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I am hoping for other editors opinions on 2 things here: #1, I have included some published responsed from chiropractors to some of the Ernst articles to bring balance to this section, but it may need some editing. #2, I propose moving this entire paragraph to the "controversies and criticisms" section of the chiropractic article, as it is clearly not established fact, but rather controversial (evidenced by the fact that Ernst has written all the negative articles and chiropractors have written all the rebuttles). Comments/criticisms are welcome and appreciated. Puhlaa (talk) 22:38, 16 December 2010 (UTC)

Proposed revision of risk-benefit paragraph

A 2010 systematic review found 26 reports of death following chiropractic manipulation since 1934 and concluded that "the risks of chiropractic neck manipulations by far outweigh their benefits."^[1] A 2007 systematic review found that with uncertain efficacy and definite risks, the risk-benefit balance of spinal manipulation can't be positive.^[2] A 2006 systematic review of systematic reviews found the risk-benefit balance does not favor spinal manipulation over other treatments like physical therapy.^[3] Chiropractors have criticized the quality of the studies which arrive at these conclusions.^[4][5][6] A 2008 study found that the best evidence suggests that chiropractic care is a useful therapy for subjects with neck or low-back pain for which the risks of serious adverse events should be considered negligible.^[7] A 2009 review evaluating maintenance chiropractic care stated that because spinal manipulation is routinely associated with considerable harm, and because no compelling evidence exists to indicate that chiropractic maintenance care can prevent symptoms or diseases, the risk-benefit balance is not in favour of chiropractic maintenance care.^[8] Puhlaa (talk) 17:11, 18 December 2010 (UTC)

COMMENTS

Ernst 2010 seems a better WP:MEDRS than the criticism. — Arthur Rubin (talk) 23:19, 16 December 2010 (UTC)

Not sure if I understand what you mean? Ernst 2010 is more reliable than his previous critical works? or Ernst 2010 is more reliable than the opposition to his early critical works? Either way, what do you suggest I change to reflect this? I could move his 2010 review to the beginning of the paragraph? Puhlaa (talk) 23:29, 16 December 2010 (UTC)

I have moved the mention of 2010 Ernst review to the beginning of the paragraph as it is the most recent article that discusses risk-benefit, and in hopes of addressing Arthur Rubin's comment. Puhlaa (talk) 23:52, 16 December 2010 (UTC)

Puhlaa, this is the sensitive part of the article. WP:MEDRS describes a hierarchy of sources which make medical claims. Per that guideline, we can't put a high-quality systematic review up against a lower quality criticism in a point-rebuke fashion. I would, very much, like to find a way to include the Chiropractic response to these studies, in some way, per WP:NPOV if not per MEDRS. I think the solution is to aggregate the criticisms at the end of the section in a shorter sentence. Something as simple as, "Chiropractors have criticized the quality of the studies which arrive at these conclusions." I can't see how NPOV doesn't give us room for that, at least. Ocaasi (talk) 16:55, 17 December 2010 (UTC)

I see what you are saying Ocaasi. My hope was that by moving this paragraph to the controversies section it would allow more 'leniency' with the whole MEDRS thing to allow balance between the 2 perspectives. This seems especially 'fair' as the Ernst articles also appear in the "Safety" section, which maintains strict MEDRS guidelines. Thus, the issue of safety and risk-benefit could appear 2x in the article, once under SAFETY (following strict MEDRS) and a second time under CONTROVERSIES (allowing for the chiropractors perspective to be included despite not being 100% consistent with MEDRS). Perhaps an alternative would be dropping this paragraph altogether, as the critical ERNST articles all appear under the topic of safety already, it is the risk-benefit issue that becomes controversial and I thought deserves some better balance. Puhlaa (talk) 17:04, 17 December 2010 (UTC)

There's the problem. The Ernst studies are not controversial by Wiki standards; they are reliable. The response by Chiropractors is part of the controversy, relevant per NPOV but not reliable per MEDRS. So we have to either split them up (Ernst in the Risk-Benefit section and criticism in the Controversy section, or we have to clearly privilege the studies as the main point and only briefly mention the Chiropractic response afterward. This is not how I'd like us to do things, but MEDRS requires it at the moment, and it's not wholly without reason. Ocaasi (talk) 17:21, 17 December 2010 (UTC)

Fair enough. I will move the mention of responses by DCs to the end of the paragraph and make it brief (now done and ready for inspection). Does this mean that the Risk-benefit paragraph should also not be moved to the controversies section? If not to bring up controversy then this paragraph seems redundant, as the 4 reviews by Ernst are already presented in the safety section? Puhlaa (talk) 17:39, 17 December 2010 (UTC)

"Chiropractors have criticized the quality of the studies which arrive at these conclusions? Chiropractors have not criticized the quality of all the studies in the risk-benefit section. See WP:OR. This is a WP:WEIGHT violation to use the minority view. QuackGuru (talk) 19:06, 17 December 2010 (UTC)

In part, fair enough. I have added additional detail to the sentence "Chiropractors have criticized the quality of some of the studies which arrive at these conclusions", but I feel it is important to provide some kind of indication that the critical reviews (all written by one author) are not the only view on the subject. Puhlaa (talk) 19:48, 17 December 2010 (UTC)

I think it's a misreading of Weight to take it as saying minority views don't get any mention. They just don't get as much. Weight is not binary. Ocaasi (talk) 21:49, 17 December 2010 (UTC)

See WP:WEIGHT: Wikipedia should not present a dispute as if a view held by a small minority deserved as much attention overall as the majority view. Views that are held by a tiny minority should not be represented except in articles devoted to those views. To give undue weight to the view of a significant minority, or to include that of a tiny minority, might be misleading as to the shape of the dispute. Wikipedia aims to present competing views in proportion to their representation in reliable sources on the subject. This applies not only to article text, but to images, wikilinks, external links, categories, and all other material as well.

If you want to include the chiropractic tiny minority view then an editor would have to start a new article created specfically for the Chiropractor's view. I will support a new article devoted to the minority view. QuackGuru (talk) 04:39, 18 December 2010 (UTC)

I disagree that the criticism of Ernst reviews by chiropractors is the 'tiny minority view' as you put it QG. The cricisms of his articles has been done via published letters to the editor, which is considered a form of post-publication peer-review. ("Wikipedia articles should be based on reliable, published sources, making sure that all majority and significant minority views that have appeared in reliable, published sources are covered") I fail to see how a letter to the editor is not a significant minority view at least, clearly the editor of these two well respected journals thought these criticisms of Ernst' work were worth publishing. Further QG, I have already diminished their size from my original inclusion, and then moved them to the end of the paragraph, and then indicated it was only a criticism of SOME of Ernst' critical works. When is it exactly that YOU bend a little to meet other editors half way to achieve concensus? Puhlaa (talk) 06:35, 18 December 2010 (UTC)

Weight requires we present disputes in proportion to their representation in reliable sources. NPOV more generally encourages that we, with appropriate contextualization and coverage, present both sides to situations. The offer here is not, as you put it, to characterize the chiropractic response as equal, merely to mention the chiropractic response at all. If you think we need a separate article for that, then I think we have a bigger problem with applying MEDRS and Weight, neither of which should keep out of an article on Chiropractic what Chiropractors think of the evaluation of their field. Ocaasi (talk) 09:21, 18 December 2010 (UTC)

The editor of the international journal of clinical practice has just found it reasonable to publish 4 rebuttles to Ernst' 2010 review of "Deaths after Chiropractic" in the Jan 2010 issue. I would be happy to email full texts to anyone who does not have access to them. Now that there are criticisms of 3 of 4 works of Ernst, plus a review that finds a different outcome, the idea that the outcomes he presents seems even less "tiny and insignificant". I have modified the proposed risk-benefit paragraph accordingly for other editos to review. You will note that I still put Ernst work primary, with the opposing critiques and outcomes secondary to appease those who still consider them as only significant minority views. The analysis of maintenance care is a somewhat different topic so it alone concludes the paragraph. Puhlaa (talk) 17:11, 18 December 2010 (UTC)

Only chiropractors are complaining about the research. This is not new. Chiropractors have a history of anti-science beliefs.

