Talk:Chiropractic/Archive 16

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serious NPOV issues (oh my)

Lead

There are serious NPOV issues with this article. The lead needs to conform to WP:LEAD and be neutrally written. The word confusion in the lead does not make much sense to me. I don't get it with respect to the word confusion. There needs to be references to verify the text in the lead. For example, a reference to support the inclusion of the four distinct chiropractic groups is necessary. --QuackGuru (talk) 21:55, 22 February 2008 (UTC)

There is still no explanation to the usage of the word confusion in the lead. Please discuss. QuackGuru (talk) 19:53, 26 February 2008 (UTC)

The word "confusion" is somewhat redundant and can easily be removed. The wording that you installed overdid the controversy a bit; I made this change to trim it down. Note that "confusion" is supported by Keating et al. 2005, a cited source; however, I doubt whether it's a big enough deal to be in the lead. Eubulides (talk) 23:23, 26 February 2008 (UTC)

I don't see any citation, either in the old version or the version that you installed, that would indicate that there are four coherent and stable groups. On the contrary, if you look at the end of Talk:Chiropractic/Archive 15 #Elimination of reform chiro, you'll see that PPC indicates that the objective-straights are defunct in practice, and it doesn't even mention a coherent reform group. With this in mind, the lead should just say something noncommittal like "The two main groups of chiropractors are the 'straights' and the 'mixers'.", which is accurate and easy to source. The lead shouldn't bother with relatively-unimportant splinter groups. Eubulides (talk) 23:35, 26 February 2008 (UTC)

Relatively unimportant according to whom, Eubulides? —Preceding unsigned comment added by EBDCM (talk • contribs) 01:34, 27 February 2008 (UTC)

Relatively unimportant to the reliable sources mentioned at the end of Talk:Chiropractic/Archive 15 #Elimination of reform chiro. For reference, here they are again:

• PPC talks only about traditional straight, mixers, and objective-straight (which it calls purpose-straight (PSC) and mentions also the alias super-straight). After characterizing purpose-straight, it has the following to say about the politics:

The PSC approach to chiropractic came into conflict with several constituencies. The nondiagnostic orientation of this perspective stands in contrast to most statutes governing the practice of chiropractic. Some degree of compromise by the chief institutional proponent of PSC, Sherman College of Straight Chiropractic (SCSC), was apparently reached with the CCE circa 1995, when the SCSC was first recognized by the accreditation agency. The CCE's educational standards require training in diagnosis and referral when appropriate to other health care providers. Accordingly, there would seem to be some disconnect between this institution's ideology and its actual instructional practices. It should be noted that several of SCSC's presidents (e.g., Thomas Gelardi, DC, David Koch, DC) have been articulate contributors to philosophical dialogue within the profession (e.g., reference 64).

The source: Keating JC Jr (2005). "Philosophy in chiropractic". In Haldeman S, Dagenais S, Budgell B et al. (eds.) (ed.). Principles and Practice of Chiropractic (3rd ed. ed.). McGraw-Hill. pp. 77–98. ISBN 0-07-137534-1. {{cite book}}: |edition= has extra text (help); |editor= has generic name (help)CS1 maint: multiple names: editors list (link)

• Ernst talks only about straights and mixers. The source: Ernst E (2008). "Chiropractic: a critical evaluation". J Pain Symptom Manage. doi:10.1016/j.jpainsymman.2007.07.004. PMID 18280103.
• I looked in Google Scholar for any paper mentioning "straight", "mixer", "reform", and "chiropractic". In the summaries I found, there was no mention of "reform chiropractic" or "reform chiropractors" or anything like that.

It seems clear that this reform group is marginal and is currently overemphasized in Chiropractic. The PSC/objective straight group seems to be somewhat overemphasized as well: it seems to be a group that is no longer a major bifurcation from straight. Perhaps discussion of PSC aka objective straights should be moved to the "History" section. Eubulides (talk) 07:47, 27 February 2008 (UTC)

The ACA and whole profession have certainly used an awful lot of ammunition on attacking a "relatively-unimportant splinter groupss." They obviously didn't consider it "unimportant." BTW, they haven't done much to oppose straights, since they are so numerous and dominant in many ways, and are the ones who are defending the philosophical and legal basis for the profession's existence. OTOH, it was the NACM that was instrumental in getting the VA deal passed, since they were the ones seen as representing an acceptable (to mainstream medicine) form of chiropractic. That's a quite ironic fact. -- Fyslee / talk 06:08, 27 February 2008 (UTC)

I looked for mentions of the NACM in reliable sources published in refereed journals or high-quality textbooks in the last five years, using Google Scholar.

• PPC mentions them as one of "two much smaller groups: the National Association of Chiropractic Medicine (which advocates chiropractors' subordination to allopathic diagnosticians) and the World Chiropractic Alliance (propounder of exclusively subluxation-based chiropractic practice)." (p. 56). It also says that the work of the ACA and the ICA "is made more difficult by small organizations of extreme viewpoints that claim democratic authority and seek a profile at the national level, groups such as the National Association of Chiropractic Medicine (limiting chiropractic to the management of musculoskeletal pain syndromes) and the World Chiropractic Alliance (limiting chiropractic to location and correction of vertebral subluxations)." (p. 115).
• Menke 2003 (doi:10.1016/S0161-4754(02)54113-0) writes "Obvious ostracism persists in the guise of 'quack busters,' such as the National Association for Chiropractic Medicine (NACM) and the National Council Against Health Fraud in Loma Linda, California."
• Cates et al. 2003 (doi:10.1016/S0161-4754(03)00010-1) mentions them as part of a long list of organizations that the ICA ignored while developing guidelines.

That's all I found. These brief mentions do not indicate a prominent role for the NACM currently; quite the reverse. Perhaps they are important in chiropractic's history; I did not look back farther than five years. But they do not seem important now. Eubulides (talk) 08:16, 27 February 2008 (UTC)

I am becoming more and more convinced that NACM only exists in name at this point (if at all). I believe Dematt tried calling the number on the NACM website and it was either a recording or disconnected. -- Levine2112 ^discuss 08:25, 27 February 2008 (UTC)

OK, here's a proposed change to address this problem with the lead. Let's change the first sentence in the lead's last paragraph from this:

Chiropractors have historically fallen into two main groups, "straights" and "mixers," though "objective straights" and "reformers," who are minority groups, are recent off-shoots from the straight and mixer models, respectively.

to this:

Chiropractors have historically fallen into two main groups, "straights" and "mixers"; both have had splinter groups.

Eubulides (talk) 21:35, 27 February 2008 (UTC)

No further comment so I installed that change. Eubulides (talk) 09:29, 29 February 2008 (UTC)

I updated the lead because the refs I found said four. QuackGuru (talk) 07:00, 14 March 2008 (UTC)

• "How Do I Choose a Chiropractor?". The Health Professionals Directory. 2008. Retrieved 2008-02-02. For example, here is a reference. QuackGuru (talk) 07:13, 14 March 2008 (UTC)

• That reference is weak. It's an unsigned (no author listed) website and vaguely looks like it was derived from an old version of Wikipedia. The website is run by a media group, not by a group with medical or alternative-medical expertise. Did you see the references mentioned above? For example, Keating 2005 is a much more reliable source: it's in PPC, a standard chiropractic textbook. And Ernst 2008 is published in a refereed journal. Eubulides (talk) 19:14, 14 March 2008 (UTC)

Practice styles and schools of thought

The Practice styles and schools of thought secton is cluttered and difficult to read. In its recent form it is hard to follow and does not flow well. For example, mixing the Straight chiropractors and Objective chiropractors in the same paragraph is confusing. Having each group in its own paragraph would be best. Per WP:WEIGHT, we can still incude each group. An off-shoot refers to its origin and not its prominence anyhow. A well writtened introduction to the Practice styles and schools of thought secton is lacking. It is short but can easily be expanded. I think it would be better to move the table to the right. --QuackGuru (talk) 21:55, 22 February 2008 (UTC)

It actually reads quite well. Objective are offshoots of straights and share many similarities as straight and, accordingly, should be talked about in the straight section. Same logic goes for the reform and mixer groups. EBDCM (talk) —Preceding comment was added at 01:55, 23 February 2008 (UTC)

For readability purposes it should be in its own paragraph. The objective straights addition can be limited but also in its own paragraph. QuackGuru (talk) 03:36, 24 February 2008 (UTC)

Common themes in chiropractic care are conservative, non-invasive, non-medication approaches via manual therapy.[19] Nonetheless, there are significant differences amongst the practice styles, claims and beliefs between various practitioners.[20] Those differences are reflected in the varied viewpoints of multiple national practice associations.[33] There are four practice styles and schools of thought among chiropractors.[15][34] This was in the article and was a nice introduction to the section and well sourced. Please explain the deletion. Thanks. QuackGuru (talk) 03:40, 24 February 2008 (UTC)

I apologize for deleting the citations; they were inadvertently taken out while I reverted your omnibus bill of an edit which spanned almost every section of the article. In the future, if you keep your edits to one section at a time, they're less likely to be mistakenly taken out. Feel free to add those citations again. Thanks. EBDCM (talk) 07:56, 24 February 2008 (UTC)

At times manual therapy is synonymous with"manual medicine". Philosophically, reform chiropractors focus on the structural and functional relationships of the neuromusculoskeletal system in both health and disease. Reform chiropractors support vaccination as a cost-effective and proven preventative health measure.

There have been some calls to differentiate reform or 'contemporary' chiropractors from both straight and mixer chiropractors by establishing a Doctor of Chiropractic Medicine (D.C.M.) degree. It is argued this would distinguish them from previous diplomas, and would allow current DCs to upgrade their education to the DCM degree whivh would permit DCMs to utilize prescription drugs suitable to the limitations of their practices and have a unified scope of practice across all jurisdictions.

These sentences don't add much to the article. The section needs to be cleaned up. The vaccination bit should remain in the vaccination section and not this section. QuackGuru (talk) 20:43, 24 February 2008 (UTC)

It's notable and verifiable re: the DCM and it was written by a skeptic of chiropractic as well. It's important to clearly differentiate the different styles of thoughts and approaches hence the structure and function which is also verifiable from a reliable source. Thanks for your input, QG! EBDCM (talk) 23:58, 24 February 2008 (UTC)

According to what references it's notable and verifiable. Please explain. QuackGuru (talk) 01:15, 25 February 2008 (UTC)

I added back in the citations. QuackGuru (talk) 01:55, 25 February 2008 (UTC)

You apoligized for deleting the citations but you deleted the citations again. Please discuss the deletions. QuackGuru (talk) 05:33, 25 February 2008 (UTC)

• I agree that this section is muddled, but that's not a serious NPOV problem, is it? I thought this talk-page section was about NPOV problems.
• I disagree that each group needs its own paragraph. Mixers and straights yes, but the other groups are splinters and don't need to be discussed at length; the splinters can be folded into the respective main paragraphs.

