as currently written. The philosophy section is literally being mixed with Treatments. -DRewG — Preceding unsigned comment added by DRrewG (talk • contribs) 23:40, 8 July 2011 (UTC)

I made the changes I agreed with. There was subtle OR in the lead. Is there anything left I missed in the lead. More details about the mixers in the body might improve the page. QuackGuru (talk) 03:00, 10 July 2011 (UTC)

Congruence in LEAD

Currently the lead states "Existing research only supports the effectiveness of manual therapy for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions.[22] The efficacy and cost-effectiveness of maintenance chiropractic care are unknown.[23] Chiropractic care is generally safe when employed skillfully and appropriately.[24] Spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or fatal complications in rare cases.[25][26] A systematic review found that the risk of death from manipulations to the neck outweighs the benefits.

The lead implies on one hand, there is research to support manual therapy (including manipulation) effectiveness for neck pain, yet the risks outweighs the benefits. Clearly a given intervention can't be both effective and then not be recommended at the same time due to undue risk. Also there might be a NPOV issue with 18 separate references to Ernst largely stating thing resulting in excessive duplication of a POV. -DRewG — Preceding unsigned comment added by DRrewG (talk • contribs) 23:32, 8 July 2011 (UTC)

I'm not so sure that is clear. If there is some evidence that supports neck pain relief, but said evidence did not show that the relief was great enough, it could very well be that the slight risk of extreme damage due to a neck/back adjustment might not be worth the risk (and thats pretty much what the reference says, based on my brief skim). I'm not sure about the 18 references issue, as I don't see that many in the paragraph you posted above. --MATThematical (talk) 05:39, 9 July 2011 (UTC)

Sponsorship details?

User:Somedifferentstuff added information about the Bronfort et al. study, indicating that it was "sponsored by the UK General Chiropractic Counci". I object to the addition of this information, because to maintain NPOV we would have to do this for every article, and there simply isn't enough room in the article for that. DigitalC (talk) 01:44, 7 July 2011 (UTC)

Agree with DigitalC. There is no need to discuss the source of funding here, or else in order to maintain NPOV we would also have to attribute the next sentence that presents Ernst's critical view. It would be tedious and un-encyclopedic to start attributing every sentence. Puhlaa (talk) 02:21, 7 July 2011 (UTC)

It would be tedious to keep the source when it is against the rules. There are far better sources available. See Wikipedia:MEDRS#Use independent sources. QuackGuru (talk) 18:45, 7 July 2011 (UTC)

Who funds Ernst reviews? The Bronfort study is technically a better source than Ernst 2008, its newer, it is a more detailed study than those done by Ernst. Anyway this article still reads as Chiropractic vs Ernst. Seems that Ernst is the one who is going against main stream. Mg87DC (talk) 23:11, 25 July 2011 (UTC)

Use independent sources

Many medical claims lack reliable research about the efficacy and safety of proposed treatments or about the legitimacy of statements made by proponents. In such cases, reliable sources may be difficult to find while unreliable sources are readily available. Whenever writing about medical claims not supported by mainstream research, it is vital that third-party, independent sources be used. Sources written and reviewed by the advocates of such marginal ideas can be used to describe personal opinions, but extreme care should be taken when using such sources lest the more controversial aspects of their opinions be taken at face value or, worse, asserted as fact. If the independent sources discussing a medical subject are of low quality, then it is likely that the subject itself is not notable enough to have its own article or relevant enough to be mentioned in other articles. See Wikipedia:MEDRS#Use independent sources.

A chiropractic source sponsored by the UK General Chiropractic Council is an obvious violation of WP:MEDRS. QuackGuru (talk) 18:45, 7 July 2011 (UTC)

I strongly disagree. DigitalC (talk) 03:38, 8 July 2011 (UTC)

QG is quite right about MEDRS's caution against using non-independent sources to contradict the mainstream view. More importantly, we should never be juxtaposing secondary sources published in the highest-quality journals like Lancet with those which have only appeared in minority publications such as Chiropractic & Osteopathy. --RexxS (talk) 00:06, 9 July 2011 (UTC)

The scientific point of view is the mainstream point of view. Chiropractic & Osteopathy is an indexed, peer reviewed journal. DigitalC (talk) 03:35, 9 July 2011 (UTC)

The mainstream, scientific point of view is that chiropractic has been shown to have a limited effectiveness in assisting with lower back pain. The rest is just hype. Chiropractic & Osteopathy ("The official journal of the Chiropractic & Osteopathic College of Australasia (COCA) and the European Academy of Chiropractic (EAC)") is a partisan, in-house publication and can not be used to refute mainstream academic sources such as JAMA, BMJ, etc. where the peer-review and editorial oversight processes are universally accepted as representative of the scientific consensus. --RexxS (talk) 11:29, 9 July 2011 (UTC)

Wait, wat? The Chiropractic journal is partisan, but JAMA (The official journal of the American Medical Association) isn't? 72.38.44.68 (talk) 14:39, 9 July 2011 (UTC)

Yes, you've got it exactly right. JAMA is where respected mainstream research and reviews are published from the vast majority of mainstream medicine; while Chiropractic & manual therapies is the place to publish such gems as "The prevalence of the term subluxation in North American English-Language Doctor of Chiropractic Programs". Surely the distinction is not so hard to understand? --RexxS (talk) 21:46, 9 July 2011 (UTC)

I disagree RexxS, yours is a straw-man arguement contrasting 2 topics from 2 journals. The prevalence of subluxation in chiropractic curricula is a very important topic in a profession trying to leave its vitalistic roots behind. Moreover, why would an article like this be published in a medicine joural? I am certain that a perusal of JAMA would show social science-type article regarding the medical profession or pharmaceuticals, which would be absolutely foolish to publish in a manual therapy journal. Moreover, JAMA is just as biased as Chiropractic and Manual Therapies, with a history of trying to destroy chiropractic, not improve it according to new knowledge and evidence (see antitrust case). To avoid the bias inherent in both medicine or chiropractic (or bias from wikipedia editors) we use secondary sources that are peer-reviewed. Bronfort et al 2010 is a well-done, systematic review of systematic reviews, guidelines and new RCTs and published in a peer-reviewed journal. The Bronfort et al 2010 review uses a similar protocol as Ernst 2008, but is a couple years newer and according to the methods section, more comprehensive. Attempts to say an article about chiro., published in a chiro. journal., is biased would make every study about medicine, published in medical journals and funded by pharmaceutical industries far too bias to include in wikipedia. Should we start evaluating the funding of sources in all medical topics? It is actually commendable that the authors are progressive enough to state their funding sources and allow this discussion to take place. Puhlaa (talk) 22:14, 9 July 2011 (UTC)

There's no straw in the argument. Such obvious nonsense as "subluxation" would be laughed out of court in any serious mainstream academic journal, and that puts C & M T into perspective. That's the point: JAMA is not "just as biased as Chiropractic and Manual Therapies". Your assertion that JAMA has set out to destroy chiropractic is simply incredible. All mainstream authors will clearly point out the quackery that has plagued chiropractic since its inception, but that's protection of patients from over-inflated claims based on a theory that has long been discredited. Now, if you want to move forward, you'll have to accept that Ernst 2008 represents the mainstream, scientific view and is essential to the wording of our article. The "couple of years newer" is worthless as a debating point and you need to read MEDRS if you don't understand why 2008 is as good as 2010. Nevertheless, despite being published in such an inauspicious mag as C & M T, Bronfort 2010 has some merit. It is unfortunate that it leaves itself open to the impression of bias (because that's exactly what "funded by and published in" implies), but the review appears actually well-researched and reasonably wide-reaching. I do think that its findings have a place in our article, as a counterpoint to Ernst. I hope that we can find wording to make clear both views and give them appropriate weight. Perhaps more editors will be willing to help following Digital's request at WP:MEDICINE. --RexxS (talk) 23:49, 9 July 2011 (UTC)

Did you even read the article about the prevalence of the term subluxation? Even the abstract? Where it states "There is a paucity of evidence to document the subluxations"? DigitalC (talk) 03:15, 10 July 2011 (UTC)

Again, I disagree. My point was that 'C & M T' publishes many social science articles about the profession that are critical of subluxation, which gives the journal more clout in my eyes. Further, the editorial board is multidisciplinary and I can tell you from experience, the peer-review process is equal to that of any other journal I have published in (which range in topics). Your use of phrases like "despite being published in such an inauspicious mag as "C & M T" is simple ad-hominum attack, and bears no weight whatsoever in the discussion, only reveals your bias. Yes, JAMA is definitely biased, your denial of this fact, considering the competitivness of the health care system, is simple ignorance. However, as I said, we ignore these allegations from ignorant editors like us and instead trust secondary sources from peer-reviewed journals. Bronfort is equal in quality as Ernst, but is a couple years newer. Have you read [56]? Have you recognized yet that the discussion is about removing Bronfort in favour of Ernst, not vice-versa as you claim? There was previous consensus to include Bronfort. We can discuss including Ernst as well, but you have currently reverted from a version with consensus to a version with no consensus and still have not acknowledged that you are hearing this....I want to move on to constructive discussion and stop with the ignorant ad hominum attacks of journals that editors dont like.Puhlaa (talk) 00:12, 10 July 2011 (UTC)

No, it's an "ad librum" attack, and it's perfectly valid. Nobody is going to buy in to your claim that C & M T is comparable in reputation to Lancet, BMJ, or JAMA. As you have decided to open up the question of my bias, I'll make a full disclosure: my degree in Natural Sciences dates back to the early 1970s and I am firmly biased in favour of mainstream science as opposed to the hype found in many fringe theories. I am biased in favour of the proper use of sources in Wikipedia, and regard MEDRS to be an outstanding example of how it should be done. I am also biased by being an editor in good standing, interested in numerous topics, and a writer of featured content. You, on the other hand, edit almost exclusively in the area of chiropractic, are pursuing a doctorate in the topic, and seem intent on removing sources that are less than fulsome in praise of the discipline. Am I to understand that you want to claim that you don't have a bias? --RexxS (talk) 01:07, 10 July 2011 (UTC)

First, we all have bias, my statement was not meant to accuse you of bias (I apologize if it did) only to point out that your ad hominum (sorry, librum) attack is an obvious display of bias, which most editors seem to avoid in order to disguise that their bias may be influencing their edits. I have never stated that I have no bias, in fact I have disclosed myself 100% on my profile. To question my intent after I have fully disclosed my bias is just more ad hominum attack? Would you care to share which article I have removed from the chiropractic article because it was critical (seems like an accusation of bad faith now?)? A review of my edit history shows that I am no lover of pseudoscience, I have maintained the standard of only including peer-reviewed secondary sources to articles, and never delete sourced text without consensus (Ernst wasnt deleted, only moved to the body in favour of a better summary). Yes, I admit I only tend to edit article that I know something about, this includes enzymology, microbiology and manual therapy; this does not make me any less credible an editor than you RexxS, to say so is more..... Well, I think we both know how you play by now. Is this just a special treatment for me?