Ernst 2010 seems a better WP:MEDRS than the criticism. — Arthur Rubin (talk) 23:19, 16 December 2010 (UTC)

I'm not the only person who has questioned the original proposal. QuackGuru (talk) 18:23, 18 December 2010 (UTC)

I have qualified in the paragraph that it is DCs that are criticising the work of Ernst, however, if the editor of a high quality journal such as Int J clin prac feels the criticisms are worth publishing in the journal, clearly they deserve mention in the wikipedia article. In addition, QG, It seems from a look at the history of this talk that Arthur rubin is not who posted the statement above yours, is it appropriate to fake a post from another editor? Puhlaa (talk) 18:31, 18 December 2010 (UTC)

Another editor wrote Ernst 2010 seems a better WP:MEDRS than the criticism. — Arthur Rubin (talk) 23:19, 16 December 2010 (UTC) It seems that Arthur Rubin disagrees with the original proposal.

The original proposed changes to risk-benefit was modified to address Arthur rubins concern and to attempt to reach consensus. You have editorialized his original comment to support a claim that he objects to the paragraph after it was modified as well. You seem to have a very unethical and disrespectful approach to working together for consensus. Puhlaa (talk) 19:07, 18 December 2010 (UTC)

The original proposal was changed but it seems Arthir Rubin questioned the reliability of the sources when he wrote "Ernst 2010 seems a better WP:MEDRS than the criticism". The unreliable sources are the problem according to MEDRS. QuackGuru (talk) 19:30, 18 December 2010 (UTC)

You have included the fringe minority view but not the response from Ernst.

This recent edit added a 2008 study. The study may not meet MEDRS. QuackGuru (talk) 18:44, 18 December 2010 (UTC)

I am amazed how no study that contradicts your view ever seems to meet MEDRS in your opinion. The 2008 paper is recent, review in peer reviewed journal. It can stay.

I did not include Ernst' response to the criticism because to do so would require expanding on the criticism of his work (eg: He reported this, DCs claim its biased because..., Ernst refutes the claims because...). You objected to expanding the detail of the criticisms, so instead, the "majority view" is held by his papers and the "significant minority view" is held by the criticisms in the paragraph.Puhlaa (talk) 18:55, 18 December 2010 (UTC)

How did you determine the 2008 study is a systematic review or review. How does the study meet MEDRS according to MEDRS guidelines.

I did not say it was systematic review, only that it was a review, very recently (2008) published in a peer-reviewed journal that is indexed on "Index Medicus" (thus reputable). As per 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." Puhlaa (talk) 19:17, 18 December 2010 (UTC)

Lots of sources are indexed. Where did it say the source is a general review. QuackGuru (talk) 19:30, 18 December 2010 (UTC)

I objected to including the fringe point of view and now you want to exclude the response. Seems kind of one sided. If we are to include anything we should only include the response from Ernst and exclude the tiny minority view from chiropractors. QuackGuru (talk) 19:04, 18 December 2010 (UTC)

I have already addressed why I didnt include Ernst reply, however, if you are bothered that only his primary source gets mention I would be happy to include a sentence that reads something like "Ernst objects to the DCs objection" if it will prevent further stonewalling on your part and move us closer to consensus! Puhlaa (talk) 19:17, 18 December 2010 (UTC)

You wrote "Ernst objects to the DCs objection". Please provide the text from the source to verify the claim. I strongly object to including the fringe point of view from the chiropractic community. The sources with critiques from chiropractors are unreliable per MEDRS and the chiropractic minor view is against WEIGHT. QuackGuru (talk) 19:30, 18 December 2010 (UTC)

You are failing to understand that a response by DC to Ernst' review, that has been deemed publishable by the editor of the journal, is not unreliable, it is a post-publication peer review, and it one way that scientists evaluate the literature once it is published, by examining the responses of other scientists that the journal editors sees as valid arguements and decides to publish. Thus, it becomes a significant minority view. Your opinion that they are fringe and insignificant does not outweigh the opinion of the editor of a peer-reviewed journal that they are significant enough to warrant publishing. The appearance of the DC criticisms has been reduced to a mere mention and has been diminished as much as possible while still allowing the fact that opposing perspectives exist to be revealed. Puhlaa (talk) 19:56, 18 December 2010 (UTC)

You wrote "Ernst objects to the DCs objection". I previously asked you to provide the text from the source to verify the claim.

You wrote "Chiropractors have criticized the quality of the studies which arrive at these conclusions". All three sources criticized the quality of all those studies? Using three different sources to come to the same conclusion against the studies is SYN. Chiropractic criticisms is the definition of the fringe view according to WEIGHT. QuackGuru (talk) 20:16, 18 December 2010 (UTC)

Originally I had the respective criticism mentioned and cited behind each respective Ernst article, however, it was objected to by other editors, as the DC responses are only a significant minority view, not a majority view. Thus, the 3 references, 1 for each of Ernst papers are grouped together and minimmized. However, I further minimized the responses by clumping the 4 responses to his 2010 review as one citation. Thus, the 6 responses to Ernst' 3 papers have all been clumped, minimized and not described explicitly. It is your turn to help us achieve consensus by doing a little "bending" on your part. It is reasonable to indicate that published objections to Ernst articles exist, it is unreasonable to stonewall every attempt at making the section NPOV. I will quote Ocaasi's earlier statement to remind you "NPOV more generally encourages that we, with appropriate contextualization and coverage, present both sides to situations. The offer here is not, as you put it, to characterize the chiropractic response as equal, merely to mention the chiropractic response at all." I have provided some quotes of the criticisms of Ernst work below Puhlaa (talk) 20:13, 20 December 2010 (UTC)

QG, hopefully this is what you meant when you asked for WP:V. I have only quoted the conclusions for each, if you want full text I will require an email address I guess?

Response to Ernst 2006, systematic review of SRs

“Indeed, this recent review included four `reviews of reviews' by the main author; this in itself would surely perpetuate any author bias, whether intentional or not.” And “At the end of the day, no matter how robust the methodology of a critical review, the authors are inclined to their own bias: to conduct a review of reviews of one's own opinions, adds little to a meaningful literature base.” Lewis BJ, Carruthers G. 2006. Systematic review of spinal manipulation: A biased report. J R Soc Med. Volume 99, Issue 6, Page 278.

Response to Ernst 2007, Adverse effects of spinal manipulation

“Given the number of cervical spine manipulations done worldwide it is likely, even if under-reporting is as high as Professor Ernst suggests, that the level of risk of a serious adverse event is extremely low. To turn Professor Ernst's point on under-reporting and publication bias around, could it be that journals of medicine are unlikely to publish findings which might be considered ‘positive’? Good evidence on safety is of paramount importance; what we have here is poor quality evidence and unsubstantiated claims masquerading as a systematic review.” Bolton J and Thiel H. 2007. Adverse effects of spinal manipulation. J R Soc Med. Volume 100, Issue 10, page 446.

Responses to 2010 Ernst review, Deaths after Chiro

“We found that in three separate cases, Ernst incorrectly assigned the care associated with death to a chiropractor. It is interesting that all three of the errors that Ernst made, in assigning professional identity, were errors that increased the apparent association between chiropractors and death.” Wenban A. B., Bennett M. 2011. Critique of review of deaths after chiropractic, 1. International Journal of Clinical Practice. Volume 65, Issue 1, page 102.

