To the third, fourth, and firth paragraphs of the Safety section, I added information from recent, reliable sources: literature reviews, cross-over studies, WHO recommendations, and findings from physical therapy and well as neuroscience journals. The goal is to tell a more complete story about the state of research within the medical community. I've bolded the major changes.:

The risk of a serious adverse event within one week of treatment is low to very low,^[1] although chiropractors are more commonly connected with serious manipulation-related adverse effects than other professionals.^[2] Rarely,^[3] spinal manipulation, particularly on the upper spine, can result in complications that can lead to permanent disability or death; this can occur in both adults^[4] and children.^[5] Estimates vary widely for the incidence of these complications,^[6] and the actual incidence is unknown, due to high levels of underreporting and the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern.^[4]

Several case reports show temporal associations between manipulations and potentially serious complications. Vertebrobasilar artery stroke (VBA) 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.^[7][8] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.^[9] 'A crossover study found that increased risks of VBA stroke associated with chiropractic and general practitioner visits was likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke.^[10] A literature synthesis found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.^[11]

As late as 2009, Spine journal reported that, "there is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic"^[12], and emphasized the pressing need for further research. In 2010 the first systematic review of deaths resulting from chiropractic manipulation found reports of 26 deaths in the literature published since 1934; substantial underreporting was suspected. The review identified dissection of a vertebral artery, typically caused by neck manipulation with extension and rotation beyond the normal range of motion as the likely cause. The review asserted that there is no good evidence to assume that manipulation to the neck is an effective treatment for any condition and thus concluded, "the risks of chiropractic neck manipulations by far outweigh their benefits."^[2] This view conflicted with prior recommendations of the World Health Organization, which noted: "It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects."^[13] The Journal of Manipulative Physiological Therapeutics similarly found, "the direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures."^[14] The Neurologist journal recommended further research using prospective cohort study designs to uncover both the benefits and the risks associated with chiropractic manipulation.^[15]

Ocaasi (talk) 20:45, 13 August 2010 (UTC)[reply]

• I think that works really well. You've done a great job at keeping the paragraphs balanced, with both sides being clearly shown and neither one receiving preferential wording. Great example of NPOV with opposing viewpoints. I don't see any problems with it at all. Good job. Silverseren^C 02:43, 14 August 2010 (UTC)[reply]

Please show how this meets MEDRS. QuackGuru (talk) 02:50, 14 August 2010 (UTC)[reply]

Please show how it doesn't. Besides ref #1, the rest all appear to be exactly the kind of sources that MEDRS asks for. Silverseren^C 03:01, 14 August 2010 (UTC)[reply]

I asked the question and now you are asking me a question. Please show how this meets MEDRS or I assume you are unable to show how they meet MEDRS. Which references are reviews per MEDRS. QuackGuru (talk) 03:03, 14 August 2010 (UTC)[reply]

The risk of a serious adverse event within one week of treatment is low to very low,^{[1][unreliable medical source?]} although chiropractors are more commonly connected with serious manipulation-related adverse effects than other professionals.^[2] Rarely,^[3] spinal manipulation, particularly on the upper spine, can result in complications that can lead to permanent disability or death; this can occur in both adults^[4] and children.^[5] Estimates vary widely for the incidence of these complications,^[6] and the actual incidence is unknown, due to high levels of underreporting and the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern.^[4]

Several case reports show temporal associations between manipulations and potentially serious complications. Vertebrobasilar artery stroke (VBA) 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.^[7][8] Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.^[9] 'A crossover study^{[unreliable medical source?]} found that increased risks of VBA stroke associated with chiropractic and general practitioner visits was likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke.^{[10][unreliable medical source?]} A literature synthesis^{[unreliable medical source?]} found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.^{[11][unreliable medical source?]}

As late as 2009, Spine journal reported that, "there is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic"^[12],^{[unreliable medical source?]} and emphasized the pressing need for further research.^{[unreliable medical source?]} In 2010 the first systematic review of deaths resulting from chiropractic manipulation found reports of 26 deaths in the literature published since 1934; substantial underreporting was suspected. The review identified dissection of a vertebral artery, typically caused by neck manipulation with extension and rotation beyond the normal range of motion as the likely cause. The review asserted that there is no good evidence to assume that manipulation to the neck is an effective treatment for any condition and thus concluded, "the risks of chiropractic neck manipulations by far outweigh their benefits."^[2] This view conflicted with prior recommendations^{[editorializing]} of the World Health Organization, which noted: "It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects."^[13][This part is duplication from earlier in the safety section.] The Journal of Manipulative Physiological Therapeutics similarly found^{[editorializing]}, "the direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures."^{[14][unreliable medical source?]} The Neurologist journal recommended further research using prospective cohort study[[too much attribution in the text] designs to uncover both the benefits and the risks associated with chiropractic manipulation.^[15][Many studies recommend further research. This does not tell the reader anything significant.]