With regard to Ernst, to remove an older source, in favour of a newer source that accurately summarizes the body seems perfectly consistent with MEDRS policy to me. If Bronfort et al 2010 was not consistent with the 10 most recent systematic reviews (see my list below) then I would accept that it is a fringe view. However, since it is almost a 100% accurate summary of the newest systematic reviews in the topic (which are published in a variety of journals and by a variety of authors), I would say that it represents a mainstream view. Puhlaa (talk) 01:28, 10 July 2011 (UTC)

First, I'm not playing anything here. I'm just here to build an encyclopedia and I hope you are too. You will excuse me ribbing you about bias, but you must remember you are the one who introduced the topic. Removing older sources in favour of newer ones is called WP:RECENTISM and is generally frowned on. However, MEDRS does advise us to prefer sources that are less than five years old. It most certainly does not advise us to replace a 2008 review with a 2010 review, particularly when they disagree. The correct thing to do is often to summarise and attribute both views as outlined at WP:WEIGHT. I'd honestly appreciate it if you'd take time to read the whole of that section of the guideline and see if you can fit its recommendations to our current difficulties. If its any help, I think that Ernst 2008 approximates the "majority viewpoint", that Bronfort 2010 is the "significant" "minority viewpoint" (although I understand QuackGuru considers it the "tiny minority view"). I'm happy to accept that your good faith perspective may differ from mine, and I hope you will accept the same of QG and me. Now, have we reached a position where we can apply MEDRS and WEIGHT to our disagreement and reach a solution that's acceptable to all? --RexxS (talk) 02:09, 10 July 2011 (UTC)

(outdent) I disagree that Ernst represents the majority viewpoint. He is a controversial critic, and certainly has his own biases. While I'm not American, I would think that the NCCAM would be able to point us towards a majority viewpoint? (government agency "dedicated to exploring complementary and alternative medicine (CAM) healing practices in the context of rigorous science") Let's see what NCCAM would have to say about Chiropractic - [57]. As for recentism, I disagree. We can't cherry pick sources when a new primary study comes out, but we should be attempting to use the best and latest reviews in the article, and trying to use high quality sources in the lead to summarize the body. The Ernst source does not adequately summarize the body. We can use WP:WEIGHT to make sure the sources balance each other in the body, and heck I'd be happy if the lead simply stated "Opinions differ as to the efficacy of chiropractic treatment", cited to Devocht, even if it is 5 years old. DigitalC (talk) 03:15, 10 July 2011 (UTC)

I would also be happy with wording similar to what you proposed in the spring "A 2010 systematic review concluded that manual therapies used by chiropractors are effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions,<cite Bronfort> although a 2008 critical evaluation only found evidence for the effectiveness of SM in treating back pain". This would have to be changed to remove the WP:SYN violation, though, but could be worded "A 2010 review concluded that manual therapes used by chiropractors are effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions.<Bronfort-1> A 2008 critical evaluation only found evidence for the effectiveness of SM in treating back pain". DigitalC (talk) 03:58, 10 July 2011 (UTC)

Oh, and as for the AMA not being biased, it may be a respected journal, but the AMA was found guilty in a federal anti-trust lawsuit of conspiring to undermine chiropractic. While it may be history, it certainly sounds partisan to me. DigitalC (talk) 03:19, 10 July 2011 (UTC)

We already have one tendentious editor at the article. Please don't mischaracterize other's edits. As far as I have seen, Puhlaa hasn't removed the content from the article, only the mention in the lead. The lead is supposed to be a summary of the body of the article, and the Ernst source does not adequately summarize the body. DigitalC (talk) 03:41, 10 July 2011 (UTC)

Your proposal is littered with OR ans was removed from the article. The source is not a review. QuackGuru (talk) 04:03, 10 July 2011 (UTC)

Can you explain how there is any OR? It was removed from the article against consensus for inclusion, and that qualifies as tendentious editing. Such disruptive editing has lead to you being blocked several times before. Bronfort et al. most certainly IS a review, but whether we word it as a report or review is not important in terms of WP:MEDRS - it is a reliable secondary source. DigitalC (talk) 04:25, 10 July 2011 (UTC)

The mainstream view is the one prevalent in reputable mainstream sources. That is that chiropractic has little evidence of efficacy beyond treating lower back pain, as expressed by Ernst 2008 in J Pain Symptom Manage. By WP:WEIGHT, it means we are obliged to give the mainstream view prominence. It is therefore unacceptable that the lead should not retain reference to that view and it naturally will be supported by a cite to PMID 18280103. My position is unchanged regarding Bronfort et al 2010. It's a decent review, disagreeing with the mainstream view, and representative of the chiropractic industry (which funded and published it in it in-house journal). By WP:WEIGHT, that view has a place in the article, and I have several times compromised by agreeing that it could be included in the lead, if the disagreement was notable. But the problem is that once I had offered that compromise in February, I come back to find that you've taken it as licence to remove the mainstream view and its supporting source from the lead totally. That's the part that I find insulting. As soon as editors like myself offer some compromise, that becomes the new starting point for further demands until the article is stripped of anything that is remotely critical of chiropractic. So here's my counter-offer for the wording for the lead:

• "A 2008 systematic review concluded that manual therapies used by chiropractors have been shown to be effective only for the treatment of low back pain,<cite Ernst> although a 2010 review found evidence of benefit in treating neck pain, some forms of headache and some extremity joint conditions in addition."

That gives the correct prominence to the mainstream view, while recognising a significant minority viewpoint. Let's see if other editors are willing to comment. --RexxS (talk) 16:48, 10 July 2011 (UTC)

RexxS, the link that you provided to me [58], that shows the discusion back in February suggests that the article was left exactly how you recommended? At that time you commented that the conflict between the 2 sources was not notable and recommended Ernst be put in the body (is this not a correct interpretation of your comments that are linked?) I am confused as to why you have changed your mind now and are accusing us of taking advantage? I dont understand? Puhlaa (talk) 16:57, 10 July 2011 (UTC)

2010 report

• Bronfort G, Haas M, Evans R, Leininger B, Triano J (2010). "Effectiveness of manual therapies: the UK evidence report". Chiropractic & Osteopathy. 18 (3): 3. doi:10.1186/1746-1340-18-3. PMC 2841070. PMID 20184717.{{cite journal}}: CS1 maint: multiple names: authors list (link) CS1 maint: unflagged free DOI (link)

The current text is "A 2010 report found that manual therapies commonly used by chiropractors are effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions." According to the article and the title it is a report. The source and text is still in the article. QuackGuru (talk) 02:08, 8 July 2011 (UTC)

You have deleted a stronger source (Bronfort 2010) and replaced it with a weaker source (Ernst 2008) in the lead. Your controversial edits [59] are against concensus [60] and is also against convention at this article, where controversial edits are discussed on the talk page first. Do you agree that the text you have edited against consensus needs to be reverted? Do you agree that controversial changes should still be discussed on the talk page first? Puhlaa (talk) 03:20, 8 July 2011 (UTC)

According to the link, it is a review. According to the link, it is comprehensive. DigitalC (talk) 03:21, 8 July 2011 (UTC)

Ernst 2008 is a much stronger source than Bronfort 2010 considering the publishing journals. In addition, Ernst has been published in a variety of highly respected academic journals (such as Journal of the Royal Society of Medicine and International Journal of Clinical Practice), while Bronfort has published little outside the field of chiropractic, except for Spine. However, I wouldn't reject Bronfort 2010 since it clearly is a review and has been able to include later evidence than Ernst was able to in 2008. I would certainly recommend reading both reviews fully before attempting to distil a wording for our article. I think there is sufficient difference in the general thrust of conclusions for both views to be represented: Ernst acknowledging effectiveness in LBP but clear that other conditions show no effectiveness; while Bronfort cautiously suggesting moderate quality evidence for effectiveness in a number of other problems (for example non-specific neck pain). It is premature to remove Ernst and I see no consensus to do so. I have therefore returned the article to its earlier state. Please let's agree a form of wording here, rather than try to push changes through without consensus. --RexxS (talk) 22:35, 9 July 2011 (UTC)

RexxS, you have just reverted the original version of the article in favour of a version that has no consensus. There may not have been consensus to remove Ernst 2008, but there certainly WAS consensus to include Bronfort [61]. Do you think this was an appropriate move? On what authority have you decided to revert the chiropractic article without consensus. I am asking you to revert your changes back to the original version as it existed before QGs controversial edits on July 8, it is up to editors to gain consensus for changing the article. Have you read [62]? Puhlaa (talk) 22:50, 9 July 2011 (UTC)

Well, I couldn't leave your version in place with the red "citation missing" tags all over the references section, could I?[63] I'm pretty sure that there was no consensus for that. The authority I used was WP:COMPETENCE. I, at least, bothered to preview my revert to make sure it left the article in an encyclopedic state. So, if you want to suggest the references that should be used and the text that goes with them, I'd be happy to discuss that with you, but I will repeat that I've read your assertions and still seen no consensus for removing Ernst 2008. Your previous effort was not acceptable. --RexxS (talk) 00:01, 10 July 2011 (UTC)

I am new, but isnt convention and/or policy to fix the reference before deleting the text? Especially when the reference is known to you? Regardless, thanks for acknowledging that you have read my assertions regarding previous consensus. I tend to disagree with your comment though, I think that consensus for inclusion of Bronfort was pretty clear, I will find the ProjectMedicine talk archive that shows consensus for inclusion on that forum as well and will post it for you if it will help. Puhlaa (talk) 00:24, 10 July 2011 (UTC)

No need to play games. I was part of those discussions, as were you. There is not now, and never has been a consensus to remove Ernst 2008 from the lead of this article. It is the mainstream view. I suggested some text that attributed both views (and ought to be acceptable) back in March Talk:Chiropractic/Archive 33#Are we dropping the Ernst review too soon?, but you are giving the impression that your only intent is to remove mainstream references that you don't like. As for your other point, I'm under no obligation to clean up your mess, so I'm content to restore the article to its state immediately prior to your ham-fisted attempt to excise a source without consensus. I'm sure you'll excuse my bluntness, but I'd rather set out clearly what is wrong with your position, so that I don't have to keep coming back here every few months to counter the same tired arguments that were found wanting quite some time ago. --RexxS (talk) 00:44, 10 July 2011 (UTC)

I strongly object to your assertions that I remove mainstream sources I dont like, this is the second accusation of bad faith on your part (other at projectmedicine). Are you a veteran editor who believes in all wikipedia policies, including those regarding ettiquette? I had left in the LEAD the mention that published sources conflict with regard to efficacy, which summarizes the controversy in the body of the article. Also, Ernst was maintained in the body of the article. I agree that there was not consensus yet to remove Ernst from the LEAD, but there was consensus to include Bronfort, whose conclusions are a good summary of the 10 or so newest systematic revies found in the evidence section of the body of the article. I fully admit to trying to remove Ernst from the LEAD, but only because it is a narrative review from 2008 that is inconsistent with many new systematic reviews have been published in 2010/2011 (see below: Continued deletion of Bronfort from the LEAD). Those new systematic reviews listed below represent the mainstream view....dont you think? Do you think that Bronfort 2010 is not a good summary of those mainstream systematic reviews I listed below? Maybe I am way off, but it seems a good summary to me. I think we should replace Bronfort 2010 into the LEAD as it has been for months and discuss if/how to include Ernst as well? Puhlaa (talk) 01:00, 10 July 2011 (UTC)

Go ahead and object even more strongly if you like, but it's not an assertion that you removed Ernst, it's a fact.[64] You are perfectly well aware of the consensus reached in March: Talk:Chiropractic/Archive 33 refers. Why do you think I am obliged to assume good faith of your attempts to remove a top quality MEDRS-compliant source against the established consensus? I'm a believer that WP:AGF is not a suicide pact, if that helps you understand why I'm not a fan of faux civility.