“The design of his research allows him to ignore these data and avoid an ‘inconvenient truth’ behind his argument –the fact being that the most comprehensive research on the subject has found no evidence of excess risk of vertebrobasilar artery (VBA) stroke associated with chiropractic care.” Poelsma C., Owen D. 2011. Critique of review of deaths after chiropractic, 2. International Journal of Clinical Practice. Volume 65, Issue 1, page 103.

“We question the objectivity of research that does not follow its stated purpose, obtains information from non-public sources and mischaracterises this information, misquotes sources, ignores the best evidence on causation contrary to author views, and ignores high quality systematic reviews that clearly contradict review conclusions.” Perle S. M., French S., Haas M. 2011. Critique of review of deaths after chiropractic, 4. International Journal of Clinical Practice. Volume 65, Issue 1, page 104.

“Although the author described the study as a systematic review, it clearly did not meet standards recommended by The Preferred Reporting Items for Systematic Reviews and Meta-analyses (PRISMA) statement (2). According to our review, the study met only two of the 27 PRISMA checklist items. The article is best described as a case series and although a case series is of value for generating hypotheses, it is not usually used for drawing conclusions about the efficacy or risks associated with an intervention. Ernst stated that spinal manipulation performed by chiropractors is less safe than that performed by other professionals and in support of this argument, he cited a study conducted by Terrett (4) that reported 17 deaths associated with chiropractic spinal manipulation and 13 deaths associated with spinal manipulation performed by other types of providers. However, because 90–95% of spinal manipulation is performed by chiropractors and 43% of the deaths reported in this study were caused by procedures performed by non-chiropractors, it appears as though chiropractors actually perform this procedure more safely than other professionals.” Whedon J. M., Bove G. M., Davis M. A. 2011. Critique of review of deaths after chiropractic, 5. International Journal of Clinical Practice. Volume 65, Issue 1, page 105 — Preceding unsigned comment added by Puhlaa (talk • contribs) 19:24, 20 December 2010 (UTC)

You have not shown how a guideline recommendation is equal to the other sources in the long back pain section. It is obvious that this particular section should be trimmed and this controversial change should be reverted. If you continue to insist the DC critism is notable then I will add it myself as soon as this is resolved as a token of good faith. We can't include all the fringe views. Which one do you think is most notable. Do you think the response by Ernst is notable. QuackGuru (talk) 20:45, 20 December 2010 (UTC)

I do not need to show how guidelines are equal to the other sources. I have already explained that MEDASSESS does not limit us to using only systematic reviews, it asks that we consider the strength of the source and give appropriate weight. I have already shown you that the guidelines are a secondary source as per MEDRS, thus among the highest level of evidence. Would you like me to paste the exact wording from MEDRS again as I have already? Your statement "I will add it myself as soon as" suggests you dont want anyone else touching this article? Instead, I would be happy to comment on a proposal to include the minor but significant views of DCs, plus Ernst response, if you post one here in talk as I have courteously done for you. However, in the proposal that I have posted here, I have already reduced the weight of those minor but significant views a fair bit, I wonder how you could diminish them further without removing them? Perhaps I could merge the 7 references into a single citation so that after the statement "DC have criticised..." there is only one citation and it thus doesnt appear to get too much weight? Puhlaa (talk) 21:15, 20 December 2010 (UTC)

Per MEDASSESS 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).

You do need to show how guidelines are equal to the other sources beucase we have a lot more higher quality sources presented. According to MEDASSESS, rely upon high-quality evidence, such as systematic reviews, rather than lower-quality evidence.

"A 2010 systematic review determined 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."[26]"

The systematic review in the risk benefit section is specifically about risk-benefit. Do you have a DC criticism of the risk-benefit.

Your proposal is vague, combines different conclusions together to come to a new conclusion and does not explain anything specific criticisms. If it was a specific DC criticism such as a DC criticism of the risk-benefit and a response by Ernst it might work.

We should choose only one reference to avoid a WEIGHT violation. Which CD criticism do you think is notable. QuackGuru (talk) 21:45, 20 December 2010 (UTC)

Perhaps instead I could merge the 7 references into a single citation so that after the statement "DCs have criticised..." there is only one citation and it thus doesnt appear to get too much weight? All the letters are to 2 journals, so I could combine all 7 into 1 citation.Puhlaa (talk) 21:55, 20 December 2010 (UTC)

Perhaps you could only choose the most notable source per MEDRS. QuackGuru (talk) 22:00, 20 December 2010 (UTC)

Sure, I would retain the most recent (2010), as it is most relevant per MEDRS. However, do we then need to move the mention of DCs criticism to immediately following the mention of the 2010 review? Do you want specific mention of the criticism? (“DCs question the objectivity of research that does not follow its stated purpose, obtains information from non-public sources and mischaracterises this information, misquotes sources, ignores the best evidence on causation contrary to author views, and ignores high quality systematic reviews that clearly contradict review conclusions.”)? This would give much more weight to the opposing view than a generic mention of DCs criticism as it currently exists in the proposal ("DCs question the quality of...").

Here is an interesting quote from Ernst response: "The authors criticise me for not evaluating the potential benefits of chiropractic. This detail was not the subject of my review"...so how does we use his article to make claims of risk-benefit? Anyways...I digress Puhlaa (talk) 22:28, 20 December 2010 (UTC)

We would only use this ref but limit the weight of the DC criticism. For the DC criticism we can limit it to rewriting the following quote. "The authors criticise me for not evaluating the potential benefits of chiropractic." This part can be rewritten without quotes and then we can include the specific response by Ernst. The mainstream view usually has more WEIGHT. All the other references do not meet MEDRS. Only this ref might possibly meet MEDRS. QuackGuru (talk) 02:30, 21 December 2010 (UTC)

A 2010 systematic review determined 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."[26] "The authors criticise me for not evaluating the potential benefits of chiropractic." The rewritten sentence can go right after the first sentence as long as DUE WEIGHT is given to the response by Ernst. Things would move a lot faster if you just edit the article. I'm busy and I want to move on. If you can't think of a rewrite just add the quotes for now and I can rewrite it and format the ref too. QuackGuru (talk) 02:40, 21 December 2010 (UTC)

I previously explained we would only use one reliable reference that met MEDRS. This change using more than one reference was against consensus for including the fringe view using the unreliable reference. Puhlaa agreed to only use one reliable reference. I also disagree with the changes to the first sentence of risk-benefit. I don't see any agreement for all the changes. The meaning of the first sentence was changed and the text was taken out of context from the source. QuackGuru (talk) 19:29, 21 December 2010 (UTC)

You asked me to modify the article, I did so, using one criticism and Ernst's response. You wanted to hurry up and told me to choose and add one notable source and give due weight to Ernsts response. I did so. I am happy to comment on a proposal from you to replace the current edit. I am also happy to take alot of time and move very slow and make sure we get this exactly right.Puhlaa (talk) 20:31, 21 December 2010 (UTC)

You did not use only one ref as agreed. I did not ask you to modify the article using two references. You also changed the first sentence without consensus. QuackGuru (talk) 20:40, 21 December 2010 (UTC)

I did only use one reference as agreed, the other reference is not a criticism, it is Ernst response to said criticism. You said you wanted Ernst response to be given due weight so I included the response. Feel free to edit my edit and we can discuss your proposal. Heck, I would have been happy with just a generic mention that DCs criticise the reviews, you are the one who wanted to expand it to detail some of what they criticise.