Here are the problems to begin with. This is a massive MEDRS violation. QuackGuru (talk) 03:20, 14 August 2010 (UTC)[reply]

...*sighs* Here goes...

• Ref #1 is from the Journal of Manipulative and Physiological Therapeutics, which fits under the Biomedical Journals section of MEDRS.
• Ref #2 is obviously the systematic review that started this entire discussion in the first place.
• Ref #3 is guidelines set forth by the World Health Organization (WHO), which fits under the Medical and scientific organizations banner of MEDRS.
• Ref #4 is from the Journal of the Royal Society of Medicine, which fits under both the Journals and Organizations heading.
• Ref #5 is from PEDIATRICS, which is, yet again, a Journal.
• Ref #6 is from Spine, another Journal
• Ref #7 is from Spine.
• Ref #8 is from European Neurology, another Journal.
• Ref #9 is from Neurologist, another Journal.
• Ref #10 is also from Spine.
• Refs #11, 12, and 14 are from the Journal of Manipulative and Physiological Therapeutics Journal.
• Ref #13 is also from the WHO.
• Ref #15 is also from Neurologist.

There, all covered...except for why 6 is blank. Silverseren^C 03:25, 14 August 2010 (UTC)[reply]

6 just didn't copy-over for some reason. I updated it. It's also from Spine. Ocaasi (talk) 03:49, 14 August 2010 (UTC)[reply]

You have not shown how the newly proposed refs are reliable per MEDRS. QuackGuru (talk) 03:29, 14 August 2010 (UTC)[reply]

Assess evidence quality

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., conventional wisdom).

I don't see even one of the newly proposed text using a systemetic review. QuackGuru (talk) 03:29, 14 August 2010 (UTC)[reply]

Then I suppose the first step would be to find out what type of studies the supplied references are. Though I will leave that up to Ocaasi to determine, since he is likely much better and more able at finding that out than I am. Silverseren^C 03:38, 14 August 2010 (UTC)[reply]

According to you previous argument any reference appearing in a journal is reliable. That is clearly not the intent of MEDRS. For medical information we rely on reviews for example. In this case we already have plenty of reviews in the safety section. The recent proposal uses any low-quality reference to argue against high-quality references. QuackGuru (talk) 03:45, 14 August 2010 (UTC)[reply]

You have yet to explain why the supplied references are "low-quality". Silverseren^C 03:54, 14 August 2010 (UTC)[reply]

I have already explained the newly proposed references are not systematic reviews. Any reference appearing in a journal is not reliable per MEDRS. QuackGuru (talk) 03:57, 14 August 2010 (UTC)[reply]

You are clearly misunderstanding what MEDRS means. Otherwise, there would be no section on Biomedical Journals on MEDRS. Yes, systematic reviews are the highest quality and the most reliable, but that doesn't mean that reviews in journals are non-reliable. s the section in MEDASSESS states...

• "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."

Which shows that other types of material besides systematic reviews are seen as reliable, per MEDRS. And, as the section on Biomedical Journals states, "Peer-reviewed medical journals are a natural choice as a source for up-to-date medical information in Wikipedia articles. They contain a mixture of primary and secondary sources, as well as less technical material such as biographies. Although almost all such material will count as a reliable source, not all the material is equally useful." Thus, journal reviews can be used, as they are in the new proposal, to show opposite viewpoints to a systematic review. You do not have to have a systematic review to counter the views of another systematic review. That would be ridiculous and far too restrictive. Silverseren^C 04:05, 14 August 2010 (UTC)[reply]

You clearly did not show which references are reliable per MEDRS. According to your argument editors can cherry pick any reference as long as it is from a journal. This goes against WP:MEDASSESS. The intent of MEDRS is not to allow editors to reach down into primary studies to argue against high-quality reviews. You do have to have a systematic review to counter the views of another systematic review instead of using a primary study to argue against a systematic review. QuackGuru (talk) 04:15, 14 August 2010 (UTC)[reply]

You have yet to prove (or even explain how) that any of the supplied references are primary sources, which is why I stated above that we need to figure out what type of reviews they are so we know where they rnk on the scale of reliability. Silverseren^C 04:22, 14 August 2010 (UTC)[reply]

You think it is ridiculous and far too restrictive to have to have a systematic review to counter the views of another systematic review. Then you think MEDRS is ridiculous. QuackGuru (talk) 04:29, 14 August 2010 (UTC)[reply]

I did take a close look at the newly proposed references. None are systematic reviews. The Safety section uses primarily reviews. To reach down into low-quality references is against MEDRS. QuackGuru (talk) 04:29, 14 August 2010 (UTC)[reply]