Let me make this clear: the mainstream view is that expressed in the quality mainstream journals. We both know what those are. Now, if you want to get to real discussion, you already know that I approved of Bronfort 2010 in March and approve of it now. It's the minority point of view of the chiropractic industry, in my opinion, but nevertheless a significant opinion which disagrees, to some degree, with the mainstream (as exemplified by Ernst 2008). The actual disagreement is not as great as it may look from the summaries, since Bronfort et al only conclude that there is moderate quality evidence of chiropractic efficacy in many cases, or often that chiropractic is better than no treatment, but no better than some other treatments. I'd agree that some people may reasonably feel that is as close to the mainstream view as Ernst is (although I'm not one of those people). So, please re-read my response to you here on 16 February 2011 [65] and see if we can encapsulate the two different views and reference both sources. Otherwise, I'd be grateful if you'd avoid re-removing an agreed source while we wait for others to chip in. --RexxS (talk) 01:46, 10 July 2011 (UTC)

RexxS, I have not reverted you once yet, so to give your stern warnings is insulting. I did not remove Ernst, I moved him to the body. This was consistent with your recommendations according to the link you provided [66]. It seems to me that we agreed 100%, and I took your advice, and your recommendations are almost exactly how I finalized the edits of the article. We indeed had consensus in February!

• You wrote: "If pressed, I'd suggest the body contained something along the lines of: "A 2010 systematic review concluded that manual therapies used by chiropractors are effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions,<cite Bronfort> although a 2008 critical evaluation only found evidence for the effectiveness of SM in treating back pain.<cite Ernst>"

This is exactly how the body read, and I think it still reads this way unless it was also accosted during QGs many undiscussed edits on July 7.

• You wrote: "The lead at present says: "Many studies of treatments used by chiropractors have been conducted, with conflicting results. Collectively, research has suggested that manual therapies commonly used by chiropractors are only effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions." and I guess that is a fair overview of what we know. Does anyone want to see much more detail than that?"

Here you seem to agree that the finalized edits to the article's LEAD are acceptable, and how it read until QG started the edit war on July 7. It seems we had consensus, as I mentioned here and at ProjectMedicine, when you accused me of insulting your intelligence?

RexxS, please re-read [67] and see that I conformed to your requests at that time, we had consensus as I said. You were ok with putting Ernst in the BODY and Bronfort in the LEAD then because the dispute was not notable, I am confused about what is happening now? Please look at the articles edit history prior to the QG barrage on July 7, you will see that it is consistent with your recommendations in Feb that you linked above. I am 100% OK to go back to what you suggested at the above link you provided, this is what I have been trying to do and QG has been preventing it. Have I missed something here???Puhlaa (talk) 02:25, 10 July 2011 (UTC)

I propose that we make the LEAD read:

• "Many studies of treatments used by chiropractors have been conducted, with conflicting results. Collectively, research has suggested that manual therapies commonly used by chiropractors are only effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions.(cite Bronfort) The efficacy and cost-effectiveness of maintenance chiropractic care are unknown. Chiropractic care is generally safe....."

I propose the BODY should read:

• "A 2010 review concluded that manual therapies used by chiropractors are effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions,(cite Bronfort). A 2008 critical review only found evidence for the effectiveness of SM in treating back pain.(cite Ernst)"

This is very close to how the BODY and the LEAD used to read prior to QGs edits on July 7. Also, this version seems to have recieved consensus 6 months ago from multiple editors (please see: [68] AND [69]). Also, this proposal accurately summarizes the evidence section of the BODY and uses the most recent secondary sources available. Finally, this proposal accurately summarizes the position of NCCAM with regard to chiropractic [70]. Puhlaa (talk) 04:11, 10 July 2011 (UTC)

A 2010 report found that manual therapies commonly used by chiropractors are effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions.[121]" This text in the body is neutrally written. We don't need to go back to the OR. According to your edit summary the source is a report. Do you know the source says "The purpose of this report is to provide a succinct but comprehensive summary...".

I don't see any problem with the wording of Ernst in the body or the lead. I do have a problem with the OR and your proposal. Collectively, research has suggested? The word suggested is OR. A 2008 critical review only? The word only is also OR. You claim it is a review when the source says it is a report written by chiropractors. As a compromise I did ad in-text attribution to the Ernst review in the lead. Do you understand that Bronfort is the minority view. QuackGuru (talk) 00:38, 11 July 2011 (UTC)

It's as simple as this: If you want to go along with the wording of the lead from February,

• "Many studies of treatments used by chiropractors have been conducted, with conflicting results. Collectively, research has suggested that manual therapies commonly used by chiropractors are only effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions."

then you have to recognise (as I was implying at the time) that there are conflicts between studies. In which case, you are obliged to cite those conflicting sources in support of that wording. I had assumed that you would be even-handed and cite both Ernst 2008 and Bronfort 2010, but I was drawn back here by Digital's request at WikiProject Medicine to find that you had ignored WP:WEIGHT and removed the cite to Ernst (the mainstream view) from the lead, replacing it with a citation to the minority view (Bronfort). So my response is clear: if there's a notable disagreement between reliable sources, mention it in the lead; attribute both positions by citing the sources which disagree. On the other hand, if (as you now claim), there is no notable disagreement between reliable sources, then the February wording is not usable, and we must return to the the lead stating only the mainstream view, which requires a cite to Ernst 2008 as it has done for a considerable time. --RexxS (talk) 17:05, 10 July 2011 (UTC)

OK, perhaps this all comes down to my misunderstanding of your comments in February? As I outlined above as plain as I could, your comments appeared to support a version of the text that only included Ernst in the BODY, not the LEAD, and this is why it was left like that.

• You wrote here [71]: "The lead at present says: "Many studies of treatments used by chiropractors have been conducted, with conflicting results. Collectively, research has suggested that manual therapies commonly used by chiropractors are only effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions." and I guess that is a fair overview of what we know. Does anyone want to see much more detail than that?"

Thus, there was no ill-intent, and certainly no-one was taking advantage of you! I didnt realize that you expected Ernst to be used as a reference for this sentence in the LEAD....that is my mistake. Are you then of the opinion that Ernst is consistent with the 2010/2011 mainstream systematic reviews listed below that are also in the body of the article? My opinion has always been that Bronfort is a better summary of those systematic reviews, whereas Ernst might be considered to contradict some of those new systematic reviews. Regardless, now that I understand your comments from February, I agree that if the disagreement between Ernst and Bronfort is notable then the LEAD should include both sources (as I said, I thought your point in February was that the disagreement was NOT noticeable, I apologize again). I would be happy for you to make changes to the articles LEAD based on this discussion and the discussion above with DigitalC, after which we can make fine-adjustements if necessary according to further discussion. Last time I made the changes (which I thought were consistent with your suggestions) I obviously messed it up. Puhlaa (talk) 17:31, 10 July 2011 (UTC)

Let's try to see where we can get some common ground. I apologise for making assumptions when I didn't make my thoughts clearer earlier. You must understand that I'm no expert on chiropractic - I just read the sources and try to apply the policies and guidance for writing our encyclopedia. It has seemed to me for most of the time that I've been involved with the article that the position stated by Ernst in 2008 was more or less what was considered mainstream scientific, i.e. many claims for efficacy of chiropractic treatments, but a shortage of good quality evidence. So when a review comes along that says more evidence (even moderate quality evidence) exists, I expect that there will be a dispute about which is right - and that such a debate would be notable. That's why I phrased my comments at the time as questions - others will often know the answers before I do. I hope you can see that Ernst has been the 'accepted' position here for quite some time, probably in the absence of a recent Cochrane review. QG has taken the position that Bronfort 2010 is not sufficiently independent to satisfy MEDRS, and I accept that is a perfectly valid judgement to make; although I don't share his position. I respect it. On the other hand, I can also see that you believe Ernst is outdated, and that Bronforth now represents the mainstream view. I can also respect your position (if it is as I have characterised it), but not agree with it. I think you've made a step too far in removing a citation to Ernst from the lead, but I also think QG is mistaken to dismiss Bronfort entirely.