I guess our next 'debate' is going to have to be the change to the first sentence, the summary of the 2010 review, is important as it puts the findings in context. As it was, the text said that the 2010 review found no benefit from spinal manipulation, however, the author admits himself that the review did not examine the benefits. Thus, the original sentence incorrectly attributed the examination of benefits of chiropractic to this review. I am happy to quote the conclusion "the benefits outweigh the risks" but I am not ok with attributing the statement "the review found no benefits" to this review when clearly this review did not examine the benefits of manipulation. This is stated in the Authors own words as per the response to the chiropractors "The authors criticise me for not evaluating the potential benefits of chiropractic. This detail was not the subject of my review".Puhlaa (talk) 20:59, 21 December 2010 (UTC)

You did agree to use only one reference but you clearly added two. I previously disputed the reference you added. You have taken the text from the source out of context. QuackGuru (talk) 21:16, 21 December 2010 (UTC)

I only added one critical reference, if you dont want 2 references added then I can remove the response from Ernst, but you originally asked for its inclusion. I think it is you who has taken the text from the source out of context, however, I would be happy to hear your reasoning and re-evaluate my interpretation. Puhlaa (talk) 21:41, 21 December 2010 (UTC)

I did not agree to adding any of the lower quality sources. I only agreed to including the reliable reference which does review the previous references. You originally agreed to include only one reference. You clearly indicated above that you added two references. You have not properly explained how I took the source out of context. You did not specifically complain about the text from the source when we were discussing the other changes. QuackGuru (talk) 21:53, 21 December 2010 (UTC)

You can clearly see from the proposed revisions to risk-benefit I made available in talk above that I had modified the first sentence to risk-benefits. The fact that you objected to other changes in the proposed paragraph but did not object to the proposed changes to the first sentence which I made clearly available, implied that you did not object to the changes in the first sentence.

Further, I have already stated that I would be happy to discuss the changes and consider your reasoning and re-evaluate my interpration to try to achieve consensus. Instead of helping the situation by opening dialogue with regard to your objections to those changes, you instead post another repetitive statement about how you didnt agree with the changes, which I already acknowledged. At what point will you decide to converse rather than just repeat yourself?

As an early attempt to compromise, what if I leave the first sentence as I have edited it currently, but remove the reference regarding criticisms of Ernsts work, leaving only the reference for Ernsts response? Puhlaa (talk) 22:50, 21 December 2010 (UTC)

We would only use this ref but limit the weight of the DC criticism. For the DC criticism we can limit it to rewriting the following quote. "The authors criticise me for not evaluating the potential benefits of chiropractic." This part can be rewritten without quotes and then we can include the specific response by Ernst. The mainstream view usually has more WEIGHT. All the other references do not meet MEDRS. Only this ref might possibly meet MEDRS.

A 2010 systematic review determined 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.[26 The authors criticise me for not evaluating the potential benefits of chiropractic." When this sentence is rewritten it can go right after the first sentence as long as DUE WEIGHT is given to the response by Ersnt. Things would move a lot faster if you just edit the article. I'm busy and I want to move on. If you can't think of a rewrite just add the quotes for now and I can rewrite it and format the ref too.

My previous comment was for keeping the first sentence as is and giving due weight for the response while only using one ref. It seems you have taken the source out of context when I previously disagreed based on my proposal. What if you tried to collaborate with others and at least remove the unreliable reference and restore the first sentence. Also, you still have not shown how a guideline meets MEDASSESS when the low back pain section is littered with systematic review after systematic review. QuackGuru (talk) 00:22, 22 December 2010 (UTC)

It seems the text you added did not included the response by Ernst and actually misquoted Ernst. That is not how to write neutral text according to WP:NPOV.

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 accross the world."[163] This is the response by Ernst in accordance with WP:WEIGHT. I checked my messages. I did have a copy of the source. As previously explained, you taken the source out of context. It was a possible WP:BLP violation to misquote a living person. See BLP: "Editors must take particular care when adding information about living persons to any Wikipedia page. Such material requires a high degree of sensitivity, and must adhere strictly to all applicable laws in the United States, to this policy, and to Wikipedia's three core content policies: Neutral point of view (NPOV), Verifiability (V) and No original research (NOR)." QuackGuru (talk) 01:40, 22 December 2010 (UTC)

I have left your edit to risk-benefit but have removed your controversial changes to low back pain. I hope you will take this as a sign of good faith. Puhlaa (talk) 03:48, 22 December 2010 (UTC)

The second half of the Ernst response has nothing to do with risk-benefit, only bashing chiropractic, it has nothing to do with the criticism of his reviews by DCs that he has not evaluated the benefits, which he admits to. The article could stay NPOV without it.Puhlaa (talk) 04:15, 22 December 2010 (UTC)

You agreed to including the response by Ernst which is relevant. We should not misquote Ernst and leave out the however part per BLP and WEIGHT. Ersnt did, however, refer to such evaluations. QuackGuru (talk) 04:27, 22 December 2010 (UTC)

Per WP:MEDASSESS: 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).

Editors do need to show how the recenty added guidelines are equal to the other sources because there are a lot more higher quality sources presented. According to MEDASSESS, rely upon high-quality evidence, such as systematic reviews, rather than lower-quality evidence.

• Review of guidelines. Chou R, Huffman LH; American Pain Society; American College of Physicians (2007). "Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline". Ann Intern Med. 147 (7): 492–504. PMID 17909210.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• The original guidelines. Chou R, Qaseem A, Snow V; et al. (October 2, 2007). "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society". Ann Intern Med. 147 (7): 478–91. PMID 17909209. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

There are two similar references being used in the low back pain section. There is a guideline and the review of the guidelines. A guideline is a lower-quality reference than the review of the guidelines. The low back pain section is too long and I think it can be shortened a bit. See under Chiropractic#Effectiveness. For now, I think it would be better to at least remove the recently added guideline reccomendations because it is a weaker source. There is no extra room to use weaker sources when there is a currently two Cochrane reviews and a mix of recent state of the art systematic reviews summarised in low back pain. QuackGuru (talk) 21:21, 21 December 2010 (UTC)

The review is not a review of the guidelines as has been suggested. The review was a systematic review of the existing literature, and was performed first by the American Pain Society/American College of Physicians. Secondary to the publication of the review, the American Pain Society/American College of Physicians published a set of guidelines for physicians, for the "Diagnosis and treatment of low back pain".

As per WP:MEDRS: "A secondary source in medicine summarizes one or more primary or secondary sources, usually to provide an overview of the current understanding of a medical topic, to make recommendations or to combine the results of several studies. Examples include the literature reviews and systematic reviews found in medical journals; specialist professional or academic books; and position statements or medical guidelines published by major health organizations."

As the guidelines meet MEDRS and in addition, bring context to the paragraph which the many systematic reviews in the paragraph alone do not bring, it is important to retain them in the section. If there is a problem with no extra room, then there are older references in the paragraph which could be removed, as their findings will have been covered in the newer reviews. As per WP:MEDASSESS: "Look for reviews published in the last five years or so, preferably in the last two or three years." AND "If recent reviews don't mention an older primary source, the older source is dubious.". Perhaps the older (2006) systematic reviews should be looked at for removal before discussion of removing newer secondary sources such as the 2007 guidelines by the American Pain Society/American College of Physicians? The Murphy et al 2006 reference is summarized twice in the paragraph and it is older than the 2007 guidelines, also, the Ernst 2006 reference is the oldest sytematic review and older than the guidelines. These 2 references should both be summarized in the newer systematic reviews thus add little to the paragraph and can be removed if we need to reduce the size of the paragraph.