Eubulides (talk) 00:39, 27 February 2008 (UTC)

I had done this originally but QG seems determined to go against the majority of editors here. Your calls for deletion of cited sources is your own fault; editors have asked you previously to add content one section at a time instead of a mass edit in case stuff gets mistakenly deleted. Feel free (like I mentioned 4 times now) to ADD THE REFERENCES ONLY that way your edit won't get reverted THEN add your input. Thanks for cooperating quack guru we really appreciate your new and improved tone since your block. EBDCM (talk) 01:33, 27 February 2008 (UTC)

I f it is of any worth, Citizendium articles are still not considered a reliable source according for Wikipedia's purposes. -- Levine2112 ^discuss 05:17, 27 February 2008 (UTC)

History

The history section can include the survey. It does not fit in the lead but can be included somewhere else in this article such as the history section. The text of the survey is as follows: A 2003 paper showed that 90% of North American chiropractors surveyed believed vertebral subluxation played a significant role in all or most diseases. --QuackGuru (talk) 21:55, 22 February 2008 (UTC)

The survey was selected by Mccready. If editors prefer, we can select another study. That's fine with me. I thought this information would improve this article. We can try using other references such as the Biggs study. We can add the Biggs study instead "that shows that 36% of DCs think vert sub causes disease." I am open to suggestions. --QuackGuru (talk) 04:31, 23 February 2008 (UTC)

Safety

The safetey section is a huge POV probem. There is too much WP:WEIGHT being given to describing The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. It seems pointy to have a lengthy description of The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders. It can be shortened. The reference linking to the The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders website and the reference linking to chiropractic advocacy group's news release in the article are not WP:RS. This can easily be fixed by replacing it with the Spine journal reference. The following text in the safety section seems out of place and is not referenced: Patients should be screened and undergo a complete clinical exam including history, physical and at times additional specialized imaging and laboratory diagnostics in order to rule out any of these contraindications before undergoing a treatment regime that includes spinal manipulation. Spinal manipulation is a controlled health act and should not be performed except by licensed health professionals whose scope allows it. There are many references to include in this section that will expand and explain about the safety issues. Deleting well sourced sentences supported by references is a clear NPOV issue. In this regard, my first option would be the Wikipedia:WikiProject Neutrality. We need more uninvolved Wikipedians. Agreed? --QuackGuru (talk) 21:55, 22 February 2008 (UTC)

I agree that we should use spine as the main reference. Good suggestion, GQ. Lets get those references (you do agree that there is a clinical examination and diagnosis prior to treatment and SMT, right? You do agree that the practice of SMT is limited by scope of practice and legislated acts, right? What do oyu mean by uninvolved? Uninformed? The community here is very knowlegeable and has a scientific bent to it which, IMO is a huge bonus because the quality of citations, and accordingly, the article, goes up. EBDCM (talk) 08:39, 23 February 2008 (UTC)

I did not say to use the Spine ref as the main ref. It should be the only ref because it is RS and because The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and the chiropractic advocacy group is not RS. It there a RS ref for "the practice of SMT is limited by scope of practice and legislated acts" you described above? What do I mean by uninvolved? I want more uninvolved editors to help NPOV this article. Please explain your reasons for deleting the new Spine ref, the WHO reference, and the Edzard Ernst ref anyhow. --QuackGuru (talk) 03:33, 24 February 2008 (UTC)

In February 2008, the World Health Organization sponsored Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, the largest and most comprehensive study on neck pain to date. The task force was comprised of a group of international clinician-scientists and methodologists to undertake a best-evidence synthesis on neck pain and its associated disorder and make recommendations of clinical practice guidelines for the management of neck pain and its associated disorders. This included a consensus of the top experts in the world whose findings will be collated using best-evidence synthesis, which addresses risk and prevention, diagnosis, prognosis and treatment risks and benefits. Please explain your reason to add such a HUGE amount of text to describe The Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders. It smacks WP:POINT. QuackGuru (talk) 03:58, 24 February 2008 (UTC)

The NPOV problems with this section has continued. I will restore the facts and add more information to strengthen WP:NPOV. QuackGuru (talk) 20:59, 24 February 2008 (UTC)

The neck pain study was 6 years in length, comprised over 1 million patient years and was a landmark study which included a various array of health professionals and researchers (i.e. there was a consensus). This helps readers to know that the findings and conclusions are accepted by a wide majority of professional researchers. It also explains to readers why it's an important study whose conclusions are worth including. Thanks. EBDCM (talk) 00:00, 25 February 2008 (UTC)

It is still way too much text. The length of the study does not mean we should add such a huge amount of text. QuackGuru (talk) 01:11, 25 February 2008 (UTC)

Describing The Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders does not need to be so long. QuackGuru (talk) 01:31, 25 February 2008 (UTC)

The WHO report in the 'Safety' section was referenced but the reference was deleted. Please explain this. QuackGuru (talk) 01:17, 26 February 2008 (UTC)

I don't understand this last comment. The first URL does not point at a reference, and the second URL does not point at the deletion of a reference. Eubulides (talk) 01:30, 26 February 2008 (UTC)

In a 2005 report, the World Health Organization states that when "employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems." The WHO report goes on to say, "there are however, known risks and contraindications to manual and therapeutic protocols used in chiropractic practice," and, "Contraindications to spinal manipulative therapy range from a nonindication for such an intervention, where manipulation or mobilization may do no good, but should cause no harm, to an absolute contraindication... where manipulation or mobilization could be life‐threatening." This was referenced but the reference got deleted. QuackGuru (talk) 02:14, 26 February 2008 (UTC)

Sorry, I still can't make heads or tails of that comment. All its URLs point to the same diff listing, which contain zero diffs, so I don't see what changed. I agree with you that the section in question is overly POV. But I still don't understand this specific comment. Eubulides (talk) 08:38, 26 February 2008 (UTC)

A lot of the above text (including the reference) was removed and now it reads: According to the World Health Organization "employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems."[cite this quote] I will add the text + reference back. QuackGuru (talk) 08:45, 26 February 2008 (UTC)

Originally the 2005 WHO report was NPOV and referenced. Currently it is POV and unreferenced. QuackGuru (talk) 08:56, 26 February 2008 (UTC)

I have included more text and references to verify the facts but it was deleted without any good explanation. QuackGuru (talk) 19:56, 26 February 2008 (UTC)

I agree the safety section is POV and has too much about the Bone and Joint study. I also object to the 'cherry picking' of the WHO statement, deleting the contraindication part.

"Spinal manipulation, the most common modality in chiropractic care, has been increasingly studied in recent years as critics and proponents debate the merits of its efficacy and safety.

Spinal manipulation has generally regarded is a safe and effective procedure for the treatment of various mechanical low back pain syndromes."[74][75][76][77] [78][79] These references don't support the second sentence. Refs 74-77 are pretty negative; "not clinically meaningful"74, "not clinically worthwhile in decreasing pain and mobility" 75, "not effective for any condition" 76, "not established as effective" and spinal manipulation "burdened with severe adverse reactions" 77 The last two refs are vaguely positive. The second sentence should say something like "many studies have found spinal manipulation to be only mildly effective or ineffective" Any mention of safety was toward the negative side, but the impression the reader is left with is "safe and effective".CynRNCynRN (talk) 21:17, 28 February 2008 (UTC)

http://en.wikipedia.org/w/index.php?title=Chiropractic&oldid=194269776#_ref-Hurwitz_0 Here is the NPOV version along with the correct reference placement. QuackGuru (talk) 21:27, 28 February 2008 (UTC)

What would be helpful here is to draft a new version of Chiropractic#Safety that addresses the above concerns. I have created a new section #Safety 2 below to do this. The initial version is the version you suggested; I hope we can all edit it into something that addresses the POV problems and approaches consensus. Eubulides (talk) 22:20, 28 February 2008 (UTC)

There is a growing consensus for the well sourced NPOV version and not the blatant POV worded problems. QuackGuru (talk) 22:31, 28 February 2008 (UTC)

Nice job quack guru, you plant crappy references and deceive the editors here because there is much better, stronger and BALANCED refereces for your claims. You might want to start here for a decent lit review on all chiropractic care. http://www.ccgpp.org/ Until then, do us a favour and stop making weak edits with weak citations leading to equally weak claims. I hope you take my words to heart; as a growing # of editors here and becoming frustrated by your 'approach' to editing the chiropractic article. EBDCM (talk) 05:37, 29 February 2008 (UTC)

Vaccination

All the tweaking to this section had diluted the entire section. I will restore the missing well sourced sentences. QuackGuru (talk) 20:47, 24 February 2008 (UTC)

This first sentence is a little wierd."Mandatory vaccination is controversial within the chiropractic community controversial with different schools of thought" Controversial with different schools of thought doesn't make sense. I think it means straights often oppose it and mixers may not, but it could use clearing up. Just a little history of where the opposition came from would be useful; initial opposition to the germ theory, etc.CynRNCynRN (talk) 21:23, 24 February 2008 (UTC)

I liked this lead in from Eubulides:"although vaccination is one of the most cost-effective form of prevention against infectious disease, it remains controversial in chiropractic. Most chiropractic writings on vaccination focus on its negative aspects.[16]" This is accurate and referenced.CynRNCynRN (talk) 21:30, 24 February 2008 (UTC)

As long as it differentiates between the varying opinions within the chiropractic profession it's all good by me though we really don't need to go into germ theory, IMO. EBDCM (talk) 00:02, 25 February 2008 (UTC)

Most chiropractic writings on vaccination focus on its negative aspects, despite its being one of the most cost-effective forms of disease prevention. I think this would work too. QuackGuru (talk) 01:21, 25 February 2008 (UTC)

I brought back the wording CynRN liked at about the same time that you suggested the other wording. Either wording is fine with me. Eubulides (talk) 01:29, 25 February 2008 (UTC)

Both ways work for me. QuackGuru (talk) 02:12, 25 February 2008 (UTC)

Vaccination is such a minor issue. . . talking about it any more than a single sentence or two violates NPOV. . . the Undue Weight clause.TheDoctorIsIn (talk) 00:51, 13 March 2008 (UTC)

Please see Talk:Chiropractic/Archive 15 #Chiropractic and vaccination for why it is the way it is. It could be shortened a bit, but I don't see how to cut it down to a sentence or two without running into the POV issues mentioned there. Eubulides (talk) 04:38, 13 March 2008 (UTC)

Education, licensing, and regulation

I will fix the red links and format a ref. QuackGuru (talk) 20:52, 24 February 2008 (UTC)

I fixed the red links and formatted a reference but it was reverted. QuackGuru (talk) 05:36, 25 February 2008 (UTC)

I fixed the red links again and formatted a reference among other things. It was reverted. The edit was partial vandalism to this section. QuackGuru (talk) 19:50, 26 February 2008 (UTC)

Treatment techniques vs. Manipulative treatment techniques

I think the appropriate title for the section should be Chiropractic treatment techniques because there is more than just manipulative techniques. QuackGuru (talk) 21:13, 24 February 2008 (UTC)