Looking at the possible wording for the lead, I accept it's not easy to add citations with precision, and that may be part of the problem. Anyone reading Bronfort would see that it verifies the second sentence, but not the first. If we wanted to be pedantic, we could cite both Ernst and Bronfort for the first sentence. Perhaps it would be acceptable to add the citations for both studies after the second sentence, which is less precise but allows the reader to see both sources and make their own mind up. Letting the reader form their own opinions from the sources cited is probably a good thing. However, I'm willing to be persuaded that some other wording is best. I'd be interested in hearing what regular contributors like BullRangifer and Ocaasi would bring to this discussion. I'm going to be on holiday soon, and don't really have much else to add, so I'll trust to your collective good judgement to do what's right for the article. --RexxS (talk) 21:49, 10 July 2011 (UTC)

Continued deletion of Bronfort et al 2010 from the LEAD

The 2010 comprehensive review by Bronfort has been continually removed from the LEAD against consensus.[72] We originally achieved consensus to include this article in the LEAD because it is the most recent and comprehensive review of the literature on effectiveness. An older narrative review by Ernst (2008) is still included in the body, but is lower quality than the 2010 Bronfort review (see below):

• The Ernst paper says: "A narrative review of selected articles from the published chiropractic literature was performed."[73]
• The UK evidence report says: "The conclusions are based on the results of systematic reviews of randomized clinical trials (RCTs), widely accepted and primarily UK and United States evidence-based clinical guidelines, plus the results of all RCTs not yet included in the first three categories."[74]

Moreover, the older Ernst review is not consistent with the body of the article, so it does not alone accurately summarize the body. Ernst says that manipulation is not effective for anything except maybe back pain. However, the MEDRS-compliant systematic reviews published in the last 2-3 years seem to contradict Ernsts older review from 2008:

• Dagenais et al 2010 - systematic review found that most studies suggest manipulation achieves equivalent or superior improvement in pain and function when compared with other commonly used interventions for back pain.[75]
• Chaibi et al 2011 - systematic review found evidence that manipulation might be as effective as some commonly used medications in the prevention of migraine headaches.[76]
• Hahne et al 2010 – systematic review found moderate quality evidence to support the use of spinal manipulation for the treatment of acute lumbar disc herniation with associated radiculopathy.[77]
• Leininger et al 2011 - systematic review found moderate quality evidence to support the use of spinal manipulation for the treatment of acute lumbar radiculopathy.[78]
• Gross et al 2010 - systematic review found low quality evidence that SM was more effective than a control for neck pain, and moderate quality evidence that cervical manipulation and mobilisation produced similar effects on pain, function and patient satisfaction.[79]
• Brantingham et al 2010 - systematic review found limited or fair evidence supporting manipulative therapy for leg conditions.[80]
• Pribicevic et al 2010 - systematic review found low level evidence supporting manipulation for treatment of shoulder pain.[81]
• Shaw et al 2010 - systematic review found low level evidence that suggests chiropractic care improves cervical range of motion and pain in the management of whiplash.[82]

Thus, the 2010 comprehensive Bronfort review is newer (2010 vs 2008), higher quality (Bronfort examines sys reviews, RCTs and guidelines, Whereas Ernst only looks at Sys reviews) and is more consistent with the literature sourced in the body of the article. Perhaps most importantly, we had consensus to include Bronfort et al 2010 in the LEAD, which is being ignored. Until there is consensus to remove it from the LEAD again, it should be left alone. Puhlaa (talk) 15:38, 9 July 2011 (UTC)

The chiropractic source is a report according to the absract and full text. Do you understand this source does not represent the mainstream point of view. Editors thought it was a review but when you take a closer look the source is a report funded by a chiropractic organisation. QuackGuru (talk) 15:59, 9 July 2011 (UTC)

A chiropractic article funded, authored, and published by chiropractors does not represent the scientific mainstream point of view.

See Wikipedia:MEDRS#Use independent sources:

"Many medical claims lack reliable research about the efficacy and safety of proposed treatments or about the legitimacy of statements made by proponents. In such cases, reliable sources may be difficult to find while unreliable sources are readily available. Whenever writing about medical claims not supported by mainstream research, it is vital that third-party, independent sources be used. Sources written and reviewed by the advocates of such marginal ideas can be used to describe personal opinions, but extreme care should be taken when using such sources lest the more controversial aspects of their opinions be taken at face value or, worse, asserted as fact. If the independent sources discussing a medical subject are of low quality, then it is likely that the subject itself is not notable enough to have its own article or relevant enough to be mentioned in other articles."

"Whenever writing about medical claims not supported by mainstream research, it is vital that third-party, independent sources be used." according to Wikipedia:MEDRS#Use independent sources. There seems to be some confusion. The source is a report not a traditional review. "The UK General Chiropractic Council provided the funding for this scientific evidence report." A UK chiropractic report sponsored by the UK General Chiropractic Council is a low-quality source. See WP:WEIGHT.

See WP:MEDASSESS:

"Knowing the quality of the evidence helps editors distinguish between minority and majority viewpoints, determine due weight, and identify information that will be accepted as evidence-based medicine. In general, editors should rely upon high-quality evidence, such as systematic reviews, rather than lower-quality evidence, such as case reports, or non-evidence, (e.g., anecdotes or conventional wisdom).

The best evidence comes from meta-analyses of randomised controlled trials (RCTs), and from systematic reviews of bodies of literature of overall good quality and consistency addressing the specific recommendation. Narrative reviews can help establish the context of evidence quality. Roughly in descending order of quality, lower-quality evidence in medical research comes from individual RCTs, other controlled studies, quasi-experimental studies, and non-experimental studies such as comparative, correlation, and case control studies. Although expert committee reports or opinions, along with clinical experience of respected authorities, are weaker evidence than the scientific studies themselves, they often provide helpful overviews of evidence quality. Case reports, whether in the popular press or a peer-reviewed medical journal, are a form of anecdote and generally fall below the minimum requirements of reliable medical sources."

"Narrative reviews can help establish the context of evidence quality." according to WP:MEDASSESS. It is not our job to question the experts like Ernst. The Ernst 2008 source clearly meets MEDRS but the source was deleted from the lead again and replaced with a source funded, authored, and published by chiropractors.

"Table 3 gives an overview of the most up-to-date systematic reviews by indication.137e144 These systematic reviews usually include trials of spinal manipulation regardless of who administered it. Thus, they are not exclusively an evaluation of chiropractic. Collectively, their results fail to demonstrate that spinal manipulation is effective. The only possible exception is back pain. For this condition, manipulation may be as effective (or ineffective) as standard therapy.137" (Ernst 2008)

• "137. Assendelft WJJ, Morton SC, Yu Emily I, Suttorp MJ, Shekelle PG. Spinal manipulative therapy for low-backpain. The Cochrane Database of Systematic Reviews 2004;(Issue 1)10.1002/14651858. Art No.: CD000447.pub2.
• 138. Gross AR, Hoving JL, Haines TA, et al. Manipulation and mobilisation for mechanical neck disorders (Cochrane Review). In: The Cochrane Library, Issue 1, 2004. Chichester, UK: John Wiley & Sons, Ltd, 2004.
• 139. Fernandez-de-Las-Penas C, Alonso-Blanco C, Cuadrado ML, et al. Are manual therapies effective in reducing pain from tension-type headache?: a systematic review. Clin J Pain 2006;22:278e285.
• 140. Ernst E. Chiropractic spinal manipulation for neck painda systematic review. J Pain 2003;4: 417e442.
• 141. Proctor ML, Hing W, Johnson TC, Murphy PA. Spinal manipulation for primary and secondary dysmenorrhoea. The Cochrane Database of Systematic Reviews 2001;(Issue 4)10.1002/14651858. Art. No: CD002119.pub2.
• 142. Husereau D, Clifford T, Aker P, Leduc D, Mensinkai S. Spinal manipulation for infantile colic. Technology report no 42. Ottawa: Canadian Coordinating Office for Health Technology Assessment, 2003:ie36.
• 143. Balon JW, Mior SA. Chiropractic care in asthma and allergy. Ann Allergy Asthma Immunol 2004;93:S55eS60.
• 144. Reid SA, Rivett DA. Manuel therapy treatment of cervicogenic dizziness: a systematic review. Man Ther 2005;10:4e13."

The Ernst 2008 narrative review does summarise the effective section with regard to higher-quality systematic reviews. This source represents the mainstream point of view. 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. QuackGuru (talk) 15:59, 9 July 2011 (UTC)

QG, you have listed a bunch of older (older than 2004) systematic reviews which Ernst uses in his 2008 narrative review to say SM is only effective for back pain. I have above listed just as many 2010/2011 systematic reviews that contradict Ernst's narrative. Clearly you agree that Ernst does not accurately summarize the body of the article, nor the CURRENT state of the literature. You would be better off trying to achieve consensus to include both sources rather than to try and remove a new, high-quality source that has consensus for inclusion [83] Puhlaa (talk) 16:11, 9 July 2011 (UTC)

Moreover, how can you think that the narrative review of one author (Ernst) represents the mainstream view when Bronfort et al, 2010; Dagenais et al 2010; Chaibi et al 2011; Hahne et al 2010; Leininger et al 2011; Gross et al 2010; etc., and all other I listed above have different findings in a variety of newer systematic reviews?Puhlaa (talk) 16:16, 9 July 2011 (UTC)

A 2008 source is not dated according to MEDRS. Do you agree the chiropractic report is funded, authored, and published by chiropractors? Do you agree the report does not represent the scientific mainstream point of view when there is a better source that does represent the mainstream point of view (PMID 18280103). See WP:WEIGHT. We have better sourcing. See Wikipedia:MEDRS#Use independent sources. Moreover, it is not our job to question the experts from independent sources. The newer references support back pain. Words like "suggests", "might" or "low quality" in not conclusive, anyhow. You are not the expert and you are not supposed to conduct your own WP:SYN review. QuackGuru (talk) 16:31, 9 July 2011 (UTC)

No, I do not agree. Bronfort et al 2010 is a good summary of the article, and a good summary of the many new systematic reviews used as sources in the article. Moreover, the discussion at [84] seems to show that many editors agree that Bronfort is ok according to MEDRS. You seem to be the only one pushing to remove it. We were at this same impass a few months ago when you used different arguements to attempt and prevent Bronfort from being included in the LEAD, and you were then also the only one fighting it. I guess we are in the same situation, except now you are alone arguing against a previous consensus.[85] As we already had consensus, you should not remove it again until you have a new consensus. As I mentioned, you would be better off trying to get consensus to include Ernst 2008 in the LEAD with Bronfort 2010, rather than trying to reverse the previous consensus to include Bronfort 2010 in the LEAD.