As the guidelines are currently the only reference included in the paragraph which bring any context to the findings of the many reviews, it is important to retain them. As they are considered a secondary source as per MEDRS and are up-to-date evidence as per MEDRS, no valid reason has been provided for why they should be discarded in favour of older reviews such as Murphy 2006 or Ernst 2006.Puhlaa (talk) 22:37, 21 December 2010 (UTC)

Murphy 2006 gives context to the low back pain section such as explaining there is continuing conflict of opinion on the efficacy of SMT for nonspecific low back pain and methods for formulating treatment guidelines for low back pain differ significantly between countries, casting some doubt on their reliability. If there is a newer source that summarises this point Murphy 2006 makes we can use a newer source. As for the 2006 Ersnt review, I thought you previously agreed to keep it in the low back pain section. Ernst 2006 is not a typical systematic review. It is actually a systemtic review of systematic reviews. It is of higher quality than even regular systematic reviews. The systemtic review of systematic reviews summarises, among other reviews, the 2004 Cochrane review. I proposed we just remove the guidelines for the time being but we have to look at both 2007 sources that are not systematic review per MEDASSESS. See Wikipedia:MEDASSESS#Assess evidence quality. QuackGuru (talk) 00:47, 22 December 2010 (UTC)

I agreed to keep the 2006 references and leave the section long, but I am not in favour of removing newer, high quality secondary sources so that older secondary sources can stay. If the section needs to be made shorter then older sources should be the first to go. The guidelines give context to the section and are newer than the Murphy reference and are from a more reputable medical body (American Pain Society/American College of Physicians), thus the guidelines can replace Murphy. Ernst is the oldest systematic review in the section, so if the section still needs to be shorter after removing Murphy 2006 then Ernst 2006 should be next to go as the new Cochrane 2010 and Spine Journal 2010 systematic reviews will mention the data from the older Ernst review.Puhlaa (talk) 03:56, 22 December 2010 (UTC)

This is not how to write encyclopedic text using quotes. I'm trying to remove all quotes from the section and remove lower quality sources. There is a discussion for other editors to evaluate this source. You have not explained how this source meets MEDASSES when there are 2 Cochrane reviews, recent systematic reviews, and even a very high quality 2006 systematic review of systematic reviews. A consensus has not formed with the disputed text in quotes from the guidelines recommendations. See Wikipedia talk:WikiProject Medicine#Tighter requirements per MEDASSESS. QuackGuru (talk) 05:13, 22 December 2010 (UTC)

I am in agreement with your wishes to remove all quotes. I would be happy to remove the quotes and simply summarize the recommendations.Puhlaa (talk) 05:56, 22 December 2010 (UTC)

I slightly tweaked the text to be a bit closer to the source. According to this comment the two sources are completely unrelated. So I removed the connection of the two sources. Each sentence is now independant. QuackGuru (talk) 07:28, 22 December 2010 (UTC)

The low level details from Murphy 2006 are unnecessary. The section need to be trimmed not continue to be expanded. QuackGuru (talk) 03:51, 22 December 2010 (UTC)

Shortening is fine, however, I was recently informed by you that misquoting the author is not the appropriate way of maintaining NPOV so I highly recommend that you dont shorten it by removing the second half of the sentence as it changes the meaning.Puhlaa (talk) 03:59, 22 December 2010 (UTC)

I don't think there was any significant change to the text. I want to trim the section and you want to trim the Cochrane review and continue to expand the low pack pain section. QuackGuru (talk) 04:02, 22 December 2010 (UTC)

There was significant change, he original "trimming" of the murphy quote made it sound like the general use of SM was controversial, not just that when it should be applied was controversial. The controversy is not about IF SM should be used for LBP but rather WHEN it should be used. The 2007 guidelines by the American Pain Society and American College of Physicians answer the question so Murphy is not even necessary. The 2007 guidelines say SM should be considered after self-care has failed.Puhlaa (talk) 04:07, 22 December 2010 (UTC)

CONCLUSION: Treatment recommendations for nonspecific LBP, particularly spinal manipulation, remain inconclusive. Guideline developers need to consider guidelines in neighboring countries and reach consensus on how evidence is graded and incorporated into guidelines. Guidelines should continue to be regularly updated to incorporate new evidence and methods of grading the evidence.

According to the conclusion the shorter version is sourced and accurate. I don't see a reason to continue to expand and clutter the low back pain section. QuackGuru (talk) 04:14, 22 December 2010 (UTC)

The shorter version misrepresented, and you know it. Adding 7 words does not make the section excessively long. I did not change what was written there, I only added the remaining 7 words of the sentence that were conveniently left off. I am happy to leave the section as it is. Any deletions are obviously controversial and should be discussed on talk first. If we cannot find consensus I am happy to work up the chain of conflict resolution. Puhlaa (talk) 04:20, 22 December 2010 (UTC)

The conclusion did not support your recent controversial change. The shorter version represents the conclusion. QuackGuru (talk) 04:24, 22 December 2010 (UTC)

The shorter version was a gross misrepresentation by saying there is was controversy over the efficacy of spinal manipulation. There is no controversy over the efficacy, and Murphy certainly doesnt say that. All systematic reviews from 2006 on indicate that SM is equal or better than other therapies (most say equal, one says better). The inconsistencies in the guidelines according to Murphy are with regard to WHEN to apply SM. Regardless, Murphy should be removed altogether to appease your complaint about the section being too long. I will not remove it though until there is consensus, as it is controversial. Further, I am not interested in listening to you repeat yourself. If you have nothing new to say, and cant work with other editors on this and the above controversy regarding the low back pain section then I submit that we need conflict resolution.Puhlaa (talk) 04:33, 22 December 2010 (UTC)

You are right on one thing...my edit too Murphy was too long and is repetitive. Although I think Murphy should be removed to shorten the section (as per your concerns) I propose that until this is settled the Murphy reference text read:

"Specific treatment recommendations with regard to spinal manipulation for nonspecific LBP remain inconclusive." This is a direct summary of the first sentence of the conclusions. What is your opinion?Puhlaa (talk) 04:40, 22 December 2010 (UTC)

This is better than the longer WP:Bold changes version. QuackGuru (talk) 05:19, 22 December 2010 (UTC)

The words do have different meaning and thus modified the meaning of the sentence. QuackGuru (talk) 08:37, 22 December 2010 (UTC)

I restored the wording that is explicitly used in the source per NPOV. QuackGuru (talk) 04:44, 23 December 2010 (UTC)

Could you explain the difference in meaning? We should avoid jargon where it is not necessary for precision. What is the difference between 'cause' and 'causality' in this case?

Per prior posts, I would request that you change the title of this section, so that your conclusion is not announced in the place where we can discuss whether or not it is correct. Perhaps, 'Change from causality to cause?' Ocaasi (talk) 05:04, 23 December 2010 (UTC)

In this case the term 'causality' is the relationship between chiropractic neck manipulation and the 'effect' of vascular accidents.

The word 'cause' claims it is the source of vascular accidents when there is only a relation with neck manipulation and the after effect. It not about a cause. It is about the 'relation' with the cause and the effect. It is the association with a relationship with manipulation of the neck and vertebrobasilar artery stroke or death. QuackGuru (talk) 05:51, 23 December 2010 (UTC)

Thank you for changing the header. I am wondering whether the current phrasing is accurate, actually. I'll use your definition and 'plug it in'.

• The current version: The dissection of a vertebral artery, typically associated with neck manipulation beyond the normal range of motion, is a possible causality.
• The current version with your definition of causality: The dissection of a vertebral artery, typically associated with neck manipulation beyond the normal range of motion, is a possible relationship between chiropractic neck manipulation and the 'effect' of vascular accidents.
• The current version with your definition of cause: The dissection of a vertebral artery, typically associated with neck manipulation beyond the normal range of motion, is a possible source of vascular accidents.

Does that still look right to you?. Ocaasi (talk) 06:06, 23 December 2010 (UTC)

I think this change simplified the sentence. The part 'dissection of a vertebral artery' was a bit technical. QuackGuru (talk) 06:18, 23 December 2010 (UTC)

I actually didn't mind that part, since it was specific. Is 'vascular accidents' a meaningful term to include dissection, as well? Is there anything that happens to damage the VA that isn't a dissection? Ocaasi (talk) 06:22, 23 December 2010 (UTC)

Both have similar meanings but vascular accidents is more specific to spinal manipulation and is not the technical wording.