QuackGuru, you are either high, or stupid. What you are proposing is that in any article on Wikipedia, the only references that can be used are systematic reviews. In order to do this, you would have to delete half of Wikipedia. You are misunderstanding MEDRS - it says that systematic reviews are the highest quality - it does not say they are the ONLY thing acceptable. Controlled studies are also of high quality. You need a reality check Javsav (talk) 04:52, 14 August 2010 (UTC)[reply]

You can't use low-quality references to argue against systematic reviews. I did delete not half but all the lower quality references recently added against MEDRS. QuackGuru (talk) 05:00, 14 August 2010 (UTC)[reply]

You have no right to do that. The article needs to be balanced - this way several points of view are stated. I've said it before, medicine is far more dangerous to a patient than chiropractic, and even though you may think it has more benefits (and i do too) that is completely subjective. It has been stated in the article that there are 26 deaths since 1937, that is fact. Then there are some opposing view points - this is how an article should be, not one sided. Your reckless behaviour acting as a one-man band and ignoring and misinterpreting Wikipedia policy calls for an admin. Javsav (talk) 05:03, 14 August 2010 (UTC)[reply]

You don't get that those sources weren't negating the other source - they were just offering opposing view points - like a BALANCED article should be.Javsav (talk) 05:04, 14 August 2010 (UTC)[reply]

You have not shown there is a reference that contradicts the new Ernst review. You claimed there are some opposing view points. Please show which ref in accordance per MEDRS contradicts the risk of death from chiropractic neck manipulation by far outweighs the benefits. QuackGuru (talk) 05:10, 14 August 2010 (UTC)[reply]

This reference was written by the Palmer College of Chiropractic West. Do editors seriously think this reference is reliable per MEDRS from Jan 2005. QuackGuru (talk) 06:36, 14 August 2010 (UTC)[reply]

Yes. Do you have a reliable source which suggests otherwise? The review is given full in-text attribution so that if users have any doubt they can immediately see who published the article and make their own determinations. I believe that concept lies at the very core of NPOV. Ocaasi (talk) 09:09, 14 August 2010 (UTC)[reply]

• WP:MEDRS: "Peer-reviewed medical journals are a natural choice as a source for up-to-date medical information in Wikipedia articles. They contain a mixture of primary and secondary sources, as well as less technical material such as biographies. Although almost all such material will count as a reliable source, not all the material is equally useful.
• WP:RS#Scholarship: "Material such as an article or research paper that has been vetted by the scholarly community is regarded as reliable. If the material has been published in reputable peer-reviewed sources or by well-regarded academic presses, generally it has been at least preliminarily vetted by one or more other scholars."

The source is reliable per MEDRS and RS. We can discuss issues of impartiality and weight but not if you choose to cite policy only to support your preference rather than to apply policy as a whole. Ocaasi (talk) 10:51, 14 August 2010 (UTC)[reply]

"Please show which ref in accordance per MEDRS contradicts the risk of death from chiropractic neck manipulation by far outweighs the benefits." The whole point is we don't need to show that because in the article the text that Ocaasi has contributed does not contradict that statement, it merely offers opposing viewpoints. It's like saying "this review stated this, but other sources disagreed" then the reader can make up their mind as to what they believe - it offers a balanced view. Those sources do not need to contradict Ernst because in the article, Ocaasi's text was in no way contradicting Ernst's claims, just offering opposing viewpoints. Javsav (talk) 09:59, 14 August 2010 (UTC)[reply]

That is correct. This is in addition to the statements by Ernst. Ocaasi (talk) 10:51, 14 August 2010 (UTC)[reply]

That is incorrect. This MEDRS violation Jan 2005 reference was written by the Palmer College of Chiropractic West. The proposal has all kinds of editorializing and irrelevant text too. For example, This view conflicted with prior recommendations of the World Health Organization... That is OR. This is also not an opposing viewpoint. The Neurologist journal recommended further research using prospective cohort study[too much attribution in the text] designs to uncover both the benefits and the risks associated with chiropractic manipulation[This is irrelevant information. Many studies recommend further research]. QuackGuru (talk) 21:36, 14 August 2010 (UTC)[reply]

It seems editors wanted more material about risk-benefit. So, I added more material per MEDRS. _-Quack ^o Guru-_ 00:26, 15 August 2010 (UTC)[reply]

I see that there is an ongoing dispute here. I agree that, per WP:MEDRS, a specific claim or statement made by a systematic review should not be countered by a primary source. If another high quality secondary source makes a differing claim, then it is ok to add the two opposing viewpoints.--Literaturegeek | T@1k? 16:34, 14 August 2010 (UTC)[reply]

Uptodate has a great overview:

In general, spinal manipulation is felt to be a relatively safe procedure, although it may be associated with a number of minor complaints and, rarely, serious adverse events. Serious adverse events — The most common serious adverse events associated with spinal manipulation include disk herniation, the cauda equina syndrome, and vertebrobasilar accidents. Estimates of the incidence of these complications range from 1 per 2 million to 1 per 400,000 manipulations [31]. These estimates are primarily derived from published case reports, case series, and retrospective surveys, all of which may be unreliable due to underreporting and the dependence on recall.