Do you agree that we had consensus to include Bronfort et al 2010 in the LEAD?[86] Do you agree it is against policy to continue making controversial edits to the article without consensus on the talk page (as the rest of us do)?Puhlaa (talk) 20:25, 9 July 2011 (UTC)

Do you agree you were mistaken to claim the source was a review? Editors thought the source was a review. It is not a review in the traditional sense. It is a UK report printed in a chiropractic journal. The 2010 report is still in the body but using a low-quality source to replace (or contradict) high-quality mainstream sourcing in the lead is ridiculous. QuackGuru (talk) 03:15, 10 July 2011 (UTC)

According to Chiropractic & Manual Therapies, it is a review. Click here See that word right above the title? It says "review". The article is a comprehensive narrative review. It is definitely not a low-quality source, and to claim that anyone is using a low-quality source to replace "high-quality mainsteam sourcing" is tendentious editing. DigitalC (talk) 03:54, 10 July 2011 (UTC)

The Source says "The purpose of this report is to provide a succinct but comprehensive summary...". This is a report. Do you understand part of the title includes the word report. The title is "Effectiveness of manual therapies: the UK evidence report". QuackGuru (talk) 03:56, 10 July 2011 (UTC)

What is your point? The title of it is "The UK Evidence report", but we aren't going to call it by its title. It is a narrative review. By describing what it is, and by using words that are not original research, we benefit the reader. DigitalC (talk) 04:04, 10 July 2011 (UTC)

Do you understand the source says "The purpose of this report is to provide a succinct but comprehensive summary...". QuackGuru (talk) 04:06, 10 July 2011 (UTC)

IF you want to use the report, use the systematic reviews. If they say the same thing as the report, I see no reason to avoid them in preference to the material produced by the chiropractic association.TheThomas (talk) 16:57, 19 July 2011 (UTC)

The discussion continues in yet another thread. See Talk:Chiropractic#Still_no_mention_of_Bronfort_in_the_LEAD. QuackGuru (talk) 20:48, 19 July 2011 (UTC)

1979 New Zealand Commission report

The first part of the text is OR and the rest of the unencyclopedic text is from an unreliable source. QuackGuru (talk) 15:18, 9 July 2011 (UTC)

It appeared that the source for the text removed without discussion on the talk page was a government report? Is this not correct? A government report would be a fine source. Please correct me if I am wrong. Puhlaa (talk) 15:42, 9 July 2011 (UTC)

There are far better source including peer-reviewed sources in the section. Do you agree the first part of the text is editorialising and the rest is unencyclopedic. QuackGuru (talk) 15:54, 9 July 2011 (UTC)

NO, I dont agree. If it is a government report then the text meets WP:V and should be left alone.Puhlaa (talk) 16:08, 9 July 2011 (UTC)

I explained there are far better source including peer-reviewed sources in the section. You think the report is peer-reviewed or peer-reviewed is irrelevant to you? QuackGuru (talk) 16:15, 9 July 2011 (UTC)

I think that if were to remove all non-peer reviewed source from wikipedia that we would be in big trouble to try and find sources. I think that if it were medical advice then peer-reviewed would be very important, MEDRS is for medical advice. To maintain NPOV we must include the opinions of more than just critics. As the New Zealand source is a government document, it is good enough to use as a source for a non-medical section in the article (eg: history, philosophy, education, etc).Puhlaa (talk) 20:30, 9 July 2011 (UTC)

Chiropractic#Scope of practice contains a lot of peer-reviewed sources when they are available. You claim "To maintain NPOV we must include the opinions of more than just critics." You claim researchers are critics. This is absurd. I don't see a proposal that will improve the page. QuackGuru (talk) 02:56, 10 July 2011 (UTC)

Dont you think you should have made a proposal to edit the article in such a drastic way before actually doing so on July 7? Isnt this the convention we follow here? My proposal now is to revert the text back to how it was before July 7, then you can propose a revision of the text, section by section, as the rest of us do. You made a thousand assorted changes to the article mixed among 15 edits over 2 days with no consensus or discussion for any of them. It is confusing people because there were so many major changes made so fast with no prior discussion. Do you agree that this is innappropriate? Puhlaa (talk) 03:06, 10 July 2011 (UTC)

I removed a lot of OR and editorialsing against core policy. I tagged OR but editors were slow to help. I had to improve the article or the OR and other problems would stay. QuackGuru (talk) 03:12, 10 July 2011 (UTC)

So you are claiming that we do not need to discuss changes to the article before making the edits as long as we think our changes are an improvement? This is absurd! Do you not agree that you need to present changes on the talk page before making edits like the rest of us, even if you think they are improvements? Your definition of OR seems different from other editors. Other editors never had an opportunity to comment because you never started a discussion. DigitalC asked you to stop tagging without starting a discussion on the talk page as well. Instead, you just made all the changes that you wanted at locations tagged but not discussed. Puhlaa (talk) 03:33, 10 July 2011 (UTC)

QuackGuru, you know that tagging the article without discussing those tags on the talk page is improper, as is removal of information from the article without consensus. There is no consensus to remove the NZ information, and you have yet to present a better source for this information. It is not the type of information that needs a peer-reviewed source. DigitalC (talk) 03:37, 10 July 2011 (UTC)

A lot of changes were made to the article without discussion. For example, the New Zealand Commission report was added to the article without discussion. I cleaned up the mess and absurd changes. QuackGuru (talk) 03:40, 10 July 2011 (UTC)

If you look at this talk page, it seems you have created an absurd mess. DigitalC (talk) 03:48, 10 July 2011 (UTC)

On the contrary, the absurd mess was there before QG's edits. I haven't checked there was previous discussion of the {{or}} claim in the archives, but there was and is a lot of {{synthesis}} and use of unreliable sources in the article. — Arthur Rubin (talk) 15:16, 10 July 2011 (UTC)

Which unreliable sources? DigitalC (talk) 15:22, 10 July 2011 (UTC)

I agree that we want to remove synthesis and unreliable sources from the article. However, the point is that changes should be discussed on the talk page first so we can form consensus that text is or is not OR. I feel especially strong about this when edits remove text that has been long-standing in the article (although I admit I am relatively new, so sometimes text might have appeared just before I did and I just assume it was there for the long-term). This is the tedious courtesy I and others extend, and I would simply like to have that courtesy extended back. The text under discussion might well be OR and from an unreliable source, it is tough to tell what was changed with so many things done so quickly by one editor with no prior discussion. Aurthur Rubin, please consider starting discussion about any text that you feel is OR or sourced to something unreliable. Improving the article is the primary goal here, but with such a controversial subject as chiropractic, things need to be preented for other editors to see and discuss before radical deletions are made. Is this an absurd request? Puhlaa (talk) 15:36, 10 July 2011 (UTC)

Cochrane review summary

I think a summary of the main chiropractic treatment in the WP:LEAD will improve this article. So, I made this change using an authoratative source per WP:MEDRS. QuackGuru (talk) 21:54, 17 July 2011 (UTC)

Sure, Cochrane review is a great summary, however, using the Cochrane review's 'plain language' summary is more reader-friendly than the text that was included. The plain language summary [87] reads:

"The results of this review demonstrate that SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy. However, it is less clear how it compares to inert interventions or sham (placebo) treatment because there are only a few studies, typically with a high risk of bias, which investigated these factors. Approximately two-thirds of the studies had a high risk of bias, which means we cannot be completely confident with their results. Furthermore, no serious complications were observed with SMT. In summary, SMT appears to be no better or worse than other existing therapies for patients with chronic low-back pain. " Puhlaa (talk) 11:42, 18 July 2011 (UTC)

I prefer encyclopedic language from the conclusion rather than the summary.

Conclusion: "High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions for reducing pain and improving function in patients with chronic low-back pain."[88] I would change low-back pain to low back pain. QuackGuru (talk) 20:45, 18 July 2011 (UTC)

I might agree with you QG, now that I read them both again. I will change it back to your version until something better is thought up, or we decide your original version was best to start with. I still think that the phrase "no clinically relevant difference", while being excellent language for a scientific publication, may not be encyclopedic. I think it may be confusing for lay people (the target audience of an encyclopedia) and I suggest we might change the wording to something more reader friendly. What about:

High quality evidence suggests that that SMT is (equal/comparable/equivalent) to other interventions for reducing pain and improving function in patients with chronic low back pain.

Is there a policy regarding the language used in wikipedia article? For example, what kind of audience should an article be written for? Puhlaa (talk) 22:02, 18 July 2011 (UTC)

I summarised the conclusions fairly closely without excessive wording like "in patients" or confusing language like "equal/comparable/equivalent". If the conclusions were more simple then the text I added would of been more simple. The writng is similar to a paper encyclopedia when we acurately summarise the conclusions. I don't know what is the policy on writing styles but I prefer to write accurate text to meet V policy. QuackGuru (talk) 04:02, 19 July 2011 (UTC)

Still no mention of Bronfort in the LEAD

There is still no mention of Bronfort et al 2010 in the LEAD. To include Bronfort in the LEAD has already achieved consensus among multiple editors, here: [89] and here: [90]. Also, the rationale for why Bronfort et al 2010 is appropriate for the LEAD has been described at length here: [91] and was originally described at length here: [92] when the original consensus was achieved. Perhaps the editor who removed this source from the LEAD [93] against concensus should replace the deleted text and source in the LEAD? Puhlaa (talk) 11:53, 18 July 2011 (UTC)

If that's the consensus of editors here, there's no reason you shouldn't do it yourself. BE——Critical_{__Talk} 18:04, 18 July 2011 (UTC)

We have better sources available. For example, the Cochrane review summary in the WP:LEAD is a more authoratative per WP:MEDRS and I prefer we summarise the body with independent sources. Editors were not so sure of the Bronfort text in the lead. See Wikipedia talk:WikiProject Medicine#MEDRS complaint source. The text in the body was rewritten because it was WP:OR. The previous text in the lead from Bronfort failed WP:V and was not attributed per WP:ASF. QuackGuru (talk) 20:37, 18 July 2011 (UTC)

Are you saying that you were adhering to WP:CONSENSUS when you made that edit? This discussion is about the consensus of Wikipedia editors. I'm sure the arguments over sources and phrasing are covered elsewhere. BE——Critical_{__Talk} 20:56, 18 July 2011 (UTC)

See this diff for the argument by another editor. QuackGuru (talk) 21:35, 18 July 2011 (UTC)

@ QG, please dont mistakenly mislead other editors. According to your diff, RexxS made the revert because there was not consensus to remove Ernst from the LEAD, it had nothing to do with Bronfort. We both know that RexxS wanted both sources (Ernst and Bronfort) in the LEAD. This diff[94] is where RexxS states explicitly back in February that he thinks Bronfort should be in the LEAD. Then there is this diff[95] from last week, where after discussion RexxS again acknowledges that Bronfort is suitable for the LEAD along with Ernst. At least 6 editors have stated that they agree with putting Bronfort in the LEAD ([96],[97],[98]). QG, you are the only editor who has maintained that Bronfort should not be included in the LEAD.Puhlaa (talk) 21:51, 18 July 2011 (UTC)

I see, so the actual consensus was to put both in the lead? Are there others here who can also help clarify so we can know the full set of opinions on what the consensus was? BE——Critical_{__Talk} 23:38, 18 July 2011 (UTC)

I see you want a chiropractic article funded, authored, and published by chiropractors that does not represent the scientific mainstream point of view in the lead. See WP:WEIGHT. Is the current consensus to keep this in the lead. QuackGuru (talk) 04:14, 19 July 2011 (UTC)

I'm not sure what is the current consensus. For now I self reverted my addition to the lead. I am also not sure how the source is a good summary of the body. For example, the body says "A 2011 systematic review found that the evidence does not support the use of spinal manipulation for the treatment of migraine headaches.[142]" This systemtic review has a much different conclusion than the report for migraine headaches. QuackGuru (talk) 04:56, 19 July 2011 (UTC)