The name "Chiropractic treatment techniques" runs afoul of WP:HEAD, which says "Avoid restating or directly referring to the topic." To fix this particular problem I removed the word "Chiropractic" from the section header. Currently the body of the section talks only about manipulative techniques: shouldn't that be fixed too? Eubulides (talk) 02:30, 25 February 2008 (UTC)

Agreed. "Treatment techniques" works in accordance with WP:HEAD. QuackGuru (talk) 02:36, 25 February 2008 (UTC)

Are all techniques manipulative or not all techniques are manipulative. QuackGuru (talk) 05:23, 25 February 2008 (UTC)

http://en.wikipedia.org/w/index.php?title=Chiropractic&diff=next&oldid=194269776 I agree with this edit. QuackGuru (talk) 22:51, 26 February 2008 (UTC)

Holistic and naturopathic approach

This header seems unecessary. I don't see any point to keeping it. QuackGuru (talk) 22:23, 24 February 2008 (UTC)

I agree. The current redrafts of the philosophy section seem to omit it, so it looks like it will go at some point. Eubulides (talk) 02:31, 25 February 2008 (UTC)

Disagree. Why don't you want to readers to know this? EBDCM (talk) 04:52, 25 February 2008 (UTC)

Section headers are supposed to be short and to the point. It's not a question of what I want readers to know; the material in question will be in the body, and doesn't need to be in a section header. Besides, it's strange for the entire contents of a section to consist of a single subsection, with no other text; I don't recall ever seeing that in any featured article in Wikipedia. Eubulides (talk) 05:21, 25 February 2008 (UTC)

We will add conservative to the mix. Thanks.EBDCM (talk) 01:29, 27 February 2008 (UTC)

Comments on the 2008-02-22 12:06:18 edit

Here are some comments on the 2008-02-22 12:06:18 edit that QuackGuru just made.

• There are a lot of changes in that one edit, and many of them are no doubt controversial. Surely it'd be better to discuss the changes one by one; that's more likely to achieve a working consensus.

• Wheeler 2006 is not published in a refereed journal. I'd prefer a higher-quality citation.

• I disagree that chiropractors fall into four distinct groups. See the comment "I checked two reliable sources on this subject." in #Elimination of reform chiro above. Reliable sources agree about the two main groups (straights and mixers); the existence of the other two as formal groups is in doubt, and the article should not give greater emphasis to the other groups than reliable sources do. It is OK to mention the two less-well-supported groups, but not in so much detail that they appear to be just as important as the two main groups.

• The cited source does not support the claim that "All groups, except reform, treat patients using a subluxation-based system." It doesn't say that mixers use a subluxation-based system.

• The claim "A 2003 paper showed that 90% of North American chiropractors surveyed believed vertebral subluxation played a significant role in all or most diseases." is supported by McDonald 2003. I don't have easy access to that source, but this summary doesn't mention that figure. The summary mentions a bunch of other numbers, which may well be more notable than the 90% figure; why was the 90% figure selected here? Eubulides (talk) 00:18, 23 February 2008 (UTC)

• I haven't had the time to wade through all the studies on the efficacy and safety of spinal manipulation so I can't comment on the material in the many edits made in that section. However, I suggest using "cite journal" with pmid= instead of "cite news" with URLs in citations to Pubmed-indexed articles. I made that change just for Ernst 2008, to give you a feeling for how it works. Eubulides (talk) 00:18, 23 February 2008 (UTC)

Eubulides (talk) 00:18, 23 February 2008 (UTC)

It appears that quack guru has cherry picked the evidence and neglected to include meta-analyses which have already been performed on this subject and shown SMT for LBP to be both safe and effective. It also demonstrates common reductionistic thinking that still pervades conv med. [12] EBDCM (talk) 02:01, 23 February 2008 (UTC)

I will make the necessary adjustments based on all the comments above. QuackGuru (talk) 21:20, 24 February 2008 (UTC)

I will adhere to NPOV and edit the article. QuackGuru (talk) 10:32, 26 February 2008 (UTC)

I have included a meta-analyses study in the Safety section but it was deleted. QuackGuru (talk) 20:01, 26 February 2008 (UTC)

partial vandalism and NPOV violation

http://en.wikipedia.org/w/index.php?title=Chiropractic&diff=next&oldid=194142433 This edit was in part vandalism. For example, references were removed that cited the text.

Evidence at the trial showed that the defendants took active steps, often covert, to undermine chiropractic educational institutions, conceal evidence of the usefulness of chiropractic care, undercut insurance programs for patients of chiropractors, subvert government inquiries into the efficacy of chiropractic, engage in a massive disinformation campaign to discredit and destabilize the chiropractic profession and engage in numerous other activities to maintain a medical physician monopoly over health care in this country. I provided a reference that verified the above text.

A 2005 World Health Organization report states that when "employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems." The report continued, "there are however, known risks and contraindications to manual and therapeutic protocols used in chiropractic practice," and, "Contraindications to spinal manipulative therapy range from a nonindication for such an intervention, where manipulation or mobilization may do no good, but should cause no harm, to an absolute contraindication... where manipulation or mobilization could be life‐threatening."[51] I provided a reference that verified the above text.

The current text reads: According to the World Health Organization "employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems."[cite this quote] This is not the entire story of the 2005 report by WHO. The reference was deleted along with the balance facts. Therefore, it is an NPOV violation.

In February 2008, the World Health Organization sponsored Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, the largest and most comprehensive study on neck pain to date. The task force was comprised of a group of international clinician-scientists and methodologists to undertake a best-evidence synthesis on neck pain and its associated disorder and make recommendations of clinical practice guidelines for the management of neck pain and its associated disorders. This included a consensus of the top experts in the world whose findings will be collated using best-evidence synthesis, which addresses risk and prevention, diagnosis, prognosis and treatment risks and benefits.[77]

Here is another example of an NPOV violation. The above text is a description of The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders. It also has WEIGHT problems.

In February 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, comprising a group of experts to evaluate neck pain and its associated disorder, released a manuscript of their findings with recommendations and guidelines, including associated risks and benefits. Here is the shortened text.

http://en.wikipedia.org/w/index.php?title=Chiropractic&diff=prev&oldid=194142433#Safety This edit shortened the text and is NPOV as ever.

Also a Spinal journal reference was added to replace the unreliable reference but it got deleted. The Spinal journal is a reliable reference.

[13] The same edit fixed the red links and formatted a reference in the Education, licensing, and regulation section. But the formatted reference and the proper blue links were reverted. It was a clear policy violation (partial vandalism) to remove a formatted reference.

[14] formatted reference number 79

[15] deleted reference number 70 in red

A reference was formatted but the reference was deleted.

Spinal manipulation is a regulated medical intervention and can only be performed by chiropractors and a limited number of physical medicine professionals.[90][91]

Most patients have no adverse effects from cervical manipulation,[95] though the risk of stroke is not zero.[96][97]

Here are a couple of more examples. The above text was referenced but the references were deleted.

There are problems with the Practice style and schools of thought section.

The four different groups were in its own paragraph along with a nice introduction but the introduction got shortened and the citation got removed. The current version reads: Common themes in chiropractic care are conservative, non-invasive, non-medication approaches via manual therapy. Nonetheless, there are significant differences amongst the practice styles, claims and beliefs between various practitioners. Notice the missing citations.

Common themes in chiropractic care are conservative, non-invasive, non-medication approaches via manual therapy.[18] Nonetheless, there are significant differences amongst the practice styles, claims and beliefs between various practitioners.[19] Those differences are reflected in the varied viewpoints of multiple national practice associations.[34] There are four practice styles and schools of thought among chiropractors.[15][35] Now here is a quality introduction to that section along with references. No good explanation has been given to remove a good introduction.

[16] Before and NPOV.

[17] After and POV.

It was a WP:POINT violation to undo a quality edit. --QuackGuru (talk) 21:12, 26 February 2008 (UTC)

Eubulides agrees with me that the 'Safety' section in question is overly POV. Any suggestions on NPOVing this article would be helpful. QuackGuru (talk) 21:49, 26 February 2008 (UTC)

Feel free to insert references, but do it one section at a time; otherwise your controversial edits will get reverted including accidental omissions of your sources. With all due respect; Eubulides POV is not the end-all-be all. What specifically do you have a problem with? EBDCM (talk) 01:23, 27 February 2008 (UTC)

It can't be an accidental omission of the sources when editors are fully aware of the additional sources were added to the article that verified the text. It was an intential ommission.

I will insert the references along with the NPOV sentences that went along with the facts. I will follow the references. The sentences must be written in accordance with NPOV policy. WP:NPOV states: Neutral point of view is a fundamental Wikipedia principle. NPOV is absolute and non-negotiable. EBDCM asked: What specifically do you have a problem with? I already explained that above. QuackGuru (talk) 21:03, 28 February 2008 (UTC)

Historical material belongs in "History"

The following material in Chiropractic #Treatment techniques is mostly about history, not about techniques. Let's move this material to Chiropractic #History.

The medicinal use of spinal manipulation can be traced back over 3000 years to ancient Chinese writings. Hippocrates, the "father of medicine" used manipulative techniques, as did the ancient Egyptians and many other cultures. A modern reemphasis on manipulative therapy occurred in the late 1800s in North America with the emergence of the osteopathic and chiropractic professions. While some manipulative procedures now associated with chiropractic care can be traced back to ancient times, the modern profession of chiropractic was founded by Daniel David Palmer in 1895 in Davenport, Iowa. Spinal manipulative therapy gained recognition by mainstream medicine during the 1980s.