If people wish to read the entire section email me. Cheers. Doc James (talk · contribs · email) 08:47, 15 August 2010 (UTC)[reply]

For the article we can't use this older systematic review from 2002. QuackGuru (talk) 00:58, 16 August 2010 (UTC)[reply]

From the wiki reliable source page: " Literature reviews, systematic review articles and specialist textbooks are examples of secondary sources, as are position statements and literature reviews by major health organizations." - position statements by major health organisations, e.g. the WHO. Maybe ocaasi's wording should be changed from "this conflicted" to "However, the WHO". Even saying "this conflicted" it doesn't negate the other source. Lets not forget that this systematic review is by a biased author whose other studies have been shown to be rife with methodological flaws. The main point is that the Ernst paper didn't conclude that the risks outweigh the benefits, Ernst did, and he was referencing his own study. A paper can not conclude something like that, it is completely subjective Javsav (talk) 07:55, 16 August 2010 (UTC)[reply]

Where in the WHO reference does it discuss risk-benefit. Part of the conclusion of systematic review is that the risk of death from spinal manipulation by far outweights the benefit. The review referenced many studies. It was not a paper. It was a systematic review. There is attribution in the text to satisfy the editors who consider it an opinion despite there is no serious dispute per ASF. This systematic review is by a leading researcher of chiropractic. Lets not forget that the lead should be kept a summary. QuackGuru (talk) 01:47, 17 August 2010 (UTC)[reply]

My point is that according to Wikipedia guidelines, it is fine to say "This view conflicted with prior recommendations of the World Health Organization, which noted: "It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects." because position statements by major health organisation are counted in the same realm as systematic reviews Javsav (talk) 01:16, 18 August 2010 (UTC)[reply]

"This view conflicted with prior recommendations of the World Health Organization" is editorialising and OR. This is also irrelevant to the risk-benefit section and somewhat repetitive to the safety section. QuackGuru (talk) 02:50, 18 August 2010 (UTC)[reply]

I could not find any references for the risk-benefit of children's spinal manipulation in accordance with MEDRS. QuackGuru (talk) 03:03, 18 August 2010 (UTC)[reply]

General response about Ernst, WHO sourcing, the risk/benefit section, and a possible RFC

• Ernst's conclusions are in conflict with the following: "It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects." That is direct from the WHO report, which was already mentioned above in the Safety section proposed edits. It might not be a 'recommendation'. Call it a 'perspective' instead. Either way, it's not original research. And it's not really repetitive if it hasn't been mentioned yet.

• Here is the full WHO section on Vascular Accidents:

5.4 Vascular accidents

Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that “critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical manipulation. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects” (43).

In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which, almost by chance, results in a very serious consequence (54, 55, 56, 57). http://www.kiropraktiikka.fi/media/Final_Chiro-guidelines_03-11-2005.pdf

• The Safety section proposal was supported by Javsav and Silver Seren who addressed your sourcing objections. Though Doc James took no position on the new edits, he did provide a citation to adverse risk rates of between 1:400k to 1:2m. Those numbers should be included.

• The risk-benefit section was added without consensus. It currently cites three articles all written by Ernst. Ernst has also written articles with an explicit POV to criticize chiropractic.( link) Ernst may be a reliable source, but he has consistently taken a stance against complimentary alternative medicine in general. His conclusions shouldn't stand alone. Even per WP:MEDRS, other sources deserve WEIGHT, even if they are not systematic reviews. They are not mere primary sources.

• According to this article by a fellow scientist, Ernst himself described adverse effects of chiropractic as "hotly disputed": "Ernst then moved on to the risks of chiropractic, noting that mild to moderate adverse effects of the treatment were not disputed - in comparison to severe adverse effects which were hotly disputed. Discussion of chiropractic ended with a slide showing a pair of scales labelled "harm" and "benefit", with the harms being shown as heavier than the benefits."link It's just a blog, but given its scientific perspective I think it at least adds weight to the claim that there is in fact a dispute about the frequency of adverse events.

• If you find none of this relevant, then we should probably move toward clarifying the questions for an RfC. Not much point in going back and forth if the points aren't being addressed. I recommend we produce two alternate drafts of the Safety and Risk/Benefit sections, a list of implicated policy questions, a list of specific disputed claims, and a list of specific disputed sources. User:Ocaasi 18:43, 19 August 2010 (UTC)[reply]

Javsav and Silver Seren where not able to address the sourcing issues per MEDRS. We can't use a low-quality source to argue against a systematic review and add editorializing WP:OR. This view conflicted with prior recommendations[editorializing?] is not stated in the source. That is your personal interpretation and original research. I don't see in the WHO report that the risk of death from manipulations to the neck does not outweigh the benefit and the WHO report can't be used in the risk-benefit section because it is not specifically about risk-benefit. Do you have any WP:MEDRS sources that are specifically about risk-benefit and not generally about stated risk that meet MEDRS. QuackGuru (talk) 00:36, 20 August 2010 (UTC)[reply]