I believe that there is consensus to keep this in the lead, and I don't see that WP:WEIGHT applies. DigitalC (talk) 15:50, 19 July 2011 (UTC)

(edit conflict)QG re your first post, I don't know anything about the particulars on this article, so there's nothing I want or don't want. Thanks for being willing to work with consensus. BE——Critical_{__Talk} 17:23, 19 July 2011 (UTC)

Reply to DigitalC. One of the main issues here is the text in the WP:LEAD must summarise the body. There are systematic reviews that do disagree with the report. For example, I did explain about one of the systematic reviews on migraine headaches disagrees with the report. I can continue to cut and paste text from the body that shows there is a disagreement with the 2010 chiropractic journal report. "A 2010 systematic review stated that there is no good evidence to assume that chiropractic neck manipulation is effective for any medical condition,...". QuackGuru (talk) 20:45, 19 July 2011 (UTC)

It should be part of the lead, otherwise there is unbalanced representation of the current research available. Also with all the new research coming out in support of chiropractic as a equal treatment option even from medical journals not just chiropractic journals It seems that the 'mainstream' view of chiropractic is changing. Everywhere from the Mayo Clinic to Web MD explain that Chiropractic and or spinal manipulation are a reasonable treatment option for Low back pain, headaches. This excerpt is from the American Pain Society "GLENVIEW, IL, Oct. 2, 2007 - For low-back pain patients and their doctors, a new, evidence-based, clinical practice guideline, published today in the Annals of Internal Medicine, recommends less reliance on expensive diagnostic imaging and reports there is strong evidence supporting the benefits of several therapies, with and without medication." There are many more like it, however, this research that is being presented and helping to change the current medical landscape is being overshadowed by low budget systematic reviews many of which are made by Ernst. The laws and practice guidelines for physicians are changing to include more complimentary and alternative treatments for mild to moderate pain management. This article is not reflective of this changing field. Mg87DC (talk) 23:37, 25 July 2011 (UTC)

Why don't you suggest the text of the lead here? Alternately, edit the article. You will likely get reverted, but then we can discuss it here. Do others have a comment on the reliability of this new source? BE——Critical_{__Talk} 01:44, 27 July 2011 (UTC)

I propose that we restore the version that existed before the edit war started on July 7. If editors are unhappy with this version then we can always start discussion to change it. The previous version (prior to edit war) read:

"Many studies of the treatments used by chiropractors have been conducted, with conflicting results. Collectively, research has suggested that manual therapies commonly used by chiropractors are effective for the treatment of low back pain, neck pain, some forms of headache and some extremity joint conditions.([99], [100])"

Evidence for consensus with regard to the wording of this version can be found here [101] and here [102].

Evidence for consensus to include both the Bronfort and Ernst reference can be found here [103]

The reason this version achieved consensus was because:

1. It uses the most recent peer-reviewed secondary sources available as per WP:MEDRS
2. It conforms to WP:LEAD because it accurately, but concisely summarizes the most recent sources used in the body (see the following systematic reviews that are sources in the body: [104], [105], [106], [107], [108], [109], [110], [111])
3. It maintains WP:NPOV by qualifying that some studies have conflicting results and also sources the most recent critical review by Ernst.Puhlaa (talk) 20:34, 27 July 2011 (UTC)

(edit conflict) @Mg87DC / BECritical: It's not a new source and it was discussed in February. It's not published in a mainstream journal such as the ones that publish Ernst's articles, so it should be considered a weaker source. The 'recentism' thinking behind asserting "it's newer so it's better" really needs to be kicked into touch, since 2008 is just as good as 2010 for our purposes (per WP:MEDRS#Use up-to-date evidence). Nevertheless as has already been made clear, I believe it is a serious study and deserves exposition in the body and summary in the lead. What I don't agree with is removing the mainstream view as expounded by Ernst, and replacing it with the conclusions from Bronfort, which represent a minority (although perfectly valid) view. I fail to see why we can't follow the guidance at WP:WEIGHT and present both views in proportion. Although I suppose we will need to come to some consensus on what that proportion is. A few years ago, there was little serious evidence for efficacy of chiropractic, and I have no doubt that QG was quite right to insist that the claims made at the time had so little support within evidence-based medicine that they deserved no mention in an encyclopedia article (per WEIGHT). But as you observe, views do shift over time; and it is worth making the case for treating Bronfort perhaps as the minority view of chiropractic industry. My advice is to make that case and seek a form of words that QG would find acceptable. Involve as many other editors from as wide a range of opinions as you can. A consensus reached in such a way is likely to be far more robust that simply writing one's own opinion. I agree generally with Puhlaa's approach. Hope that helps. --RexxS (talk) 21:03, 27 July 2011 (UTC)

RexxS, I can fully appreciate your perspective, that we cannot just replace one set of findings with another when they contradict. However, I will agree to disagree regarding which source is better.

Would it be easier to gain consensus if we simply remove the reference to Bronfort from the LEAD and just use the highest-quality systematic reviews as sources, rather than lower-quality sources like Bronfort and Ernst that offer summaries? For example:

"Systematic reviews have suggested that manual therapies commonly used by chiropractors might be effective for the treatment of low back pain,[112],[113] disc herniation with lumbar radiculopathy,[114],[115] neck pain,[116],[117] some forms of headache,[118],[119] and some extremity joint conditions.[120][121]"

I admit, this proposal is nearly identical to what I originally proposed, but using the best MEDRS sources available (systematic reviews in medical journals). I personally still think that my originally proposal is better for the LEAD, but this approach avoids the issues that result from the questioned reliability of the Bronfort article. Also, I admit, both this proposal using systematic reviews and my original proposal using Bronfort contradict Ernst's 2008 narrative review that states: "systematic reviews of this research have not demonstrated that spinal manipulation is effective, with the possible exception of treatment of back pain."Puhlaa (talk) 22:28, 27 July 2011 (UTC)

Remember I have no knowledge of this subject, but Puhlaa's suggestion seems to actually summarize both sides: everyone agrees it might be effective for low back pain. As far as reverting to the version before the edit war, I think that should be universal standard practice in order not to reward non-consensus editing. BE——Critical_{__Talk} 13:27, 28 July 2011 (UTC)

There is no universal standard practice and we're not in the business of 'rewarding' anybody. The statements in the article should be sourced to the best quality MEDRS, with disagreements between RS presented with due weight. I don't see that removing one valid mainstream source and replacing it with a source that provides different conclusions is how we should be working to improve an article.

We now have a 2011 Cochrane Review on SMT (PMID 21328304), and I'd recommend that as wholly sufficient as a source for the efficacy of SMT on lower back pain (LBP) in both the body and the lead, as I'm not aware of any mainstream source that offers a different view - PMID 20869008 is superfluous when it only says the same as the Cochrane Review. I do think that the conclusion wrt LBP should be written as 'SMT is effective' (rather than 'might be'). Sadly, I really don't think that PMID 21292148 or PMID 20421859 say anything conclusive about the efficacy of chiropractic on LDHR, other than an indication that it may be useful for treating acute (but not chronic cases). A similar picture emerges for the neck (PMID 20510644 & PMID 20364057), migraine and some extremity joint conditions. From what I can see of the abstracts, in each of these cases the quality of evidence is described as lower level, and often restricted to particular instances, with recommendations for further research. However, there's certainly enough there to write 'might be'. So, I'd go along with the thrust of what you've offered, but I'd suggest that the LBP conclusion is presented more emphatically, i.e. as established fact sourced to the Cochrane Review. I'm not sure that I'd be anywhere near as confident about the LDHR, neck, headache, and joint results, but I don't have access to the full texts yet. Perhaps it is possible that someone who has full access can be more definitive? --RexxS (talk) 23:51, 29 July 2011 (UTC)

RexxS, I am in agreement with most of your summary of the literature (above), however I must disagree with your claim that with regard to back pain " PMID 20869008 is superfluous when it only says the same as the Cochrane Review". I disagree because while the cochrane review examines chronic low back pain, PMID 20869008 reviews studies of acute low back pain. Does this change your view or is it still superfluous in your opinion? What do you think of the following proposal to replace what currently exists in the LEAD? All of the references used in the proposal are already found in the body of the article. Comments from other editors are also welcome...please!

• "Manual therapies commonly used by chiropractors are effective for the treatment of low back pain,[122],[123] and might also be effective for the treatment of lumbar disc herniation with radiculopathy,[124],[125] neck pain,[126],[127] some forms of headache,[128],[129] and some extremity joint conditions.[130][131]"

Puhlaa (talk) 22:16, 4 August 2011 (UTC)

Ah, mea culpa - I hadn't spotted that PMID 20869008 addressed acute pain as well. Please go ahead, my comment is struck. I'd also like to hear if other editors have anything to add, but I wouldn't recommend waiting too long (even if there is no deadline). Cheers, --RexxS (talk) 00:15, 5 August 2011 (UTC)

I have made the above discussed change in the chiropractic article.Puhlaa (talk) 18:58, 6 August 2011 (UTC)

Misleading statement

To say " a systematic review found the risk of death from manipulation to the neck outweighs the benefits" when clearly at the end of the article it states varied opinion on risk is a bit of a biased statement. Not to mention that the source for that statement is a systematic review of case studies thus cannot state any true cause and effect relationship. Either find a better source or remove. 76.175.50.187 (talk) 04:37, 29 July 2011 (UTC)

No. The source is the best type, a systematic review - see WP:MEDRS for the sort of source we are looking for - and it is published in a journal with impeccable credentials. So it's not 'a bit of a biased statement'. It is true that opinions differ, but if it's a case of taking your opinion against that of a high quality secondary source, I think we'll stick with the sources. So the onus is on you to find secondary sources published in equally high quality mainstream journals to back up your hunch, and then we can discuss how much weight each needs to be given - see WP:WEIGHT. --RexxS (talk) 22:56, 29 July 2011 (UTC)

My argument is not opinion its simple research methods 101. Do you know the difference between a systematic review of case studies (case series) and a systematic review of RTC's? One you can state a causal relationship from and the other you can only say that it "may" cause a particular effect but that actual research in order to prove the link must be done in a randomized controlled setting. Simply said, to say that a systematic review of case studies found a causal link such as risks outweigh benefits is a misleading statement. Just because it's a systematic review of observational studies does not suddenly make them experimental. I admit I assumed possible bias (especially when Ernst is involved ) but the fact remains the statement is not appropriate for the citation.