Eubulides (talk) 00:47, 27 February 2008 (UTC)

Vehemently disagree. It seems if editor Eubulides had his/her way the whole article would be flipped upside down according to his/her standard. This section is perfectly referenced and gives readers insight and appropriate context of manipulative therapies the #1 modality used in chiropractic clinical practice. Of course, I cannot wait to add some contrasting material with medicine that Eubulides is so desperately trying to keep out of the page despite appropriate citations and perfectly allowable contrast. Thanks. EBDCM (talk) 01:28, 27 February 2008 (UTC)

Be careful with the contrasting. This article is about chiropractic, not medicine. If you stay on topic, you can avoid problems. -- Fyslee / talk 06:21, 27 February 2008 (UTC)

I am not asking that the material be removed, nor am I saying that the material is poorly sourced. I am merely saying that material about 3000-year-old manipulation is obviously historical, and that it therefore ought to be in Chiropractic #History. I disagree that the historical material provides any real insight into the nature or types of spinal manipulative techniques. All it says is that the techniques go way back, so it's useless for the purpose of a section that describes the main techniques. I do not know what EBDCM means by "contrasting material with medicine that Eubulides is so desperately trying to keep out of the page", and I do not understand why that point (whatever it is) is relevant here. Eubulides (talk) 07:37, 27 February 2008 (UTC)

The material about SMT belongs in the SMT (procedures) section. The history section is more about the political and foundings on the profession and it's subsequent struggles for legitimacy, the AMA blurb, etc. We will leave it here. Thanks. EBDCM (talk) 15:35, 27 February 2008 (UTC)

Chiropractic #History should be about the history of chiropractic. If it's really just about politics, then it should be labeled Politics and we should start a new History section. The first sentence in Chiropractic #History is about spinal adjustment; if it really was the case that every sentence in this article that mentions SMT should be in the Treatment section, then we'd have to move that sentence and many other chunks of the article into Treatment, which would be silly. What matters is what is the best section for a particular point, not what sections that point could conceivably be put in. On balance, the material under dispute is far more about history than it is about SMT (it says nothing about what SMT is). I don't see why it belongs anywhere but the history section. Eubulides (talk) 16:44, 27 February 2008 (UTC)

Another point: WP:SUMMARY says that when a section summarizes a subarticle, as Chiropractic#Treatment procedures summarizes Chiropractic treatment techniques, the section's material should be in sync with the subarticle. And yet in this case we have a section whose text spends most of its time on a topic (history) that is not in the subarticle. This is another indication that the historical material is ill-placed. Eubulides (talk) 16:55, 27 February 2008 (UTC)

Until you made wholesale changes to the entire table, it was all about manipulation, so you comment is disingenious. Please do not refer to me like a special-ed child; I cannot stand being spun wikipedia policy. Clearly a few sentences about the history and re-ermegence of SMT as a modality in a chiropractic article under a treatment methods section is appropriate. EBDCM (talk) 01:48, 29 February 2008 (UTC)

Whether the table mentions only spinal manipulation or other procedures is irrelevant to the question whether "Treatment procedures" should devote most of its text to history. This is not a Wikipedia policy issue; it is a guideline issue. It's not necessary to discuss chiropractic's ancient history in Chiropractic #Treatment procedures, and there are strong and obvious arguments for putting the history discussion under Chiropractic #History. Eubulides (talk) 06:39, 29 February 2008 (UTC)

No further comment, so I moved the historical material to Chiropractic #History. Eubulides (talk) 22:48, 3 March 2008 (UTC)

(outdent) That movement was reverted with the log entry "no consensus for this move; see talk page". I don't see a consensus against the move either; perhaps another editor can weigh in? In the meantime I made this change in an attempt to better address the concerns noted above. This change keeps a brief introduction to the history of chiropractic in Chiropractic #Treatment procedures, but puts the bulk of the historical material in Chiropractic #History, a more natural home for historical material. Eubulides (talk) 06:34, 4 March 2008 (UTC)

Integrative Medicine

Proposed amendment. Integrative Model of Care or Integrative medicine or another fitting title. With the rise of popularity of complementary and alternative therapies [33] and the reformation of health care systems internationally[34][35] integrative models of health care delivery are becoming increasingly prevalent.[citation needed] National Center for Complementary and Alternative Medicine defines integrative medicine as combination of mainstream medical therapies and CAM therapies for which there is some high-quality scientific evidence of safety and effectiveness."[36] Consequently, some chiropractors, in particular refom chiropractors, are beginning to become integrated in formal public health settings such as hospitals[37][38][39], interdisciplinary health teams [40] and within governmental institutions[41][42] to provide their expertise in the management of neuromusculoskeletal disorders.

This was swept away in the archives but we should discuss it here first, as always before incorporating it into the main article. Eubulides, do you have any problems with the language and what section do you think this belongs in? EBDCM (talk) 02:05, 27 February 2008 (UTC)

As I mentioned at the end of Talk:Chiropractic/Archive 15 #Mainstream integration, I can't easily review this proposal because it has has zero citations; it has merely uninformative numbers like "[40]". Without that information, I cannot verify that the claims are well-sourced. Can you please fix this so that I can do a proper review? Thanks. Eubulides (talk) 07:26, 27 February 2008 (UTC)

Thanks Go--- I mean Eubulides, but the sources are well sourced. Personally I think that it's condecending of you to infer that only your eyes and brain can make a call on what is well sourced. I have 8 years of university education, am very familar with EBM and research protocols I think I can tell the difference between a poor source and a good one. Anyways, I was asking you about the language first. EBDCM (talk) 15:38, 27 February 2008 (UTC)

Please provide the sources. I cannot tell whether I have problems the language without seeing the sources. Eubulides (talk) 16:48, 27 February 2008 (UTC)

EBDCM, what Eubulides is saying is that he doesn't know what you mean by [33] or [40] as there is no hyperlinked text. Are you referring to sources already in the article? Sources in the notes section of the talk page? On the other hand, Eubulides, you should not need the sources to decide if you have a problem with the way the text is worded. 121.44.227.79 (talk) 00:24, 28 February 2008 (UTC)

I see some minor problems with the phrasing, but I'd rather not waste everybody's time with those while the major problem of sourcing remains unaddressed. Eubulides (talk) 05:31, 28 February 2008 (UTC)

Why don't you mention those now, because otherwise you are wasting everybody's time. 121.44.227.79 (talk) 05:50, 28 February 2008 (UTC)

Let's go Eubulides, as anonymous suggests. The sources have already been provided in the archives in both the main article and talk page. EBDCM (talk) 15:48, 28 February 2008 (UTC)

Problems with proposed text

I disagree that strong sources have been provided. However, since you asked, here are some problems with the existing text:

• Integration implies being integrated with some other professionals. Who are these other professionals, and how do they interact with chiropractors in an integrated models? Without this information the paragraph isn't saying much, other than "Integration good" (which raises POV issues).
• "With the rise of popularity of complementary and alternative therapies". Lawrence & Meeker also point out that the chiropractic is rising in popularity only modestly.
• "The reformation of health care systems internationally" This doesn't say much. Health care systems are always changing, and people are always reforming them. This phrase can go.
• "integrative models of health care delivery are becoming increasingly prevalent". What is the source for the claim that integrative models are more prevalent? How much more prevalent are they?
• "National Center for Complementary and Alternative Medicine defines" There's no need to mention the NCCAM in the main text; a citation suffices.
• "in particular reform chiropractors" This phrase is not needed (and I suspect is not supported by the sources).

Eubulides (talk) 17:57, 28 February 2008 (UTC)

New version of last sentence, with citations

I fetched some of them though I think I had a more recent revision with better quality references,

Some chiropractors, particularly reform chiropractors, may practice Integrative medicine in hospitals, within interdisciplinary health teams . Chiropractors are also becoming more integrated in scientific research communities and within governmental institutions. —Preceding unsigned comment added by EBDCM (talk • contribs) 05:00, 29 February 2008 (UTC)

Comments on new version of last sentence

• does not support the cited claim. It does not mention reform chiropractors. It is a Norwegian feasibility study.

No it's not, it's a study that confirms that a DC has been integrated as a staff member in the Orthepedic department in a Norwegian hospital. This goes under the "DC in hospitals" claim. EBDCM (talk) 03:38, 5 March 2008 (UTC)

is a primary study involving just one chiropractor between 2001 and 2003. It hardly supports a claim about "some chiropractors"; it's just one chiropractor. It does not at all support a claim about "reform chiropractors"; there is no mention of reform in the study. Let's get a better source, preferably a secondary source whose main subject is integrative medicine and chiropractic; that would be much stronger than this one. Eubulides (talk) 07:06, 5 March 2008 (UTC)

Liar. http://hospitaldc.com/ [18]. Some DCs are in hospitals. You are being owned. EBDCM (talk) 15:49, 5 March 2008 (UTC)

This new citation (Kopansky-Giles et al. 2007, PMID 17996546) does not invalidate the comments I made about whether supports the claim in question. The new citation is much better than the older one, since it's more on point. Please use it instead, changing the text to match what this study supports about integrative medicine. (For example, this new citation does not talk about reform chiropractors, so that part of the claim would need to be removed.) Better yet, I suggest finding a reliable secondary review of the subject; that'd be much better than relying on a primary study. Eubulides (talk) 20:07, 5 March 2008 (UTC)

• is a brochure describing Ontario's payment procedures for interdisciplinary health care. I guess it's being cited to prove that interdisciplinary health care exists? If so, that's not at all obvious; and surely there is a better source.

What it does is confirms that DCs are part of interdisciplinary health teams (family, community health). That's the claim I was making. It also supports my previous claim that the reformation of the health care system has begun and integrative models (i.e. including complementary health providers like DCs) are part of this new model and paradigm. EBDCM (talk) 03:38, 5 March 2008 (UTC)

Then let's see a better source. Wikipedia sources are not supposed to be clues that one follows like a detective. They are supposed to directly state the point that the article is summarizing. That's not being done here. Eubulides (talk) 07:06, 5 March 2008 (UTC)

You don't need to be a detective, you need half a brain. It proves my point, DCs are part of interdisciplinary teams (i.e. they're part of the primary care provider list). It real and it stays. EBDCM (talk) 15:49, 5 March 2008 (UTC)

Again, Wikipedia sources are supposed to directly state the point that the article is summarizing. This source is merely a payment-procedure brochure. If the article were talking about payment procedures for chiropractors in Ontario, the source would be directly relevant. But this part of the article is about integrative medicine. Please find a better source. It can't be that hard to find on-point sources on this topic in refereed journals. Perhaps something can be found in the journal Integrative Medicine, for example. Surely there are many other sources that are better than payment-procedure brochures. Eubulides (talk) 20:19, 5 March 2008 (UTC)

• is to a list of speakers and publications. I fail to see how it supports the claim that chiropractors are becoming more integrated in scientific research communities. If it's evidence, it's too indirect.

Granted this one could be improved and I was lazy. Nonetheless there are many more DC/PhDs, more of them are contributing to conservative health care policies and many are involved in interdisciplinary research conferences like Fascia which was led by a DC/PhD. ~~

OK, then let's get a better source. I'm sure one is available. Eubulides (talk) 07:06, 5 March 2008 (UTC)

Ok. EBDCM (talk) 15:49, 5 March 2008 (UTC)

• is to a list of publications relating to health care policy reform in Canada, which does not say "chiropractic" anywhere. I don't see the relevance.
• does not mention chiropractic either.

I supported my claim that health care reform is happening in both the US and Canada. EBDCM (talk) 03:38, 5 March 2008 (UTC)

Sources in this article should be about the role of chiropractic in health care reform, not about health care reform in general (which is an enormous topic, and besides which, must have hundreds of higher-quality sources than a list of publications at a conference). It shouldn't be that hard to supply good sources on this particular topic. Eubulides (talk) 07:06, 5 March 2008 (UTC)

By all means, if you can find better sources, please go ahead. I was simply providing evidence that health care reform is a legitimate, ongoing event. If I had provided no evidence for this statement it could be wiped out. EBDCM (talk) 15:49, 5 March 2008 (UTC)

They are just a list of publications, and a pointer to a health-care advocacy website that nowhere mentions either chiropractic or integrative medicine. They do not support the claim they're attached to, namely "Chiropractors are also becoming more integrated in … within governmental institutions." A general healthcare reform web site that never mentions chiropractic does not support that claim. To support such a claim, I suggest starting with the journal Integrative Medicine, mentioned above, for higher-quality sources. Eubulides (talk) 20:34, 5 March 2008 (UTC)

• is a VA press release saying VA facilities offer chiropractic care. The press release does not talk about integrative medicine, and does not support any claims about integrative medicine.