"In medical pathology, dissection (or dissecting aneurysm) refers to a tear within the wall of a blood vessel, which allows blood to separate the wall layers, creating a pseudoaneurysm." Here is a definiton of dissection. I'm not the expert on what else could happen to damage the VA. QuackGuru (talk) 06:39, 23 December 2010 (UTC)

I posted at project medicine about cause/causality. Editors seemed to prefer 'cause' in this case. Ocaasi (talk) 07:21, 23 December 2010 (UTC)

The word 'cause' is sourced? The source does explain about the causality between chiropractic intervention and arterial dissection. QuackGuru (talk) 08:00, 23 December 2010 (UTC)

I have read the source. I would request you refrain from commenting on my perceived but unseen behavior. Verifiability is not a requirement for copying (in fact, without quotations it is advised against). We are still encyclopedia writers and we make word choices to present sources in a way that makes sense. This is not a violation of policy, it's just writing. The source explains the causality, and I am not disputing that. I am disputing our current usage of 'causality' which is not the best word choice in context. We could rephrase it so that 'causality' is used, but the words we use have to fit the article as well as the source. Do you think that 'cause' is some ploy to weaken to claim? Cause seems just as clear, in fact more clear, that there is a suspected connection. Ocaasi (talk) 08:07, 23 December 2010 (UTC)

I think the word 'cause' is stronger than the wording used in the source. The source says the 'causality' between chiropractic intervention and arterial dissection is not proven but is at least likely. So when you claim it is a 'possible cause' it seems to be stronger than the source because a 'possible causality' explains there is a 'possible relationship or connection'. QuackGuru (talk) 08:26, 23 December 2010 (UTC)

Yes, the source's use of causality makes sense; ours does not. We aren't saying that 'the causality is not proven but at least likely'. We are saying that 'vascular accidents... are a possible causality'. That literally doesn't make sense. Just using the same words does not guarantee that we are constructing a grammatically precise sentence. In this case only two options are internally consistent: to use 'causality is...likely', or, 'vascular accidents... are a possible cause'. Either one is logical. Either one is sufficiently supported by the source, in my opinion. But the mix of the two, saying that 'vascular accidents... are a possible causality' is actually incorrect, not because of V, but because of English syntax. If you require the phrase 'causality' be used, then I think we must choose the 'causality is...likely' phrasing. Ocaasi (talk) 09:02, 23 December 2010 (UTC)

I think this edit is closer to the source and fixes the English syntax. QuackGuru (talk) 09:22, 23 December 2010 (UTC)

I noticed that 'causality...is at least likely' turned into 'is probable'. Do you think that is supported by the source? Ocaasi (talk) 09:51, 23 December 2010 (UTC)

Synonyms are different words with almost identical or similar meanings. Words that are synonyms are said to be synonymous, and the state of being a synonym is called synonymy. I think probable is synonymous with at least likely. So I do think it is sourced. QuackGuru (talk) 09:58, 23 December 2010 (UTC)

If there are any suggestions for improving the article it can be done here rather than proposing mass rewrites in a draft. QuackGuru (talk) 05:51, 23 December 2010 (UTC)

I know that it can be done here, but the editing environment here is, sometimes not particularly constructive. Is there a policy issue relating to working on userspace drafts, particularly on controversial articles? Ocaasi (talk) 05:55, 23 December 2010 (UTC)

I prefer the talk page is used for simpler proposals editors can understand rather than complex mass changes. Editors can start a draft. But you have not explained what is the issue with this article. A draft is usually done with short articles or when there are major problems with an article. There is also the mediation page where the mediator might have suggestions. See Wikipedia:Mediation Cabal/Cases/2010-08-23/Chiropractic. QuackGuru (talk) 06:01, 23 December 2010 (UTC)

You are a strident advocate for your point of view, but don't always give other editors room to develop substantial suggestions without disagreeing with them on multiple fronts first. Doing a draft elsewhere allows changes to happen gradually and with input that doesn't view changes as inherently threatening to the article's integrity. Mediation was not particularly different in that regard. I'd prefer that changes offered here were not immediately accused of a variety of policy violations and were instead greeted with an effort to see how they intended to improve the article and constructive suggestions to aid in that. Doing a draft in userspace is just a way to avoid friction between alternate views until they can be better formulated. I recognize that any drafts: a) can't be content forks; b) should be in userspace or talkspace; c) have to be presented on the article talk page first; d) need to be improvements along the intention of policy; and e) should be presented in an accessible, systematic or itemized way to explain how they differ, when they do make it to the talk page. Ocaasi (talk) 06:17, 23 December 2010 (UTC)

A draft may be used to improve an article. I hope we don't go back to previous problems. QuackGuru (talk) 06:39, 23 December 2010 (UTC)

I think you've just proved my point, cheers. Ocaasi (talk) 06:49, 23 December 2010 (UTC)

WP:POVFORK: "In contrast, POV forks generally arise when contributors disagree about the content of an article or other page. Instead of resolving that disagreement by consensus, another version of the article (or another article on the same subject) is created to be developed according to a particular point of view..." I hope you are just trying to improve the article. QuackGuru (talk) 23:56, 24 December 2010 (UTC)

• WP:Userspace: Work in progress or material that you may come back to in future (usually on subpages): Drafts, especially where you want discussion or other users' opinions first, for example due to conflict of interest or major proposed changes
• WP:Forking: One technique sometimes used to reach consensus on difficult articles is to create a temporary copy which people can then edit to show others proposed refactorings, rephrasings, or other changes. This can be helpful for controversial subjects or controversial changes; editors can show others exactly what their vision for a proposed change is – without the controversy of having that new proposed version automatically replace the existing version...However, just as "spinout" articles have sometimes been mistaken for POV forks, temporary subpages have been mistaken for POV forks. Care should be taken on both sides to minimize such mistakes. New drafts should be written in the "user:" or "talk:" namespace and not in the main namespace; however, accidents happen and those who think they have found a POV fork, in turn, should check to see whether the article title indicates a temporary subpage and whether the talk page of the main article indicates that this is a place to work on consensus rather than to dodge it.

It's a draft, QG, in talk space, and that's clearly stated in the header. Your insinuations of ulterior motives speak to why such a draft is necessary. Cheers, Ocaasi (talk) 01:09, 25 December 2010 (UTC)

Go for it. QG proved your point for you. To keep matters simple I suggest that one deal with one issue/section at a time, then propose it for approval on this talk page. (Work on other sections can still continue on the draft page.) Making vast changes to the whole article at one time often creates more problems than it's worth. -- Brangifer (talk) 03:08, 25 December 2010 (UTC)

That's good advice, and also what I was thinking, one section at a time. Please check in to see how it's going. Ocaasi (talk) 03:14, 25 December 2010 (UTC)

This recent change did not summarise the body. See WP:LEAD. The change failed verification using the Ernst ref. The word "However" is not supported by the ref. There was also WP:OR editorialising. QuackGuru (talk) 17:25, 12 January 2011 (UTC)

Although I personally agree with some of the ideas that the change brings up, I also agree with QG that it is OR and definitely does not reflect the highly critical work by Ernst. If it were to stay as is then an appropriate source would have to be cited. Puhlaa (talk) 21:41, 12 January 2011 (UTC)

See WP:LEAD: "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."

On the contrary, even if a source were cited it would not pass WP:LEAD. QuackGuru (talk) 22:10, 12 January 2011 (UTC)

You just love to cause other editors grief, even when one agrees with you hey QG?