Also, just because something is published in a reputable journal does not make it a perfect study....I have found thousands of mistakes in reputable(whatever that is supposed to mean... there's some articles in the "reputable" journal science that will make me laugh in just about every publication) journal articles. The most common being mathematical such as using the wrong stats (paired t vs unpaired t...etc.). Anyhow, I am simply trying to help make wikipedia a better source of info. Also, on another note, I have read quite a few Ernst reviews...some have been excellent while others he seems to exclude relevant studies...or maybe he just doesn't search through databases to the same extent...what I have come to understand is that he seems to have a marked bias. If you question what I am mentioning simply do some research on a particular topic he published on and then review his exclusion criteria and you may ask (as I have) why he excludes certain "reputable" published journal findings. I am interested in your response and appreciate your previous response but I think my previous statement apparently needed clarification. You are right it is difficult not to have opinions but in this case it's a misleading statement that logically cannot be made with that particular source. 76.175.50.187 (talk) 06:57, 4 August 2011 (UTC)

Unfortunately, you'll have to understand Wikipedia 101 to make sense of what I'm trying to tell you. This encyclopedia is designed to produce content by reporting what has been written and accepted elsewhere. This has the effect that we insist on giving no weight whatsoever to editors' opinions, and the strongest weight possible to whatever is published in journals that have the highest reputation for fact-checking and accuracy. So it doesn't matter what you or I or any other editor thinks about a study - if it's a secondary source, particularly a systematic review and published in a high-quality journal, then it has precedence over sources that have less illustrious provenance and over our own views.

In practice this means that your application of "simple research methods 101" to a secondary source is treated as original research and will be dismissed out of hand. I really don't mean to insult your expertise - it's just that there's no place for it (per se) in Wikipedia. You might find that strange, but consider the alternative: every editor could claim to be an "expert" and insist that their opinion/research/critique-of-a-source is right and all differing opinions/etc. are wrong. How then would we decide on what our article should contain? Do we go with the one who is most persistent? who shouts the loudest? who edit-wars longest? So we have accepted that our encyclopedia articles will merely report what the best sources say, even though you, or I, may think that what is written is biased/inaccurate/false or whatever. The only way we can change what the article says is to adduce better sources that support an alternate position. Even then, we may find it difficult to contradict what has been published by the Lancet or BMJ, for example. You see, we rely on the editorial oversight and peer-review process of a journal to ensure that what is published is true. If it is not, then we expect a repudiation in the same journal by other experts. When that doesn't happen, we're not inclined to accept one editor's view that what was published is flawed.

I understand what you're saying, and if this were a classroom, I'd be willing to weigh your opinion on sources like Ernst. But it's not. It's the encyclopedia that anyone can edit and we pay a price for that. The price involves an inability for each of us to do our own analysis of sources and reach conclusions - we have to leave that to other external reputable sources, otherwise anarchy ensues. Ernst has the advantage of having been published in some pretty high-powered mainstream medical journals, and it's hard to argue from Wikipedia's point-of-view that he's not enunciating the Truth® and the mainstream view. I sympathise with your views, and I even share some of your detailed concerns (particularly the misuse of statistics), but that's not enough to change the way we have agreed we will work here. Crowd-sourcing of content for an encyclopedia has its pitfalls, but it's worked so far, warts and all. --RexxS (talk) 17:38, 4 August 2011 (UTC)

History--Chiropractic Research

I have made attempts at correcting the following statement under the History heading:

"Serious research to test chiropractic theories did not begin until the 1970s, and is continuing to be hampered by what are characterized as antiscientific and pseudoscientific ideas that sustained the profession in its long battle with organized medicine."

Not only does the statement contain strongly opinionated undertones the information is inaccurate, or at a minimum incomplete. I suggest the following revision:

"Serious research to test chiropractic theories began in 1935 with the B.J. Palmer Research Clinic at the Palmer College of Chiropractic in Davenport, Iowa. The clinic was organized into two divisions--a medical division and a chiropractic division. The medical division contained all the standard medical tests of the time and was used to establish a medical diagnosis of a patient's condition before the patient received treatment. The chiropractic division administered the treatment which included passive therapies, chiropractic adjustments and physical rehabilitation for the various conditions diagnosed. Research continued in the B.J. Palmer research clinic until B.J. Palmer's death in 1961 and the results and findings of these patient cases were the substance of B.J. Palmer's publishing over this 30 year time-period. Serious attempts to further test chiropractic theories by modern standards of research began in the 1970's.

Research did begin in the 20s at Palmer and BJ was the driving force. While I don't have access to the "Chiropractic: An Illustrated History", the Keating's "Chiropractic History: A Primer" sourced in the next sentence says:

• "Although research in chiropractic legitimately claims its roots in the various theories and clinical techniques propounded throughout the chiropractic century, little more than sporadic efforts at meaningful data collection in the profession’s first 50 years are apparent (Keating et al. 1995). Gitelman (1984) suggested that the modern era, involving sustained scientific investigation of the chiropractic healing art, may be dated to the 1975 conference on spinal manipulative therapy (SMT) hosted by the National Institute of Neurologic and Communicative Diseases and Stroke (NINCDS) in Bethesda, Maryland, with funding provided by the U.S. Congress. The published proceedings of this meeting (Goldstein 1975), which brought together chiropractors, osteopaths, manual medicine practitioners and researchers, revealed the state of knowledge about SMT at that time. The consensus reached was that the clinical value of SMT was unproved, but merited serious investigation."

I therefore removed the word "Serious" from the first sentence as someone else had removed its second use.

-- Dēmatt (chat) 04:45, 6 August 2011 (UTC)

Modification to source in LEAD

The first sentence of the last paragraph in the LEAD states: "Many studies of treatments used by chiropractors have been conducted, with conflicting results.[132]" I do not necessarily disagree with this statement, however it does not seem to accurately summararize the source provided. The source's abstract states that a majority of studies agree that spinal manipulation is effective for back pain. I do like the way the text qualifies the controversy surrounding the efficacy of manual therapies, however a better source is needed. Thus, I have replaced the old source with both Bronfort 2010 and Ernst 2008.[133][134] They are each recent and thorough reviews, but each represents somewhat of a different perspective. There may be better sources, but I think that these are at least an improvement on what was used previously.Puhlaa (talk) 06:35, 7 August 2011 (UTC)

WHO Guidelines on Chiropractic Education

I think the article need a link to this document: WHO Guidelines on Chiropractic — Preceding unsigned comment added by 213.112.193.91 (talk) 10:19, 16 August 2011 (UTC)

The article already links to that source (see reference 34). In fact, the guidelines are used as a source about 5 times in the article so I do not understand the request? Puhlaa (talk) 14:52, 16 August 2011 (UTC)

NPOV

The article states: "most practitioners are "mixers" who attempt to combine the materialistic reductionism of science with the metaphysics of their predecessors". It is formulated in such a way that it assumes as a fact that science is a "materialistic reduction". Shouldn't it rather say: "most practitioners are "mixers" who attempt to combine what they believe to be the materialistic reductionism of science with the metaphysics of their predecessors"? The current wording sounds like violating NPOV to me. Am I the only one feeling this way? Vincent Lextrait (talk) 12:26, 13 November 2011 (UTC)

This doesn't sound like a major issue to me; 'material reductionism' isn't really a pejorative phrase. If it bothers you, though, I'd suggest something like ' strict empiricism' as a replacement. --Ludwigs2 13:55, 13 November 2011 (UTC)

That's fine, it sounded pejorative to me, don't bother changing it just for me. Vincent Lextrait (talk) 15:17, 13 November 2011 (UTC)

Recent Edits

I just made this change [135]. I removed text from the 'scope of practice' section that was a discussion of a battle over manipulation between chiropractors and physiotherapists, not a discussion of chiropractic scope of practice. Not sure if it belongs in this article at all, may be better for a controversies section in the spinal manipulation article? SOme of it is just a discussion of physios scope (ie: "2 states dont allow physios to do SM"...who cares, this is a chiro article). Puhlaa (talk) 01:49, 21 November 2011 (UTC)

I see you ended up moving it rather than permanently deleting it. Good choice. A whole article could be written about how chiropractic has filed lawsuits against PTs...., so it's relevant. -- Brangifer (talk) 04:59, 21 November 2011 (UTC)

DVMt, please explain this edit

Please explain this edit where you left this as part of the edit summary: "(the source (Nelson) did not support the text." Which part of Nelson doesn't support which part of the old content? IIRC, that exact wording was chosen and supported by many editors after long and hard negotiations. -- Brangifer (talk) 05:03, 21 November 2011 (UTC)

The source, freely available online, did not support the text. It is my understanding that the wording in the original source can't be modified in a way that changes as to what was written. I.e. we can't insert or replace certain words in the cited source that wasn't originally written by the authors. Otherwise that is OR. Or, that's my interpretation of it. I read the Nelson paper and the text written in the lead wasn't to be found in that article, or at least I didn't see it. What specific wording would you like to see put back in? Also, the very first sentence "chiropractic is a health profession concerned with..." was not found at all in the Nelson article. So I replaced with the WHO reference which does support the text, word for word. I did not mean to offend you, I apologize if I have done so. DVMt (talk) 05:29, 21 November 2011 (UTC)

Actually DVMt, your current version is closer to that which was agreed upon during those "previous long and hard negotiations" than what you removed. A quick look at the history revealed this edit: [136] that snuck in during March of this year and added the redundant 'Alternative medicine' label in the first sentence and removed the reference to chiropractic as a profession. Your current version is a bit different from what was there in March, but IMO better than what was there before your edit. Perhaps we could see if other editors prefer your version, or what was there March (see below)? Puhlaa (talk) 05:38, 21 November 2011 (UTC)

• March version:"Chiropractic is a health care discipline and profession that emphasizes diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system, especially the spine, under the hypothesis that these disorders affect general health via the nervous system."
• DVMt current version: "Chiropractic is a health care profession concerned with the diagnosis, treatment and prevention of disorders of the neuromusculoskeletal system and the effects of these disorders on general health"

I didn't think that my edit was controversial, but I'm beginning to see that "anything" that has to do with alt-med seems to be controversial here on WP. Based on the march version and the one I inserted, they do in fact seem very similar. I just noticed that the written text wasn't supported in the source that was cited, so I added the WHO text to support the source. I figured removing the CAM part of it was OK since it's there in the second sentence. DVMt (talk) 05:54, 21 November 2011 (UTC)

Ummmm....you're both off on the wrong track as regards my question. Those were not my concerns. I'm just asking for specific clarification. It doesn't help me to repeat what was in the edit summary. What wording in the lead wasn't supported by Nelson? That's what I want to know before dealing with anything else, that is IF I have any objections to it, and it's not certain I do. First things first. I need specifics here. -- Brangifer (talk) 07:34, 21 November 2011 (UTC)

The first sentence in the LEAD, the one defining chiropractic, I think DVMt is saying that it is not consistent with the Nelson et al source. I think he is correct! A quick search of Nelson et al [137] reveals that a definition of chiropractic is never provided in the article, and the sentence "Chiropractic is an alternative medicine that emphasizes the diagnosis, treatment and prevention of mechanical disorders...", or even a derivative of this is not to be found in the Nelson source. The only reference Nelson makes specifically towards Alt med is that chiro has the label of CAM and some chiros object to the label (we already discuss this in the second sentence of the LEAD, as indicated by DVMt above). Anyways, my point is that Nelson doesnt seem to have been an appropriate source at all for a definition of chiropractic.