QG, it doesn't appear that you read my comments carefully. I have no problem taking out what you called editorializing or original research: the WHO quote is significant, not the description of the quote which we can change. Silver Seren did address the sourcing issue per MEDRS, please see that comment. The WHO's guidlines on chiropractic are neither low-quality nor outside MEDRS. The WHO report is clearly about the context of research around adverse events. If you want to leave out the "conflicts with the view" part, that's fine, as long as we include the WHO's interpretation. All of these sources are about the claims related to VBA stroke, vascular accidents, rates of adverse events, and general safety. A source which literally says "Ernst's claims are wrong" is not necessary to include other information. It's a bar that is neither being suggested nor is required by policy. As repeated before, Ernst is not a problem. The problem is the lack of sources which provide additional/alternate/competing views which exist in reliable medical sources about these issues. If none of this makes sense, then I think we should consider something towards an RfC. Ocaasi (talk) 03:33, 20 August 2010 (UTC)[reply]

You or any other editor did not give a valid reason to ignore MEDRS or expand the safety section. You have no problem taking out what is editorializing or original research but I assume you don't understand what you want to add is against WP:OR or it does not matter to you that adding OR is against Wikipedia's consensus. The WHO report is about adverse events which is already covered in the safety section. You want to add repetitive material to double the size of the safety section that will coverup or drown the existing text.

The Neurologist journal recommended further research using prospective cohort study[This is too much attribution in the text.] designs to uncover both the benefits and the risks associated with chiropractic manipulation.[15][Many studies recommend further research. This does not tell the reader anything significant.] The proposal does not add anything significant to the safety section.

Here is a question to see if you understand MEDRS. Do you think it is appropriate to use a primary source or low-quality source to argue against a higher-quality source such as a systemetic review. QuackGuru (talk) 04:14, 20 August 2010 (UTC)[reply]

Part of the proposal is "The risk of a serious adverse event within one week of treatment is low to very low,"[1][Unreliable medical source?] This is vague and repetitive. The 24 to 48 hours is more concise.

"Spinal manipulation is associated with frequent, mild and temporary adverse effects,[21][22] including new or worsening pain or stiffness in the affected region.[144] They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours.[145]" This is currently in the article. There is no reason to change it. QuackGuru (talk) 04:36, 20 August 2010 (UTC)[reply]

Myself, and other editors, have given numerous reasons to improve the sourcing in this article per MEDRS. Your continual characterization of interpreting policy differently as ignoring policy makes this discussion difficult. Nothing I have suggested in the revised form is OR, provided the words are chosen carefully. The WHO quote cannot be OR, because, it's a quote.

I want to accurately reflect the variety of views held by reliable sources. If that changes the current balance of the section, it does not mean the current form is better. Attribution is useful where issues are contentious or where reliability is in question. Increased attribution in the instance of Neurologist, increases the credibility of the sentence rather than undermine it, as in-line attribution can be misused to do. The Neurologist recommended a specific type of study which reflected the lack of dispositive research on these contentious issues. Per your MEDRS question, none of the sources are primary, and calling them low-quality if they are not just avoids having to use the sources. An RfC will help resolve the appropriate weight the sources deserve.

The low-to-very-low summary is important, particularly considering that 24-48 hours only covers a specific timeframe. Doc James statistics about 1:400k to 1:2m are directly relevant and reliably sourced. There is reason to include additional, qualifying, contextualizing, conflicting reports. If you don't want to try and figure out which sources would best do that from the new ones that have been introduced, then we should have other editors weigh in on matters of sources and policy. If you are very confident in your interpretation of policy, then an RfC should only help bolster your position. It might also help address some of the specific claims that have been made. Ocaasi (talk) 04:48, 20 August 2010 (UTC)[reply]

For the article we can't use the statistics about 1:400k to 1:2m that are from an older systematic review from 2002.

This is dated material from 2002. This shows Ocaasi does not have a problem with violating MEDRS. We have better material currently in the article anyhow.

"Estimates vary widely for the incidence of these complications,^[6] and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern.^[4]" This is more accurate than older statistics.

The proposal will drown out the safety section and replace it with vague information and insignificant information. 24-48 hours bit is more precise than the proposal. QuackGuru (talk) 05:07, 20 August 2010 (UTC)[reply]

Here is a question to see who understands MEDRS. Do you think it is appropriate to use a primary source or low-quality source to argue against a higher-quality source such as a systemetic review. QuackGuru (talk) 05:24, 20 August 2010 (UTC)[reply]

From WP:MEDRS:

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 examined 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....Prefer recent reviews to older primary sources on the same topic. If recent reviews don't mention an older primary source, the older source is dubious....These are just rules of thumb. There are exceptions:... Cochrane Library reviews are generally of high quality and are routinely maintained even if their initial publication dates fall outside the above window.