Let's think about this for a minute. VA facility is provided exclusively by mainstream medicine. Pilot project done, DCs become integrated in the health care service loop. DC+MD primary care physicians= integrated medicine. Source: US Dept of Veterans affairs. This is a credible, reliable, notable and verifiable source. Just because it does not quote the words "integrative medicine" verbatim does not mean it's not an example of this model. In the future, please use better judgement; the claim made was that DCs are beginning to be integrated in governmental agencies. EBDCM (talk) 03:38, 5 March 2008 (UTC)

Again, let's get sources directly on the point rather than sources where one has to be an expert to follow the dots (and where even experts might disagree about the dots). Eubulides (talk) 07:06, 5 March 2008 (UTC)

Like I mentioned before, when we can find the better sources we will toss them in. However, I don't always have the time to do a good search and the inclusion of governmental releases was to provide proof, again, of the claims being made. Have you looked into quack gurus references lately for his edits? Even these government websites are far superior to the layman internet sites he quotes. EBDCM (talk) 15:49, 5 March 2008 (UTC)

Let's please source material in a controversial article like this first, before the material goes in. Using high-quality sources will avoid many problems with controversy and POV. I have not looked into Quack Guru's citations, but regardless of their quality, lower-quality work elsewhere does not justify lower-quality work here. Eubulides (talk) 20:41, 5 March 2008 (UTC)

• does not talk about integrative medicine either.

See above. EBDCM (talk) 03:38, 5 March 2008 (UTC)

Likewise. Eubulides (talk) 07:06, 5 March 2008 (UTC)

To summarize: the citations either do not support the claims, or are not relevant, or are exceedingly indirect. Better citations are needed. Have you had a chance to look at Mootz 2007 (PMID 17224347), Barrett 2003 (PMID 12816630), and Meeker & Haldeman 2002 (PMID 11827498)? Eubulides (talk) 07:25, 29 February 2008 (UTC)

Read the citations closer, Eubulides. It's not a feasiibility study and the conclusion clearly states that the DC was fully integrated into the ortho department within the hospital. It's note l a brochure (what poor wording) and it comes directly from the government of Ontario. Furthermore its proof that DCs are members of interdisciplinary teams. Health care reform is happening; the link shows proof and the interdisciplinary teams (CHC and FHT) are evidence of this. What would you call chiropractors working in the VA side by side with MDs, PTs and other professionals? Gimme a break. Your claims are unfounded and the citations support the claims made that DCs are beginning to be incorporated into CHC, FHT, governmental agencies and hospitals. Thanks for your spin though! EBDCM (talk) 13:45, 29 February 2008 (UTC)

• concludes "the inclusion of chiropractors within hospital orthopedic departments is feasible", which indicates the authors were studying feasibility; if they weren't, why would they have made feasibility an important part of their conclusion?

Was the DC in question not a full blown hospital staff member at the Orthopedic department? The claim I am making is that DCs are beginning to be integrated in hospitals. EBDCM (talk) 03:45, 5 March 2008 (UTC)

It's not a question of whether the DC was a full blown staff member. It's a question of whether it was a feasibility study, which it was. If the claim is intended to be that DCs are beginning to be integrated in hospitals, let's see a study that directly addresses that claim, not a feasibility study involving one chiropractor. Eubulides (talk) 07:06, 5 March 2008 (UTC)

Yes it does matter. I am claiming some DCs are being integrated onto hospital staff. The article states this clearly. Whether or not its a feasibility study for the rest is irrelevant as I have already provided additional references of DCs in hospitals. Did you know DCs are also beginning to teach at Med school? You must be surprised how a bunch of quacks are pulling fast ones now, eh, Eubulides? EBDCM (talk) 15:49, 5 March 2008 (UTC)

The cited source states that one chiropractor took part in a feasibility study. That does not support the claim next to the citation, which is "Some chiropractors, particularly reform chiropractors, may practice Integrative medicine in hospitals". The cited source does not mention reform chiropractors. And it does not mention integrative medicine. Therefore, key parts of the cited claim are not supported by the source. The source would support the weaker claim "One chiropractor has participated within an orthopedic department of a Norwegian hospital as part of a feasibility study." That would not be a useful claim, though. It would be better to get a stronger source and to write the claim to match the stronger source. Again, secondary (review) articles are typically the best bet here. Eubulides (talk) 20:50, 5 March 2008 (UTC)

• is some sort of document talking about who is eligible for compensation; whether one calls it a "brochure" or a "handout" or something else, it is an extraordinarily odd choice to support the claim that chiropractors are interdisciplinary health care providers. It's sort of like citing instructions to an I.R.S. tax form to support the claim that businesses have profits and losses. I could not tell from reading the source what claim it was intended to support. A better source is needed. I am not disputing the claim that some chiropractors practice as part of integrative medicine; I'm saying only that the source is inadequate.

Until we find a better source, this one is good enough. When we can find it in a PR journal we'll update the reference. EBDCM (talk) 03:45, 5 March 2008 (UTC)

It is a extraordinarily low-quality source. It is lower quality than all the sources I've reviewed in this article (granted, I have not reviewed them all). Let's not make do with low-quality sources. Let's use good sources, and write the article to match the sources. This citation cannot have been the main source for the text in question. Eubulides (talk) 07:06, 5 March 2008 (UTC)

No, Eubulides, thats a false statement. Your suggestions are dishonest and frankly you are NOT the sole judge, jury and executioner like you're trying to be here. I will ask that you desist from your constant whining. I've already said we can find a better source in time. This is a health booklet from the Ministry of Health and Long Term Care from the Government of Ontario. It's a reliable and verifiable source. 15:49, 5 March 2008 (UTC)

I see nothing dishonest about suggesting higher-quality sources. This is a reliable and verifiable source about eligibility for health-care compensation in Ontario, but it is a poor source to support the proposed claim, which is "Some chiropractors, particularly reform chiropractors, may practice Integrative medicine … within interdisciplinary health teams." For example, it talks only about eligibility, not about practice; and it never mentions reform chiropractors. Let's find a better source first, before putting the text in. Eubulides (talk) 21:02, 5 March 2008 (UTC)

• does not say that chiropractors work "side by side" with MDs. It merely says that they work at certain locations. It also makes clear that the program supports outpatient care, which suggests a non-integrated approach. Merely getting funding from the VA, or even setting up shop in a VA hospital, does not necessarily mean integrative medicine. A better source is needed to support the claim.

Where is your evidence that outpatient care suggests a non-integrated approach? You're splitting hairs here and it's in poor taste. DCs are integrated in the US DoD and VA, period. And my claim was that DCs are beginning to be intergrated as health care providers into governmental agencies. EBDCM (talk) 03:45, 5 March 2008 (UTC)

Again, the source does not support the claim. Again, merely getting funding from the VA, or even setting up shop in a VA hospital, does not necessarily mean integrative medicine. The source does not mention integrative medicine at all. One must make a leap of faith to see the integrative medicine there. That is not how sources are supposed to work. Eubulides (talk) 07:06, 5 March 2008 (UTC)

What is integrative medicine, Eubulides? Oh yes, it's integrating CAM with allopathic med. This is what is occuring at VA. You are so intellectually dishonest I'm having I really don't know if I can work with you if you do not start to improve your understanding of the issues. It does not require a leap of faith as you suggest and your insinuation that one does is in poor faith. The claim made was that DCs are beginning to be integrated into governmental agencies. Is this not true? EBDCM (talk) 15:49, 5 March 2008 (UTC)

The threshold for inclusion in Wikipedia is verifiability, not truth. If the source does not support the claim, then one or the other must be changed. Eubulides (talk) 21:06, 5 March 2008 (UTC)

• None of the other detailed comments have been addressed.
• In drafting a better version, it would be helpful to start by finding reliable sources on the subject, using the criteria suggested in WP:MEDRS, and to summarize their main points in the draft. Doing that will avoid the sort of sourcing problems noted above.

The sourcing problems you list are noted, but does not prevent them to be included in the current context. When we find BETTER sources we will naturally add them, but I have provided reliable, verifiable, notable references (i.e. Government PRs, PR journals, Government policy booklets, etc.) In short, all the references support the claims made. EBDCM (talk) 03:45, 5 March 2008 (UTC)

Again, none of the other detailed comments have been addressed; this last round of comments has talked about (and has not addressed) only the more-recent comments about the last two sentences in the proposed section. None of the comments about earlier sentences have been addressed; these sentences still await sources. The sources that have been provided are low-quality, and do not support many of the claims made. We currently do not even have a complete draft of the proposed section, with sources. A complete and reasonable-quality draft is needed before a proper review can be made of the proposed new section. Again, I suggest finding high-quality sources, and writing the text to match the sources. Eubulides (talk) 07:06, 5 March 2008 (UTC)

Everything has been addressed, though not to your liking. All claims are supported by the references provided. Sources will be forthcoming, people work sometimes, Dr. Eubulides. The text and claims does match the sources, it seems you have an interest in keeping this information out of the article at any cost including by trying to discredit all sources as low quality when you know they more than meet inclusion criteria. I'm not quoting someone's personal blog, I'm providing governmental literature, at WORST. EBDCM (talk) 15:49, 5 March 2008 (UTC)

None of the problems mentioned in #Problems with proposed text have been addressed. These problems are independent of the quality problems with the sources in the revision to the last sentence (which is what this section has discussed). The quality problems remain, and need to be fixed. Sources to the other sentences have not been provided; that needs to be done as well. Eubulides (talk) 21:09, 5 March 2008 (UTC)

Eubulides (talk) 21:39, 29 February 2008 (UTC)

References for integrative medicine

PMID 18194787

PMID 17873667

PMID 17681267

PMID 17509435

PMID 16056057

PMID 17457065

PMID 16808144

PMID 16398590

PMID 12816630

That's just the beginning, Eubulides. Should be a lot of food for thought for you. Note how MDs and medical students are not well prepared for the specialization of musculoskeletal medicine. This, in part, explains your difficulty with your edits here; fish out of water perhaps? EBDCM (talk) 03:21, 7 March 2008 (UTC)

I took a quick look and yes, these are much better sources than what's in there now. A few of them are not relevant to integrative medicine though; for example, the study of musculoskeletal training did not discuss integrative medicine. Also, generally speaking it's better to rely on secondary sources, and these seem to be primary sources and not reviews. Are there any reviews of the area? Anyway, if you could write up a complete proposal of text with references, that would be a good next step. Eubulides (talk) 17:49, 7 March 2008 (UTC)

Revision to "safety"

The following subsection, #Safety 2, contains a proposed draft revision to Chiropractic #Safety. The initial version of this draft was taken from this version; the idea is to edit this into something that addresses the POV problems discussed in #Safety above, in a way that achieves consensus. Eubulides (talk) 22:20, 28 February 2008 (UTC)

Safety 2

Efficacy

Further information: Spinal adjustment § Safety, Spinal manipulation § Safety, and Scientific investigation of chiropractic § Safety

The safety of chiropractic has been increasingly studied in recent years as researchers investigate the merits of its effectiveness and risk-benefit balance.