I definitely approve and prefer DVMt's suggested use of the World Health Organization as a source for the definition of chiropractic. My next choice would be the World Federation of Chiropractic definition, as it represents the greatest # of chiros in the world (although it is biased for this reason and thus the WHO is clearly better because it is objective and credible).Puhlaa (talk) 22:49, 21 November 2011 (UTC)

The first part of the sentence isn't referenced to Nelson, but to Chapman Smith (who represents the WFC):

• Chiropractic is a form of alternative medicine<:ref name=Chapman-Smith/>

That leaves the rest of the sentence. It's not at all certain that the rest is ALL based on Nelson. It could be that only the word or words immediately preceding the ref are actually tied to Nelson, and the rest summarizes sourced content in the body of the article. That often happens, and unless the wording is especially controversial, it's not required that the refs be provided again in the lead. Is the wording controversial? If so, then let's continue this discussion. Otherwise let's move on to whether the newer wording is indeed better.

Another possibility is that a ref has been deleted at some point in time. That also happens, often in incomplete attempts to fix vandalism.

The reason that there are "duplicate" mentions of the CAM/alt med aspect, sourced to two different RS, is that the first is to provide a concise definition. It's important to place the subject "on the map" as soon as possible, sort of like in a biography one immediately mentions the nationality of the person in the very first sentence, and often the first phrase. It cannot wait until the second sentence.

The second serves a very different purpose. Because it's a controversial matter within chiropractic, it was deemed necessary to mention that controversy in the lead, hence it should remain and not be shortened. Since it's longer, it's not appropriate in the first sentence, where one single word suffices. -- Brangifer (talk) 23:34, 21 November 2011 (UTC)

Here is the original version:

• Chiropractic is a form of alternative medicine<:ref name=Chapman-Smith/> that emphasizes diagnosis, treatment, and prevention of mechanical disorders of the human musculoskeletal system, especially the spine, under the hypothesis that these disorders affect general health via the nervous system.<:ref name=Nelson/> It is generally categorized as complementary and alternative medicine (CAM),<:ref name=Chapman-Smith/> a characterization that many chiropractors reject.<:ref name=Redwood-CAM/> Although chiropractors have many attributes of primary care providers, chiropractic has more of the attributes of a medical specialty like dentistry or podiatry.<:ref name=Meeker-Haldeman/>

The portion we need to analyze and compare with Nelson, et al is this:

• ... that emphasizes diagnosis, treatment, and prevention of mechanical disorders of the human musculoskeletal system, especially the spine, under the hypothesis that these disorders affect general health via the nervous system.<:ref name=Nelson/>

Here's a part of the Nelson ref that seems to cover most of that:

• What is the Chiropractic Hypothesis?
  Before going further it is necessary to specify exactly what is meant by the chiropractic hypothesis. While there are an abundance and variety of competing versions of this hypothesis, all of which are ferociously defended by their adherents, it is still possible to identify several principles that are both common to the majority of these, and distinct from other healing systems. These principles are:
  1. There is a fundamental and important relationship (mediated through the nervous system) between the spine and health.
  2. Mechanical and functional disorders of the spine (subluxation) can degrade health.
  3. Correction of the spinal disorders (adjustments) may bring about a restoration of health.

I think this portion of the Nelson ref pretty much covers most of that wording. It has been prosified, which is good practice at Wikipedia, as long as editors can agree that the wording doesn't misrepresent the source, and that hasn't been any problem. That doesn't mean it can't be improved. -- Brangifer (talk) 23:51, 21 November 2011 (UTC)

All this is moot IMO. There is no need for, or policy to support the redundancy and no single, impartial source that accurately reflects the previous version. Therefore, lets just remove it in favour of DVMt's suggestion, which is similar to what had consensus before the march edit anyways. No, the wording added in March is not controversial, however, it is against policy IMO. It seems to be against WP:OR because it combines/synthesizes bits of the 2 articles together to get a definition for the LEAD sentence, as you describe very well in your reply above. The consensus at all other health care pages is to define the profession in the fist section of the LEAD. There is a definition of the profession to begin the LEAD of the physical therapy article, medicine, dentistry, veterinary medicine, etc. Thus, a definition to start an article about a health care profession seems to be already established. Now, we both know that there are many 'definitions' of chiropractic, depending on which group of chiros, or critics, you are talking to. Thus, a definition sourced to an impartial and internationally recognized body, such as the World Health Organization, is necessary. WP:MEDRS says: "Ideal sources for such content includes .....and medical guidelines or position statements from nationally or internationally recognised expert bodies.", thus, I think that the World Health Organization is a perfect source.

To conclude, I am left with 3 questions for other editors:

1. Do you think that the LEAD of this article should be consistent with other health care profession articles and begin with a definition of the profession? If not, can you please justify why?
2. Is the combination of 2 sources (as BR describes above) to generate a definition of chiropractic for the Lead against WP:OR, especially considering that we have impartial medical bodies that have already done this for us?
3. Do you object to using the World Health Organization as a source instead, for the definition of chiropractic in the first sentence of the lead? If you do object, can you please recommend a group you think is more 'expert', 'impartial' or 'recognized' than the WHO that we can use? Puhlaa (talk) 00:40, 22 November 2011 (UTC)

Hmmmm.....your OR/SYNTH objection in this connection is certainly novel and new to me. This is standard practice. It's only if a new conclusion not found in the sources is created that there becomes a problem.

1. Yes, it should (and already had/has) have a definition, but that must not be instead of the requirement for a lead to contain a summation of the article, which is why a subject that is so controversial, complex, and filled with internal and external contradictory "definitions" as chiropractic needs more than just a standard definition (which only covers one POV) that doesn't cover the subject adequately.

The Lead already summarizes the article without an additional CAM thrown in. We are trying to remove the additional mention of CAM, which was added to the lead despite it already being discussed in the very next sentence.Puhlaa (talk) 03:26, 22 November 2011 (UTC)

1. If a novel and new conclusion has been reached it would be wrong, but no one has seen it before. You'll need to demonstrate that to be the case, rather than just raising an accusation without evidence. Impartial medical bodies can likely only provide a partial, one-sided, and incomplete definition. I thought we already had created our own description that summarized the relevant aspects from the body. What was lacking before that necessitated a change now? What has been done now means we are lacking an adequate description.

Nothing was lacking, the Lead was great before the edit in March[138] that you are ignoring repeatedly. This version had consensus, and I am open to returning it to this version. I want to discuss the use of a better source than a chiropractic opinion article about chiropractic philosophy and its place in mainstream healthcare (Nelson). The WHO is a great source!Puhlaa (talk) 03:26, 22 November 2011 (UTC)

1. I don't object to the WHO as a source, as long as it doesn't stand alone. Keep in mind that the WHO is only repeating what it has gotten from the WFC, IOW it doesn't have an opinion on the matter. The WHO/WFC definition is a sales brochure/marketing definition that describes intent. It would be fine to include several conflicting definitions in the body and then summarize them in the lead.

Should we start a post on the medicine forum and see if other editors agree that WHO is an unreliable stand-alone source for a medical definition. However, if you have an equivelantly robust source that raises a controversy over the WHO definition of chiropractic (ie: another nationally or internationally recognized, impartial and credible medical society/group) then I would be open to discussing it's inclusion with the WHO source in the first sentence of the LEAD.Puhlaa (talk) 03:26, 22 November 2011 (UTC)

Brangifer (talk) 01:13, 22 November 2011 (UTC)

BR, the topic of CAM is not really controversial, chiropractic is a CAM by definition no doubt and the second sentence clearly states this. To include this detail again in the first sentence, creating redundancy and forcing us to brush with OR (or maybe not), doesnt make any sense? Moreover, the description about underlying principles of chiropractic in Nelson is interesting, but not a definition of chiropractic for the first sentence of the Lead, it belongs in phiosophy, which is also discussed already in the Lead. We need a better source. Your personal opinion of the potential bias of the WHO is a pretty weak reason to 'require' another source to go with the WHO. According to MEDRS, the WHO is a recognized international medical body. If you have an equivelantly robust source that raises a controversy over the WHO definition of chiropractic (ie: another nationally or internationally recognized, impartial and credible medical society/group) then I would be open to discussing its inclusion with the WHO source in the first sentence of the LEAD. Otherwise, in the absence of controversy, the WHO definition is great and should stand alone. I mean, come on, doesnt it seem like a red flag when you are claiming that the WHO is too biased to use as a stand alone source, and trying to maintain the chiropractic opinion piece (Nelson et al) is odd.

Anyways, you can see that I disagree with you by now.....Moreover, despite your continued denial, my problem is not at all with the text that had consensus (which is pretty much what DVMt has reproduced), my problem is your trying to suggest that an edit made in March that had no consensus [139] is the best place to start now. In contrast, we should be starting with the version that was badly edited against consensus in march. I keep mentioning this, and it seems that you keep pretending that the version DVMt changed was the version that had consensus, when clearly it was not. Now that the issue has been raised by DVMt over the bad edit in March, I also think that the WHO is a better source for that first sentence than Nelson. I see no problems with the text as it stands with DVMts edit. The first sentence is the definition of chiropractic from the world health organization. The second sentence frames chiropractic as a CAM and includes a taste of the controversy surrounding this label. There is nothing wrong with this approach IMO. Should we wait for more opinions here? or take it to a forum? Puhlaa (talk) 03:08, 22 November 2011 (UTC)

I'm surprised that Bullrangifer is protesting this edit so much. The Nelson source didn't support the text and it was combined that a different source to get a hybrid lead which is OR. Also, I am surprised to hear that BR is not considering the WHO document a biased or a bad source. Doesn't WP state that verifiability is the criteria. The claim made in the lead is the exact wording in the source. It seems pretty cut and dry to me. The reason I believe that the WHO piece is superior to Nelson is because the WHO is an organization that is held in high regard and that represents an international view point which is used as training guideline for the development of future chiropractic schools. Nelson article is just a commentary and it didn't even state what the lead was prior to the edit. DVMt (talk) 05:55, 22 November 2011 (UTC)