• Doc James' stats are from uptodate.com, a reliable and 'uptodate' tertiary source. Please see this previous discussion on RSN, also here. More importantly, the source provides global ratios for incidents, which Ernst does not. 26 deaths since 1934 is significant, but out of how many treatments?

Also, as MEDRS suggest, Ernst 2010 may even be too soon to be specifically contradicted, since it has not been through a full review cycle. Since no other sources have had time to dispute its specific claims, WPMEDRS on systematic reviews might be reasonably relaxed in this context to allow competing views. Also, do you think it is curious or problematic that the risk/benefit section contains four references 'all' to Ernst?

24-48 hours is specific but not complete. It only describes the time-frame of moderate effects, not the probability of adverse effects, which published data shows is remarkably low, low enough that it is perhaps safer than many conventional treatments. There is also evidence that adverse effects (though possibly underreported) are also possibly conflated with underlying conditions. Thus, there is a broader picture which your approach does not sufficiently describe. You are again accusing me of ignoring policy when I am offering a different application of the policy in this circumstance. We could continue on the merits, but not if you are only going to repeat mischaracterizations.

I think I will try and bring some other editors' views to the page. Would you prefer WP:30, WP:Mediation, WP:RSN/WP:NPOVN, or WP:RFC? Ocaasi (talk) 06:52, 20 August 2010 (UTC)[reply]

"Spinal manipulation is associated with frequent, mild and temporary adverse effects,[21][22] including new or worsening pain or stiffness in the affected region.[144] They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours.[145]"

The estimates are about frequent, mild and temporary adverse effects.

"They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours."

Gouveia LO, Castanho P, Ferreira JJ (2009). "Safety of chiropractic interventions: a systematic review". Spine. 34 (11): E405–13. doi:10.1097/BRS.0b013e3181a16d63. PMID 19444054.

You want to delete this material from a systematic review specifically on Safety of chiropractic interventions and replace it with a reference that is not specifically about safety.

The reference from 2002 is not an up-to-date reference. This is too dated.

The Safety section is made up of text written by Wikipedians. The absurd proposal is made of attribution in the text and quotes. Adding a several quotes does not have an encyclopedic feel. It is very poor writing to add quote after quote.

There are similar references like the new systematic review. So there has been given enough time for other researchers to write about risk-benefit of the neck manipulation.

Abstract

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

Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65.

WPMEDRS on systematic reviews might be reasonably relaxed in this context to allow competing views? You have not given any other view specifically about risk-benefit. Not all the reviews are written soely by one author. There is one of the reviews written by two authors. QuackGuru (talk) 03:00, 21 August 2010 (UTC)[reply]

"The estimates for serious adverse events varied between 5 strokes in 100,000 manipulations to 1.46 serious adverse events in 10,000,000 manipulations and 2.68 deaths in 10,000,000 manipulations.[145]"

I added this material using a recent systematic review specifcally about safety. This is about serious adverse events. QuackGuru (talk) 06:26, 22 August 2010 (UTC)'[reply]

QuackGuru, you are a bully. You constantly revert other people's edits yet feel free to reign edits over the page, misinterpreting policy to back yourself up. You seem to have a very black and white view of the policy, but that is obviously due to some detriment of your own. You have disregarded all of our comments, it's like we are talking to a wall. Instead you respond by repeating the same question. And then when a systematic review with statistics that you don't like comes up, suddenly you claim that it is too old, when Ocaasi's quoting of policy proved you wrong that it was not. Hopefully the mediator will sort this out - when Ocaasi asked you whether you wanted mediation, you didn't respond, which obviously shows that you know to some extent that what you are doing is bullying and unfair. Javsav (talk) 02:47, 24 August 2010 (UTC)[reply]

Clin J Pain. 2006 Mar-Apr;22(3):278-85.

Are manual therapies effective in reducing pain from tension-type headache?: a systematic review. Fernández-de-Las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA.

Department of Physical Therapy, Occupational Therapy, Physical Medicine and Rehabilitation, Universidad Rey Juan Carlos (URJC), Alcorcón, Madrid, Spain. cesarfdlp@yahoo.es

Abstract OBJECTIVES: A systematic review was performed to establish whether manual therapies have specific efficacy in reducing pain from tension-type headache (TTH).

METHODS: Computerized literature searches were performed in MEDLINE, EMBASE, AMED, MANTIS, CINAHL, PEDro, and Cochrane databases. Papers were included if they described clinical (open noncontrolled studies) or randomized controlled trials in which any form of manual therapy was used for TTH, and if they were published after 1994 in the English language. The methodologic quality of the trials was assessed using the PEDro scale. Levels of scientific evidence, based on the quality and the outcomes of the studies, were established for each manual therapy: strong, moderate, limited, and inconclusive evidence.