The efficacy of spinal manipulation for the lower back has not been convincingly demonstrated. Nevertheless, there is supportive evidence, indicating some benefits for lower back pain treatment. Researchers in the scientific and medical community believe more studies are needed to properly evaluate its safety and efficacy. Chiropractors have frequently countered that cervical spinal manipulation was a safe and effective procedure compared to conventional medical approaches for mechanical neck pain syndromes.

A 1996 study concluded, "The efficacy of spinal manipulation for patients with acute or chronic low back pain has not been demonstrated with sound randomized clinical trials. There certainly are indications that manipulation might be effective in some subgroups of patients with low back pain. These impressions justify additional research efforts on this topic. Methodologic quality remains a critical aspect that should be dealt with in future studies."

A 2004 study concluded, "Our data synthesis suggests that recommendations can be made with some confidence regarding the use of SMT and/or MOB as a viable option for the treatment of both low back pain and NP. There have been few high-quality trials distinguishing between acute and chronic patients, and most are limited to shorter-term follow-up. Future trials should examine well-defined subgroups of patients, further address the value of SMT and MOB for acute patients, establish optimal number of treatment visits and consider the cost-effectiveness of care."

The 2005 published 'Current Concepts: Spinal Manipulation and Cervical Arterial Incidents' concludes in it's Executive Summary: "What does the evidence reveal about the effectiveness of cSMT? The evidence shows that chiropractic treatment is favorable for most conditions. Research shows a trial of spinal manipulation is advisable for patients with neck pain, neck-related upper extremity pain and headaches—as long as specific contraindications are absent. Treated conditions may include cervical sprain/strain injury, myofascial syndromes, discogenic pain, cervicogenic headache, pseudoradicular and radicular syndromes of the upper extremities."

A 2006 study concluded, "Differences in outcomes between medical and chiropractic care without physical therapy or modalities are not clinically meaningful, although chiropractic may result in a greater likelihood of perceived improvement, perhaps reflecting satisfaction or lack of blinding. Physical therapy may be more effective than medical care alone for some patients, while physical modalities appear to have no benefit in chiropractic care."

Safety

Spinal manipulation, the most common modality in chiropractic care. Spinal manipulation is associated with common but mild adverse effects as well as an unknown risk of serious complications. Most patients have no adverse effects from cervical manipulation, though the risk of stroke is not zero. Cervical spine manipulation (upper cervical specifically) has been a source of controversy. Spinal manipulation is a regulated medical intervention and can only be performed by chiropractors and a limited number of physical medicine professionals. Prior to the adminstration of spinal manipulative therapy, patients must be screened out for absolute contraindications and undergo a complete clinical exam including history, physical and at times additional specialized imaging and laboratory diagnostics. These include inflammatory arthritides, fractures, dislocations, instabilities, bone weakening disorders, tumours, infections, acute trauma as well as various circulatory and neurological disorders.

A 2005 World Health Organization report states that when "employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems." The report continued, "there are however, known risks and contraindications to manual and therapeutic protocols used in chiropractic practice," and, "Contraindications to spinal manipulative therapy range from a nonindication for such an intervention, where manipulation or mobilization may do no good, but should cause no harm, to an absolute contraindication... where manipulation or mobilization could be life‐threatening."

A 2007 study of 50,276 chiropractic manipulations of the cervical spine conducted by the Anglo-European College of Chiropractic in the UK turned up no reports of serious adverse effects; the study concluded that the risk of serious adverse effects was, at worst, 6 per 100,000 manipulations. The most common minor side effect was fainting, dizziness, and/or light-headedness, which occurred after, at worst, 16 in 1,000 treatments.

A 2007 study states, "In conclusion, spinal manipulation, particularly when performed on the upper spine, has repeatedly been associated with serious adverse events. Currently the incidence of such events is unknown. Adherence to informed consent, which currently seems less than rigorous, should therefore be mandatory to all therapists using this treatment. Considering that spinal manipulation is used mostly for self-limiting conditions and that its effectiveness is not well established, we should adopt a cautious attitude towards using it in routine health care."

Spinal adjustments on children carry a risk of injury. A 2007 review in Pediatrics concluded, "Spinal manipulation is common among children, and although serious adverse events have been identified, their true incidence remains unknown. Randomized, controlled trials will likely reveal common minor adverse events, and these events must be better reported. Prospective population-based studies are needed to identify the incidence of serious rare adverse events associated with spinal manipulation. Patient safety demands a greater collaboration between the medical community and other health care professionals, particularly chiropractors, such that we can investigate and report harms related to spinal manipulation together. In the interim, clinicians should query parents and children about CAM usage and caution families that although serious adverse events may be rare, a range of adverse events or delay in appropriate treatment may be associated with the use of spinal manipulation in children."

In 2008, the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, comprising a group of experts to evaluate neck pain and its associated disorder, released a manuscript of their findings with recommendations and guidelines, including associated risks and benefits. With respect to the association of VBA stroke and cervical manipulation the study concluded, "Vertebrobasilar artery stroke is a rare event in the population. There is an association between vertebrobasilar artery stroke and chiropractic visits in those under 45 years of age. There is also an association between vertebrobasilar artery stroke and use of primary care physician visits in all age groups. No evidence of excess risk of VBA stroke associated chiropractic care. The increased risks of vertebrobasilar artery stroke associated with chiropractic and physician visits is likely explained by patients with vertebrobasilar dissection-related neck pain and headache consulting both chiropractors and primary care physicians before their VBA stroke."

Risk-benefit

Researchers discuss whether the risk versus benefit of spinal manipulation is acceptable.

A 2001 study states, "Ultimately, the acceptable level of risk associated with a therapeutic intervention also must be balanced against evidence of therapeutic efficacy. Therefore, further research is indicated into both the benefits and harms associated with cervical spine manipulation. Practitioners of this technique should be called on to demonstrate the evidenced-based benefit of this procedure and to define the specific indications for which the benefits of intervention outweigh the risk."

A 2003 study concluded, "There is no evidence that spinal manipulative therapy is superior to other standard treatments for patients with acute or chronic low back pain."

A 2003 study concluded, "Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy."

A 2006 study states, "the risk-benefit balance does not favour SM over other treatment options such as physiotherapeutic exercise."

A 2007 study concluded, "Adverse events may be common, but are rarely severe in intensity. Most of the patients report recovery, particularly in the long term. Therefore, the benefits of chiropractic care for neck pain seem to outweigh the potential risks."

Spinal manipulation for the lower back appears to be relatively cost-effective.

Comments on safety 2

(Please place comments here.) Eubulides (talk) 22:20, 28 February 2008 (UTC)

• "Stephen Barrett of Quackwatch asserts that there is a risk of stroke associated with neck manipulation, and questions the validity of studies that find very low incidences for serious complications.[33]" This has no place in a NPOV article on Safety of SMT/Chiropractic. DigitalC (talk) 00:15, 29 February 2008 (UTC)

I agree. I have not yet had time to review the references (wow, there are tons of them!), but my initial impression is that there are way too many citations, too many of them are primary sources rather than reviews, too many of them are old, and there is no need to cite lower-quality sources like Quackwatch when higher-quality sources are available. One other thing: there's no need to mention the source's name and affiliation in the main text: this is supposed to be an article about chiropractic, not about chiropractic's critics and defenders. Eubulides (talk) 00:33, 29 February 2008 (UTC)

• "Spinal manipulation is a regulated medical intervention and can only be performed by chiropractors and a limited number of physical medicine professionals.[29][30] Prior to the adminstration of spinal manipulative therapy, patients must be screened out for absolute contraindications and undergo a complete clinical exam including history, physical and at times additional specialized imaging and laboratory diagnostics. These include inflammatory arthritides, fractures, dislocations, instabilities, bone weakening disorders, tumours, infections, acute trauma as well as various circulatory and neurological disorders" This paragraph should be moved to before the bone and joint task force paragraph. DigitalC (talk) 00:34, 29 February 2008 (UTC)

I would also like to see the two statements on contraindications put into one paragraph, rather than have them in two separate paragraphs. The one statement doesn't seem linked to the study which the paragraph seems to be about. DigitalC (talk) 00:38, 29 February 2008 (UTC)

Slowly going through it, working with the most contentious first. Is there a need for the Ernst quote? It is based on a commentary (opinion piece) article. DigitalC (talk) 01:15, 29 February 2008 (UTC)

Please review this edit. Thanks. QuackGuru (talk) 01:42, 29 February 2008 (UTC)

Wow, this proposal by quack guru is off the wall. He chides me on my talk page about being NPOV and proceeds to add references from Quackwatch and a mention of uber-chiropractic basher Stephen Barrett, Also, how many times are we going to use Ernst in this article? We all know where he stands, he has nothing new to say and his statements have come under disrepute from many physical medicine specialists. When you toss in the fact that the majority of GQs citations suck (sorry to be blunt) and this version is not an improvement over the current version I'll leave it at that. EBDCM (talk) 01:52, 29 February 2008 (UTC)

The children thing is not necessary; and you should know that there was a major reversal in the US re: chiropractic care for children (it had previously been "delisted"). The safety section now amounts nothing more to fear mongering my Eubulides and quack guru. How about we quote the 0.0000002% of serious injury just so the public truly knows the risks. This type of editing by these individuals is questionable at best and continues a trend of going against the consensus of many editors here. EBDCM (talk) 01:59, 29 February 2008 (UTC)

There is a serious safety issue for children. If you disagree, please provide the references. QuackGuru (talk) 02:04, 29 February 2008 (UTC)

The reference which you provided does not support that conclusion. If you are going to make a claim, YOU should provide the reference to back it up. DigitalC (talk) 02:23, 29 February 2008 (UTC)

You are still using a commentary (opinion piece) reference when better references are readily available. DigitalC (talk) 02:26, 29 February 2008 (UTC)

(<-- out-dent) I think the source is weak for the fear mongering notion that spinal manipulation of children. Quotes which make me think so include:

• Though researchers found only a handful of serious injuries among 13 published studies, they believe that there's still too little known about the safety of spinal manipulation in children.
  • So despite the lack of evidence that it is dangerous, the researchers are going to go ahead and say it is dangerous. Sounds pretty pseduoskeptical to me.
• Until more is learned, they suggest that parents be cautious about seeking this therapy for their children.
  • Same as above. This is classic fear-mongering.
• Only two were based on clinical trials that tested the effects of spinal manipulation on children; the rest were reports on individual cases of injuries.
  • IOW, this inconclusive review is based on pretty weak studies.
• A chiropractor performed the adjustments in most cases, though other health professionals -- including medical doctors, physical therapists and osteopaths -- sometimes offer the therapy.
  • We have seen this trick in other studies, where the "researchers" confuse (seemingly on purpose) the precision adjustments of chiropractors with those less skilled. (Were there kung-fu practitioners and Indian Barbers thrown into the mix in these "studies" as well?)