However, now I do Disagree with your latest pointless point. If Ernst 2010 makes the cut, then a secondary source (if/when one exists) that contradicts Ernst 2010 needs to be included to maintain NPOV. Thus, if a recent secondary source made the statements added to the lead they would stay. However, as I said, as it exists currently the change is OR. I dont want to read a repeat of your pointless point, as until a secondary source is acctually presented and proposed to be included it is not worth my time to partake in your circular arguements over a theoretical inclusion.Puhlaa (talk) 22:17, 12 January 2011 (UTC)

You claimed "If it were to stay as is then an appropriate source would have to be cited." The text did not summarise the body even if a source were presented. Currently, a reliable systematic review is not avaliable that contradicts Ernst. QuackGuru (talk) 22:28, 12 January 2011 (UTC)

That doesn't mean it's not a broader Weight issue, though. Ernst-Death is one review on the risk of CSM via VAD, but we have Spine and Neurology and JMPT and Herzog all suggesting that the apparent causality presented in Ernst is insufficiently researched, incidental due to preexisting conditions, or unlikely for biomechanical reasons. They should factor into our presentation of Ernst's results per NPOV. Ocaasi (talk) 08:36, 13 January 2011 (UTC)

When a MEDRS reference specifically contradicts Ernst we will evaluate it for inclusion in the body and the lead. I don't see any recent systematic review that is specific to death and the risk-benefit QuackGuru (talk) 22:07, 13 January 2011 (UTC)

A recent change by another new editor deleted sourced information from the lead. I restored it. QuackGuru (talk) 17:30, 14 January 2011 (UTC)

"A systematic review determined that the risk of death from manipulations to the neck by far outweighs the benefits.[26]"

"The risk of harm from manipulations of the neck may outweigh the benefits.[26]"

This change reverted back to the attribtuion in the lead. This is the only sentence in the lead with in-text attribution. Do editors think we should add in-text attribution if an editor disagrees with a systematic reivew or thinks the text is controversial. I think editors should keep their personal disagreement off the page. QuackGuru (talk) 17:45, 14 January 2011 (UTC)

Some editors may want to continue to make WP:BOLD deletions to the lead without discussion or consensus. If we discuss possibly controversial changes to the lead first it may help with consensus. QuackGuru (talk) 18:02, 14 January 2011 (UTC)

I have tried to find other sources that contradict Ernst but I could not find any reliable MEDRS compliant sources. The Ernst 2010 source is a peer reviewed systematic review. We can't reach down to cherry pick unreliable sources to argue against reliable sources. It would help if editors don't try to add unsourced claims to the lead or use unreliable sources again. See WP:MEDRS. QuackGuru (talk) 22:14, 14 January 2011 (UTC)

The proponents of Ernst dispute his conclusion of the recent systematic reivew but on Wikipedia we must comply with MEDRS and WEIGHT. The marginal chiropractic view does not belong in the lead nor the body. QuackGuru (talk) 20:42, 15 January 2011 (UTC)

Recently, [1], administrator Sandstein described the chiropractic page as "pseudoscience-related". It has become important to specify which pages are pseudoscientific, now that an editor has been blocked for editing a pseudoscience-related page, and editors have begun receiving pseudoscience arbitration sanctions warnings. Therefore we need to properly mark this article as pseudoscience so that editors who have been warned about (or forbidden from) editing pseudoscience articles will not accidentally get into trouble. Additionally, it is obvious that at least some of the beliefs of some versions of chiropractic are indeed pseudoscientific. These are the reasons why I added the pseudoscience category to this article. Cardamon (talk) 06:31, 16 January 2011 (UTC)

• Support I support the addition of this tag for the reasons outlined above. Some of chiropractic is pseudoscience without a doubt with lots of references to support this. [2] Doc James (talk · contribs · email) 07:04, 16 January 2011 (UTC)

• Comment My real question is whether the category has to do with notifying editors of ArbCom or properly categorizing content. In other words, is this an administrative category (i.e. [pages covered under Pseudoscience sanctions]), or are we addressing the content directly, or some of both. I agree that parts of Chiropractic are pseudoscientific, while some of it is anti-scientific, and other parts are scientific. Is the category appropriate given the complexity of the actual field? Also, we already should have a talk page warning that this page is under Pseudoscience sanctions, if it is. Wouldn't that suffice? Ocaasi (talk) 08:00, 16 January 2011 (UTC)

• Support a tag, not category Uncertain, but can be convinced. My uncertainty is based on the next paragraph, but I can see the point being made. Editors must not get in trouble when dealing with such a muddy area as this. There needs to be a clear indication for them. Since there are so many fundamental elements in the profession that are pseudoscientific, I can also go along with adding the category, but will wait to see the discussion. A side benefit (which isn't the business of Wikipedia ) is that doing so might actually motivate the profession to distance themselves from these things and clean up their act, but like I said, that can't be our motivation here, but would just be an interesting side benefit.

  I can maybe shed some light on the history of why we don't have this article in the PSI category, and we have indeed had some very hefty discussions about the matter. There are several aspects of chiropractic, including its most foundational belief (vertebral subluxation), which are indeed pseudoscientific, but to call the whole profession such was deemed inappropriate. The solution was to deal with those aspects, but not the profession, at List of topics characterized as pseudoscience#Health and medicine. There you will see the pseudoscientific elements dealt with. I hope that info helps.

  An ideal solution would be to copy the content from the List into a section here with the heading "Pseudoscientific aspects". This section could be used to deal with the past and present history and why those elements are considered PSI by mainstream and even many chiropractic sources. Editors who are topic banned from PSI subjects would not be allowed to touch that section or its mention in the lead. What think ye? -- Brangifer (talk) 08:18, 16 January 2011 (UTC)

• I have changed my !vote per Sandstein and Puhlaa. -- Brangifer (talk) 19:25, 16 January 2011 (UTC)

• I have been asked to comment here. How articles should be categorized is a content issue, and the arbitration process does not resolve content issues. An opinion by an administrator, such as myself, that an article "relates to pseudoscience, broadly interpreted" and is therefore within the scope of the "Pseudoscience" topic ban, is therefore not dispositive for the article's categorization as pseudoscience or otherwise. The scope of the arbitration case is broader than only articles about topics that are accepted to be pseudoscience; it notably also includes topics whose description as pseudoscience is contested. You might want to consider a talk page warning template instead; I believe there is something like that for Israel-Palestine conflict articles.  Sandstein  08:34, 16 January 2011 (UTC)

Is there to be a group of articles that are sufficiently "pseudoscience-related" that editors can be warned for editing them, but which can't be categorized as pseudoscience? That seems like a potentially problematic class of article. Cardamon (talk) 21:33, 16 January 2011 (UTC)

Editors are not warned just for editing pseudoscience-related pages, only if they edit pseudoscience-related pages in a problematic manner. I don't think that there is an easy way to classify all pseudoscience-related pages in the abstract. But, in addition to pages categorized and therefore generally accepted as pseudoscience, pages are normally pseudoscience-related whenever editors disagree about whether the respective topic is pseudoscientific or not.  Sandstein  07:28, 17 January 2011 (UTC)

• Oppose I oppose labelling the entire category as pseudoscience as it incorrectly labels the profession too broadly. I fully agree that traditional foundations like subluxation, and some technique systems (used by a small proportion of the profession) are indeed pseudoscientific, but can be labelled as such at specifically at List of topics characterized as pseudoscience#Health and medicine. However, Chiropractic in Denmark and Switzerland is now taught in their medical schools, and is considered one of the 5 mainstream health care professions in those countries. Further, in Canada, neither of the 2 schools (UQTR or CMCC) teach subluxation or unresearched therapies, and put a high emphasis on scientific inquiry as part of the curricula and as an expectation of faculty. Lastly, a large part of the profession in the US (representing about 7 schools) are actively trying to remove subluxation from their chiropractic vocabulary (as evidenced by the recently proposed changes to CCE legistlation). A talk page warning template is a more suitable option IMO.Puhlaa (talk) 16:23, 16 January 2011 (UTC)