RESULTS: Only six studies met the inclusion criteria. These trials evaluated different manual therapy modalities: spinal manipulation (three trials), classic massage (one trial), connective tissue manipulation (two trials), soft tissue massage (one trial), Dr. Cyriax's vertebral mobilization (one trial), manual traction (one trial), and CV-4 craniosacral technique (one trial). Methodologic PEDro quality scores ranged from 2 to 8 points out of a theoretical maximum of 10 points (mean=5.8+/-2.1). Analysis of the quality and the outcomes of all trials did not provide rigorous evidence that manual therapies have a positive effect in reducing pain from TTH: spinal manipulative therapy showed inconclusive evidence of effectiveness (level 4), whereas soft tissue techniques showed limited evidence (level 3).

CONCLUSIONS: The authors found no rigorous evidence that manual therapies have a positive effect in the evolution of TTH. The most urgent need for further research is to establish the efficacy beyond placebo of the different manual therapies currently applied in patients with TTH.

The text "A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache." is supported by Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA (2006). "Are manual therapies effective in reducing pain from tension-type headache?: a systematic review". Clin J Pain. 22 (3): 278–85. doi:10.1097/01.ajp.0000173017.64741.86. PMID 16514329.

Headache. 2005 Jun;45(6):738-46.

Physical treatments for headache: a structured review. Biondi DM.

Harvard Medical School, Boston, MA, USA.

Abstract BACKGROUND: Primary headache disorders, especially migraine, are commonly accompanied by neck pain or other symptoms. Because of this, physical therapy (PT) and other physical treatments are often prescribed. This review updates and synthesizes published clinical trial evidence, systematic reviews, and case series regarding the efficacy of selected physical modalities in the treatment of primary headache disorders.

METHODS: The National Library of Medicine (MEDLINE), The Cochrane Library, and other sources of information were searched through June 2004 to identify clinical studies, systematic reviews, case series, or other information published in English that assessed the treatment of headache or migraine with chiropractic, osteopathic, PT, or massage interventions.

RESULTS: PT is more effective than massage therapy or acupuncture for the treatment of TTH and appears to be most beneficial for patients with a high frequency of headache episodes. PT is most effective for the treatment of migraine when combined with other treatments such as thermal biofeedback, relaxation training, and exercise. Chiropractic manipulation demonstrated a trend toward benefit in the treatment of TTH, but evidence is weak. Chiropractic manipulation is probably more effective in the treatment of tension-type headache (TTH) than it is in the treatment of migraine. Evidence is lacking regarding the efficacy of these treatments in reducing headache frequency, intensity, duration, and disability in many commonly encountered clinical situations. Many of the published case series and controlled studies are of low quality.

CONCLUSIONS AND RECOMMENDATIONS: Further studies of improved quality are necessary to more firmly establish the place of physical modalities in the treatment of primary headache disorders. With the exception of high velocity chiropractic manipulation of the neck, the treatments are unlikely to be physically dangerous, although the financial costs and lost treatment opportunity by prescribing potentially ineffective treatment may not be insignificant. In the absence of clear evidence regarding their role in treatment, physicians and patients are advised to make cautious and individualized judgments about the utility of physical treatments for headache management; in most cases, the use of these modalities should complement rather than supplant better-validated forms of therapy.

The text "A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine." is supported by Biondi DM (2005). "Physical treatments for headache: a structured review". Headache. 45 (6): 738–46. doi:10.1111/j.1526-4610.2005.05141.x. PMID 15953306.

Cochrane Database Syst Rev. 2004;(3):CD001878.

Non-invasive physical treatments for chronic/recurrent headache. Bronfort G, Nilsson N, Haas M, Evans R, Goldsmith CH, Assendelft WJ, Bouter LM.

Wolfe-Harris Center for Clinical Studies, Northwestern Health Sciences University, 2501 W 84th St, Bloomington, MN 55431, USA. gbronfort@nwhealth.edu

Abstract BACKGROUND: Non-invasive physical treatments are often used to treat common types of chronic/recurrent headache.

OBJECTIVES: To quantify and compare the magnitude of short- and long-term effects of non-invasive physical treatments for chronic/recurrent headaches.

SEARCH STRATEGY: We searched the following databases from their inception to November 2002: MEDLINE, EMBASE, BIOSIS, CINAHL, Science Citation Index, Dissertation Abstracts, CENTRAL, and the Specialised Register of the Cochrane Pain, Palliative Care and Supportive Care review group. Selected complementary medicine reference systems were searched as well. We also performed citation tracking and hand searching of potentially relevant journals.

SELECTION CRITERIA: We included randomized and quasi-randomized controlled trials comparing non-invasive physical treatments for chronic/recurrent headaches to any type of control.