Finally, what I find most disheartening here is that despite chiropractic merely having a 0.0000002% hypothetical chance of serious risk, we dedicate so much of this article to the subject. While articles about health treatments with astronomically higher risks don't mention safety issues at all (i.e. See surgery... Iatrogenesis anyone?). My opinion is that this bogus section in Chiropractic needs to be severely shortened and state what WHO has said: According to the World Health Organization "employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems. Anything else is a matter of taking misguided research and hypothetical statistics and blowing them out of proportion. That the chiropractic adjustment has much of any serious risk associated with it is a true minority viewpoint and by giving this much of this article to the discussion of this subject is a clear violation of WP:WEIGHT. -- Levine2112 ^discuss 02:27, 29 February 2008 (UTC)

Everything is referenced. The scientific research and studies verify it is NPOV. QuackGuru (talk) 02:32, 29 February 2008 (UTC)

Weak reference. -- Levine2112 ^discuss 02:34, 29 February 2008 (UTC)

Furthermore, just because something is referenced, doesn't mean it is NPOV. DigitalC (talk) 02:37, 29 February 2008 (UTC)

You don't seem to get it QG, your references, well, they suck. Please review Sackett's levels of evidence if you don't get my drift. Also, I'm in complete agreement with Levine here. What a double standard being applied to the chiropractic article. Nothing like this appears in any medical article, including Eubulides personal baby, vaccination. I added contraindication there as a sign of good faith primarily for CynRN and now Eubulides and QG have taken the ball and ran with it and now it's nothing more than fear mongering. You argument has been thoroughly dismantled, quack guru, so please spare us with more of this nonsense unless you have some high quality research and not op-ed pieces. Thanks for your cooperation! EBDCM (talk) 02:39, 29 February 2008 (UTC)

There is no evidence of weak references. They are high quality references. Thanks for your comments. QuackGuru (talk) 02:57, 29 February 2008 (UTC)

A commentary article is not a high quality reference, and is indeed a weak reference when talking about safety. DigitalC (talk) 03:16, 29 February 2008 (UTC)

I can count 4 editors already here on this comments section that think your references are weak. Denial isn't just a river in Egypt, Quack Guru. Thanks for your efforts to improve the article. PS: Please do read Sackett's levels of evidence so you can better contribute to the article and save us a lot of time. EBDCM (talk) 03:20, 29 February 2008 (UTC)

Commentary articles are very high quality references. There is commentary from chiropractors. For example, Chiropractors have frequently countered that cervical spinal manipulation was a safe and effective procedure compared to conventional medical approaches for mechanical neck pain syndromes. This is in the Safety and is commentary. QuackGuru (talk) 03:30, 29 February 2008 (UTC)

CONCLUSIONS: Serious adverse events may be associated with pediatric spinal manipulation; neither causation nor incidence rates can be inferred from observational data. Conduct of a prospective population-based active surveillance study is required to properly assess the possibility of rare, yet serious, adverse events as a result of spinal manipulation on pediatric patients. QuackGuru (talk) 03:30, 29 February 2008 (UTC)

Commentary article are very LOW quality references. As EBDCM suggested, perhaps you should look at Sackett's level of evidence. Why you then linked the conclusions of a systematic review (not a commentary article) that is already in the draft, I don't know. DigitalC (talk) 03:43, 29 February 2008 (UTC)

Undent. No they are not. I'm familiar with this article, Humphreys is an author. I can easily find tons of references in favour of SMT for children that would cancel out your claim easily. The commentary you described above is a from a review of the literature which suggested that the relative risk of complications of SMT for neck pain, relative to common medical procedures shows that it IS AS or MORE effective than conventional approach. It's not a commentary it's a statement of fact. Another red herring from Quack Guru. You are also using an appeal to fear fallacy as well. EBDCM (talk) 03:44, 29 February 2008 (UTC)

More comments on safety 2

I propose a strikeout of "Spinal adjustments on children carry a risk of injury.[38] Researchers suggest that spinal manipulation is associated with common but mild adverse effects as well as an unknown risk of serious complications." because it is already covered with "there are however, known risks and contraindications to manual and therapeutic protocols used in chiropractic practice" Comments? DigitalC (talk) 06:00, 29 February 2008 (UTC)

Agreed. It would be easier to bring the current edit here and dissect rather than going the QGs proposal which is riddled with holes, WEIGHT issues, NPOV issues, poor citations and fallacies. I also like your idea of combining the contraindications in 1 paragraph rather than 2 before the Task force study so feel free to edit that on the main page. Good job. EBDCM (talk) 06:04, 29 February 2008 (UTC)

Actually, instead of striking that out, maybe we can work it into "Critics have suggested that spinal manipulation is of limited benefit and a risk factor for vertebral basilar stroke." and look into removing the WP:WEASEL word "critic" at the same time (have to look at the sources and see who suggested it). Something along the lines of "WEASEL-removed have suggested that spinal manipulation is a risk factor for vertebral basilar stroke and may carry a risk of injury in children" ??. DigitalC (talk) 06:18, 29 February 2008 (UTC)

Metacomments on safety 2

Obviously there are several disagreements here. In rereading the draft and the above comments, I have some thoughts that are not about POV directly but which I hope can help towards resolving the dispute.

• This section is titled Safety, but the draft and many of the comments have also talked about efficacy and cost-effectiveness. Shouldn't those issues be spun off into different sections? That is, shouldn't this section focus on safety? Or at least limit itself to safety and the risk-benefit ratio (with a previous section talking about efficacy)?

• The section talks only about safety of spinal manipulation. What about the other treatments used in chiropractic?

• Professions other than chiropractors do spinal manipulation. How should this be addressed?

Let's look at this in context shall we. First, DCs were historically ridiculed, jailed, called pseudoscientfic for using SMT and now suddenly SMT is en vogue, PTs are chomping at the bit to manipulate and other professions are claiming to provide adequate manipulative therapy. Hello? 1) This article is about chiropractic and chiropractors and chirorpractic manipulation (i.e. done by a chiropractor or a technique invented by a DC) and that's all the needs to be said. EBDCM (talk) 01:34, 4 March 2008 (UTC)

I agree that Chiropractic #Safety should focus on chiropractic safety. The only question is how to address the issue that other professions also do spinal manipulation. Given the other discussion below, perhaps it's best deferred to a later section that compares chiropractic cost-benefit to that of other professions, which would mean Chiropractic #Safety could ignore the issue. Eubulides (talk) 06:48, 4 March 2008 (UTC)

• It seems that much of the disagreement stems over what the best sources are to use. I looked over all the sources mentioned above, and there are many weak ones. How about if we try to come up with a short list of the best sources of chiropractic safety? By "best" I mean the usual standards: published in refereed journals or in textbooks with equivalent editorial standards; secondary sources preferred; recent sources preferred. Ideally we could come up with a short (five to ten references) list that could be use to support a revised version.

WP:UNDUE WEIGHT for this section now, as Levine2112 mentioned; how many studies will have to be done to demonstrate that SMT is safe? Clearly Ernst et al. will NEVER stop writing anti-chirorpractic and manipulation articles and will we always give him mention? The guy is losing credibility fast with his witch-hunt and is beginning to look more and more stupid as the evidence in favour of the safety of SMT adds up. He has already been severely rebutted before for this less than forthright "review" of SMT and of chiropractors. In short, his yearly anti-chiropractic op-ed pieces are becoming increasingly boring and he really has nothing new to say and is losing credibility with his continued pursuit of trying to discredit DCs and SMT. EBDCM (talk) 01:34, 4 March 2008 (UTC)

This topic of Ernst et al. is addressed under #Comments on sources for safety and risk-benefit below. Eubulides (talk) 06:51, 4 March 2008 (UTC)

Sources for safety

For starters, I thought I'd try to mention four five six of the stronger sources on spinal manipulation safety. Comments? Are there some even-stronger sources I missed?

Secondary sources on safety

These sources are high-quality reviews or other secondary sources), which are preferred (see WP:MEDRS).

• World Health Organization (2005). "WHO guidelines on basic training and safety in chiropractic" (PDF). Retrieved 2008-02-29. {{cite journal}}: Cite journal requires |journal= (help)

• The following clinical practice guideline is also available. It focuses on adult neck pain not due to whiplash. Anderson-Peacock E, Blouin JS, Bryans R; et al. (2005). "Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash" (PDF). J Can Chiropr Assoc. 49 (3): 158–209. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) Anderson-Peacock E, Bryans B, Descarreaux M; et al. (2008). "A clinical practice guideline update from The CCA•CFCREAB-CPG" (PDF). J Can Chiropr Assoc. 52 (1): 7–8. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)

• Triano J (2005). "The theoretical basis for spinal manipulation". In Haldeman S, Dagenais S, Budgell B et al. (eds.) (ed.). Principles and Practice of Chiropractic (3rd ed. ed.). McGraw-Hill. pp. 361–82. ISBN 0-07-137534-1. {{cite book}}: |edition= has extra text (help); |editor= has generic name (help)CS1 maint: multiple names: editors list (link)

• A more extensive and up-to-date version of this material should be in the following source (we don't have online access to it): Triano JJ, Kawchuck G, Gudavalli MR, Terrett AGJ (2006). Current Concepts: Spinal Manipulation and Cervical Arterial Incidents. Clive, IA: NCMIC. ISBN 1892734141. OCLC 63161672.{{cite book}}: CS1 maint: multiple names: authors list (link)

• Ernst E (2007). "Adverse effects of spinal manipulation: a systematic review". J R Soc Med. 100 (7): 330–8. PMID 17606755. (Note the followup critical comments and author's reply in the PMID.)

• Haldeman S, Carroll L, Cassidy JD, Schubert J, Nygren Å (2008). "The Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders: executive summary". Spine. 33 (4 Suppl): S5–7. doi:10.1097/BRS.0b013e3181643f40. PMID 18204400.{{cite journal}}: CS1 maint: multiple names: authors list (link) This is an executive summary (which contains a brief section on safety) of a series of studies and reviews.

• Hurwitz EL, Carragee EJ, van der Velde G (2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders". Spine. 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386.{{cite journal}}: CS1 maint: multiple names: authors list (link) This is a review of interventions, which contains a section on safety. It is briefly summarized in the executive summary noted above.