• A couple of quick points. First, I'm not opposed to some sort of notification on the talk page, but not all editors look at the talk page before editing, so there should be a notification on the article page too. Using pseudoscience category is one of the less obtrusive ways to do this. Second, I don't think all parts of a thing need to be pseudoscience for the category to be justified; it is enough that it contain a significant amount of pseudoscience. Cardamon (talk) 19:08, 16 January 2011 (UTC)

• Not sure if by tagging your comments to my response you are trying to convince me, or other editors. Dont feel obliged to try to convince me...I provided my reasons for objecting, but I am happy to go with whatever the majority consensus is.Puhlaa (talk) 19:15, 16 January 2011 (UTC)

• Just a couple comments. In Denmark it's not part of the medical school or curricula but a separate institute located within the Odense campus of the University of Denmark. The chiropractic students participate in some of the basic education along with the medical students before specializing in biomechanics. They receive the equivalent of a BS/MS (it's sort of in between) and are not termed "doctor", as in DC. The institute was created because of a large and undisclosed donation by the "Society for the Promotion of Chiropractic", a controversial organization. As such it is part of the university system, which was an unusual situation at the time. Chiropractic schools have always been privately owned institutions owned and controlled by individuals, families, or corporations. Things are changing!

  Puhlaa, would you please provide a link to the "proposed changes to CCE legistlation". If it's significant, we may be able to use it here. Thanks. -- Brangifer (talk) 19:38, 16 January 2011 (UTC)

• I must have missed something (as how Denmark came into this conversation). Medical doctors in Australia do not have MDs - they have a BS/BM (Bachelor of Medicine/Bachelor of Surgery) or BSMB. Chiropractors in Australia also do not have a DC, they have a BChiro. However, both Medical doctors and chiropractors in Australia have the legal right to call themselves doctors. I am sure that it is similar in Denmark. DigitalC (talk) 01:14, 17 January 2011 (UTC)

• Denmark was mentioned by Puhlaa above and I cleared up a little misunderstanding. No big deal. (Chiropractors aren't called "doctor" in Denmark.) Also because educational systems are different, a BS in one country isn't necessarily the equivalent of a BS in another. In Denmark a BS is about the same as a BS in the USA. MDs in Denmark study several more years longer than chiros, just as in the USA. In England and Australia a (medical) BS is equivalent to an MD in the USA, and I think a surgeon is called "Mr." -- Brangifer (talk) 09:45, 17 January 2011 (UTC)

• Comment. The present proposal mixes two things that have little to do with each other: The content/categorisation (in article space) of the article, and applicability of pseudoscience sanctions. All editor-related pseudoscience sanctions exist for a specific reason and therefore extend to those pages for which the reason applies. E.g. if a topic-banned anti-pseudoscience warrior insists insisted that relativity theory is an example of pseudoscience, then the sanction would extend to that article, even though it is very obviously unrelated to pseudoscience by any objective criteria. Similar things apply for articles that are not related to pseudoscience but on which typical pseudoscience battles are fought out.

I have no opinion on whether chiropractic should be characterised as pseudoscience in article space, or in which way. This is a content decision that requires an overview over the best available sources. Hans Adler 21:59, 16 January 2011 (UTC)

• Well put. -- Brangifer (talk) 22:25, 16 January 2011 (UTC)

• Oppose: I think that putting Chiropractic within the category Pseudoscience labels Chiropractic as Pseudoscience in Wikipedia's voice. That clearly doesn't meet NPOV. Are there aspects of chiropractic that are pseudoscience? Absolutely. Are there aspects of massage therapy that are pseudoscience? (Ear candling for one) Absolutely. Are there aspects of dentristry that are pseudoscience? Absolutely. (I recently had a dentist perform "autonomic nervous system testing" on me to see if I needed a bite realignment to prevent TMJ issues). A warning at the top of the talk page should suffice. Pseudoscience sanctions should be used for problem editors, and every editor who wants to make a minor improvement need not know about the sanctions. A problem editor can be warned, and if they are following the WP:BRD cycle they should be seeing the talk page. DigitalC (talk) 01:14, 17 January 2011 (UTC)

• Oppose - and I oppose the scope drift of the AE to cover matters outside of the intent of the original AE. If it's clear that this article is not pseudoscience then QED, it is not covered by AE regardless of how much admins would love to flex their muscles over it. HOWEVER if admins care to actual edit the article in question and join the actual editing discussion (rather than attempt to defend their particular tool usage for the day) then they are welcome - as all editors are here in the Project. Shot info (talk) 09:34, 17 January 2011 (UTC)

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)

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 [3] 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)

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."[4] 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 [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^[1]) 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.^[2] 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)

"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."[5]

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)

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.[6]"

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." [7].

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.[8]"

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"[9] 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."[10]
• 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."[11]

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.[12]

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 [13]. 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)

(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)

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)

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)

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)[14]; neck pain (Manual Therapy, 2010)[15]; migrain (J Headache Pain, 2011)[16]; shoulder pain (JMPT 2010)[17]; leg pain (JMPT 2009)[18]; lumbar radiculopathy (Phys Med Rehabil Clin N Am, 2011)[19]. 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"[20]
• 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."[21]

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. [22]

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. [23]
• 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.[24]
• 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.[25]
• 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.[26]
• Leininger et al 2011 - systematic review found moderate quality evidence to support the use of spinal manipulation for the treatment of acute lumbar radiculopathy.[27]
• 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.[28]
• Pribicevic et al 2010 - systematic review found low level evidence supporting manipulation for treatment of shoulder pain.[29]
• Brantingham et al 2010 - systematic review found limited or fair evidence supporting manipulative therapy for leg conditions.[30]
• 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.[31]

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"[32]
• 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."[33]

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. [34] 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.[35] 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.[36] 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.[37] 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.[38] 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.[39] 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.[40] The source found low level evidence.
• Brantingham et al 2010 - systematic review found limited or fair evidence supporting manipulative therapy for leg conditions.[41] 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.[42] 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.[43] 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)

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)

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)

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." [44]

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)

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)

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)

• 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 [45]. 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)

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 [46]: "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) [47]: "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 [48]: "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." [49]

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

{{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 [50]. 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 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 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."[51] 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)

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)

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,[52] and want to seperate themselves from the traditional vitalism of innate intelligence.[53]

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)

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.[54]

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. [55]

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)

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:[56]. 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 [57] --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)

"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)

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)

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)

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)

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)

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)

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)

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)

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)

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 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)

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)

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)

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 [58] 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."[59] 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)

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: [60] and here: [61]. Also, the rationale for why Bronfort et al 2010 is appropriate for the LEAD has been described at length here: [62] and was originally described at length here: [63] when the original consensus was achieved. Perhaps the editor who removed this source from the LEAD [64] 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[65] is where RexxS states explicitly back in February that he thinks Bronfort should be in the LEAD. Then there is this diff[66] 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 ([67],[68],[69]). 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.([70], [71])"

Evidence for consensus with regard to the wording of this version can be found here [72] and here [73].

Evidence for consensus to include both the Bronfort and Ernst reference can be found here [74]

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: [75], [76], [77], [78], [79], [80], [81], [82])
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,[83],[84] disc herniation with lumbar radiculopathy,[85],[86] neck pain,[87],[88] some forms of headache,[89],[90] and some extremity joint conditions.[91][92]"

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,[93],[94] and might also be effective for the treatment of lumbar disc herniation with radiculopathy,[95],[96] neck pain,[97],[98] some forms of headache,[99],[100] and some extremity joint conditions.[101][102]"

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)