DATA COLLECTION AND ANALYSIS: Two independent reviewers abstracted trial information and scored trials for methodological quality. Outcomes data were standardized into percentage point and effect size scores wherever possible. The strength of the evidence of effectiveness was assessed using pre-specified rules.

MAIN RESULTS: Twenty-two studies with a total of 2628 patients (age 12 to 78 years) met the inclusion criteria. Five types of headache were studied: migraine, tension-type, cervicogenic, a mix of migraine and tension-type, and post-traumatic headache. Ten studies had methodological quality scores of 50 or more (out of a possible 100 points), but many limitations were identified. We were unable to pool data because of study heterogeneity. For the prophylactic treatment of migraine headache, there is evidence that spinal manipulation may be an effective treatment option with a short-term effect similar to that of a commonly used, effective drug (amitriptyline). Other possible treatment options with weaker evidence of effectiveness are pulsating electromagnetic fields and a combination of transcutaneous electrical nerve stimulation [TENS] and electrical neurotransmitter modulation. For the prophylactic treatment of chronic tension-type headache, amitriptyline is more effective than spinal manipulation during treatment. However, spinal manipulation is superior in the short term after cessation of both treatments. Other possible treatment options with weaker evidence of effectiveness are therapeutic touch; cranial electrotherapy; a combination of TENS and electrical neurotransmitter modulation; and a regimen of auto-massage, TENS, and stretching. For episodic tension-type headache, there is evidence that adding spinal manipulation to massage is not effective. For the prophylactic treatment of cervicogenic headache, there is evidence that both neck exercise (low-intensity endurance training) and spinal manipulation are effective in the short and long term when compared to no treatment. There is also evidence that spinal manipulation is effective in the short term when compared to massage or placebo spinal manipulation, and weaker evidence when compared to spinal mobilization. There is weaker evidence that spinal mobilization is more effective in the short term than cold packs in the treatment of post-traumatic headache.

REVIEWERS' CONCLUSIONS: A few non-invasive physical treatments may be effective as prophylactic treatments for chronic/recurrent headaches. Based on trial results, these treatments appear to be associated with little risk of serious adverse effects. The clinical effectiveness and cost-effectiveness of non-invasive physical treatments require further research using scientifically rigorous methods. The heterogeneity of the studies included in this review means that the results of a few additional high-quality trials in the future could easily change the conclusions of our review.

The text "A 2004 review found that SM may be effective for migraine and tension headache, and SM and neck exercises may be effective for cervicogenic headache." is supported by Bronfort G, Nilsson N, Haas M, et al. (2004). Brønfort G (ed.). "Non-invasive physical treatments for chronic/recurrent headache". Cochrane Database Syst Rev (3): CD001878. doi:10.1002/14651858.CD001878.pub2. PMID 15266458.{{cite journal}}: CS1 maint: article number as page number (link)

J R Soc Med. 2006 Apr;99(4):192-6.

A systematic review of systematic reviews of spinal manipulation. Ernst E, Canter PH.

Complementary Medicine, Peninsula Medical School, Universities of Exeter & Plymouth, 25 Victoria Park Road, Exeter EX2 4NT, UK. Edzard.Ernst@pms.ac.uk

Comment in:

J R Soc Med. 2007 Oct;100(10):444; author reply 447. J R Soc Med. 2006 Jun;99(6):278; author reply 279-80. J R Soc Med. 2006 Jun;99(6):278-9; author reply 279-80. J R Soc Med. 2006 Jun;99(6):277-8, author reply 279-80. J R Soc Med. 2006 Jun;99(6):277; author reply 279-80.

Abstract OBJECTIVES: To systematically collate and evaluate the evidence from recent systematic reviews of clinical trials of spinal manipulation.

DESIGN: Literature searches were carried out in four electronic databases for all systematic reviews of the effectiveness of spinal manipulation in any indication, published between 2000 and May 2005. Reviews were defined as systematic if they included an explicit and repeatable inclusion and exclusion criteria for studies.

RESULTS: Sixteen papers were included relating to the following conditions: back pain (n=3), neck pain (n=2), lower back pain and neck pain (n=1), headache (n=3), non-spinal pain (n=1), primary and secondary dysmenorrhoea (n=1), infantile colic (n=1), asthma (n=1), allergy (n=1), cervicogenic dizziness (n=1), and any medical problem (n=1). The conclusions of these reviews were largely negative, except for back pain where spinal manipulation was considered superior to sham manipulation but not better than conventional treatments.

CONCLUSIONS: Collectively these data do not demonstrate that spinal manipulation is an effective intervention for any condition. Given the possibility of adverse effects, this review does not suggest that spinal manipulation is a recommendable treatment.

The text "Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SM." is supported by Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMC 1420782. PMID 16574972. {{cite journal}}: Unknown parameter |lay-date= ignored (help); Unknown parameter |lay-source= ignored (help); Unknown parameter |lay-url= ignored (help)