• Vohra S, Johnston BC, Cramer K, Humphreys K (2007). "Adverse events associated with pediatric spinal manipulation: a systematic review". Pediatrics. 119 (1): e275–83. doi:10.1542/peds.2006-1392. PMID 17178922.{{cite journal}}: CS1 maint: multiple names: authors list (link) (Note the followup critical comments and author reply in the PMID.)

• Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM (2008). "Does cervical manipulative therapy cause vertebral artery dissection and stroke?". Neurologist. 14 (1): 66–73. doi:10.1097/NRL.0b013e318164e53d. PMID 18195663.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• DeVocht JW (2006). "History and overview of theories and methods of chiropractic: a counterpoint". Clin Orthop Relat Res. 444: 243–9. doi:10.1097/01.blo.0000203460.89887.8d. PMID 16523145. This is a more-general review that provides context for safety concerns.

New primary sources on safety

These are primary studies, not reviews, so normally they'd be avoided. However, they are so recent that no reviews cover them, and they are high-enough quality that a case can be made for them.

• Thiel HW, Bolton JE, Docherty S, Portlock JC (2007). "Safety of chiropractic manipulation of the cervical spine: a prospective national survey". Spine. 32 (21): 2375–8. PMID 17906581.{{cite journal}}: CS1 maint: multiple names: authors list (link) It is high quality (a prospective study of 19,722 patients) and contains notable results.

Sources on safety covered by the above reviews

These are primary studies covered by the above reviews, and so probably do not need to be referred to directly by the article, as citing the reviews should suffice.

• PMID 18204390
• PMID 18204389
• PMID 14589464
• PMID 11805635
• PMID 18204397

Sources on safety of some other treatment form

These sources are not about chiropractic safety; they are about safety of some other form of treatment. They may be helpful in a later section that compares treatments' costs and benefits.

• PMID 18204388

Eubulides (talk) 11:13, 29 February 2008 (UTC)

Sources for risk-benefit

Here is a source that is high-quality, but is not as good for Chiropractic #Safety. It's only a primary study, and it's smaller than the Thiel study, and it's primarily a risk-benefit analysis rather than a safety study. It is probably more useful for a risk-benefit section (which would be some new section other than safety):

• Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW (2007). "The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study". J Manipulative Physiol Ther. 30 (6): 408–18. doi:10.1016/j.jmpt.2007.04.013. PMID 17693331.{{cite journal}}: CS1 maint: multiple names: authors list (link)

Eubulides (talk) 08:18, 1 March 2008 (UTC)

Comments on sources for safety and risk-benefit

Why not:

Or the UCSF, Smith, 2003 study indicating that manipulation is an independent risk factor? Or Reuter, et al, 2005, or Refshauge, et al, 2002.CynRNCynRN (talk) 19:01, 29 February 2008 (UTC)

• Rothwell et al. 2001 (PMID 11340209) is a high-quality study, but it's a primary study. WP:MEDRS suggests the article should prefer secondary sources when they are available, which is true here.
• Likewise for Smith et al. 2003 (PMID 12743225).
• Likewise for Reuter et al. 2006 (PMID 16511634).
• By "Refshauge, et al, 2002" do you mean Pengel et al. 2002 (PMID 12501942)? It lists Refshauge as a coauthor. That is a systematic review, which is much better, but (a) it's a bit dated and more important (b) it's about efficacy, not safety.

Eubulides (talk) 22:33, 29 February 2008 (UTC)

Again, these sources say that the risk is so minuscule that the amount of space we are dedicating to this hypothetical 0.0000002% chance of risk clearly violates WP:UNDUE. At most, mention of the possibility serious risk in the article deserves one sentence (if that). -- Levine2112 ^discuss 19:07, 29 February 2008 (UTC)

I agree that the risk is very small, but it's not zero. The refs say that the full extent of risk is unknown. Rendering the numbers into decimals make any risk look infinitesimal. However, I don't know if the safety section needs to be more than a few sentences. It should summarize the various study's conclusions.CynRNCynRN (talk) 19:50, 29 February 2008 (UTC)

I agree that safety issues need to be discussed. However, I disagree that one sentence is an appropriate length. I just now checked Google Scholar, which estimated 60,000 articles mentioning "chiropractic", and 7,540 mentioning both "chiropractic" and "safety". Obviously this is a very rough measure, but it indicates that safety is a legitimate subtopic of concern with respect to chiropractic, and that one sentence is not nearly enough to do it justice. Eubulides (talk) 22:46, 29 February 2008 (UTC)

Me thinks this children's study is significant. It seems the risk for children is higher than adults. QuackGuru (talk) 22:51, 29 February 2008 (UTC)

Yes, thanks, that's a recent high-quality review. I added that to the list. Eubulides (talk) 23:22, 29 February 2008 (UTC)

No, that's a wildly inconclusive study which amounts to saying nothing. And Google searches are a pretty weak way to make such assessments. I have been learning this recently. For all we know, 99% of the articles mentioning chiropractic and safety are there to tell us that chiropractic is safe. Or maybe "chiropractic" in mentioned on the page but with no context to the word "safety". And , CynRN, rendering the numbers into decimals only makes the risk look infinitesimal because the risks are infinitesimal. I didn't make up that percentage. That is derived from the hypothetical risk calculation based on inconclusive experiments marred by purposeful deception seemingly motivating to be a scare tactic employed by allied competition. See Terrett's study: "Vertebrobasilar stroke following manipulation." where Terrett observed that "manipulations" administered by a Kung Fu practitioner, GPs, osteopaths, physiotherapists, a wife, a blind masseur, and an Indian barber were incorrectly attributed to chiropractors. As Terrett wrote, "The words chiropractic and chiropractor have been incorrectly used in numerous publications dealing with SMT injury by medical authors, respected medical journals and medical organizations. In many cases, this is not accidental; the authors had access to original reports that identified the practitioner involved as a non-chiropractor. The true incidence of such reporting cannot be determined. Such reporting adversely affects the reader's opinion of chiropractic and chiropractors." -- Levine2112 ^discuss 23:31, 29 February 2008 (UTC)

• It's OK to use reliable sources even if they draw limited conclusions, as long as Chiropractic reports those conclusions accurately.
• I agree that the Google Scholar search figures are approximate. However, they do suggest a real concern.
• Given the level of controversy and uncertainty in this area, I doubt whether any neutral summary could report just one numeric estimate and leave it at that. More likely it will give a range, or multiple estimates by different sources, or say that reliable estimates are unavailable, or something like that. That's OK. That's how reliable reviews work.

Eubulides (talk) 00:39, 1 March 2008 (UTC)

It must be Sunday again since Eubulides (aka God, the prophet Muhammed) is telling his disciples what to do again like we're morons. First you're all "we need secondary sources" and as soon as he discovers an article that sides with his POV that SMT is unsafe it's suddenly ok to use review pieces. What a joke. Do us a favour and stop patronizing us, stop telling us what's good and not, stop playing politics here and be a little more forthright and hiding behind your INTERPRETATION of various wikipedia policies. EBDCM (talk) 01:40, 4 March 2008 (UTC)

There must be some confusion here. First, reviews are secondary sources; please see WP:MEDRS #Some definitions and basics. Second, I don't understand the comments about politics and forthrightness, but please be assured that I am attempting to improve Chiropractic as best I can. Eubulides (talk) 07:22, 4 March 2008 (UTC)

Thanks for your comments. Nevertheless, we are going to follow the references where thay take us. QuackGuru (talk) 23:38, 29 February 2008 (UTC)

Have you actually read the study? It is impossible to infer that the risk of SMT is higher in children than in adults, as the study does not report on incidence! DigitalC (talk) 23:48, 29 February 2008 (UTC)

Yes, I have read the study. QuackGuru (talk) 01:03, 1 March 2008 (UTC)

[19] "A number of risk factors may predispose a child to an adverse event as a result of spinal manipulative procedures, including immaturity of the spine, rotational manipulation of the cervical spine, and high-velocity spinal manipulations.44–47 We found that all 9 serious adverse events (eg, death resulting from subarachnoid hemorrhage, paraplegia, etc) occurred in children under 13 years of age.30,32,34 In a case series, Ragoet32 presented 3 cases of dislocated atlas as a result of pediatric spinal manipulation. Evidence suggests that there is a strong correlation between severity of injury to the spinal cord and the immaturity of the spine44 and that the atlas (cervical vertebra 1 (C1) and dens of the axis (C2) of children are more vulnerable to trauma than those of adults.45 Although 5 of our serious adverse-event reports did not specify the type of spinal manipulation used, 2 of the 4 that reported serious adverse events specified that the practitioner used rapid and/or strong rotational maneuvers.27,31 The majority of complications attributed to spinal manipulative therapy have occurred as a result of rotational manipulation of the cervical spine.46 In addition, high-velocity manipulations of the spine have the potential for serious complications resulting from diagnostic error/inadequate patient assessment.47 Although the authors did not clearly specify the type of spinal manipulation provided, 2 of the severe adverse-event reports identified underlying risk factors (spinal cord astrocytoma, congenital occipitalization) that may have predisposed the child to the subsequent serious adverse event (ie, quadriplegia, unsteady gait).29,34 An error in the diagnosis of any number of preexisting conditions such as arteritis, arthritic and cardiac conditions, clotting abnormalities, meningitis, or vertebrobasilar insufficiency may predispose children to neurologic and/or vertebrobasilar complications.45,48–50" I have read the facts. QuackGuru (talk) 23:59, 29 February 2008 (UTC)

At this point I'm not yet ready to discuss the contents of the reliable sources. I'm just trying to come up with a short list of reliable sources. Eubulides (talk) 00:39, 1 March 2008 (UTC)

This UK study is reliable and may be significant too. Thoughts. QuackGuru (talk) 01:25, 1 March 2008 (UTC)

It's less good, since it's a primary study, but there are reasonable arguments for including it despite that problem, so I added it to the list. Thanks. Does anyone have other suggestions for other sources, of this quality or better? Eubulides (talk) 07:13, 1 March 2008 (UTC)

From the pediatrics study above, and why it does not support the statement that SMT risk is higher in children than in adults: "Although our search strategy was more comprehensive, we did not feel comfortable creating risk estimates with an uncertain denominator." Without a risk estimate, it CANNOT be compared to the risk of SMT in adults. As with before, this is an acceptable source to say that "there SMT may carry a risk of injury to children". As such, this really isn't a valuable source as it does not contribute much to the section. DigitalC (talk) 07:29, 1 March 2008 (UTC)

I'm not quite ready to discuss technical details; I'm still just trying to identify the best sources. I disagree, however, that Vohra et al. 2007 provides little of value. It is sometimes valuable to point out, as they do, how little is known about an area. Eubulides (talk) 08:29, 1 March 2008 (UTC)

I also suggest using this reference. DigitalC (talk) 08:04, 1 March 2008 (UTC)

Thanks, that one looks more apropos for a (not-yet-written) risk-benefit section. I created a new subsection #Sources for risk-benefit for it; we can add other citations to that section as needed. The source does have some safety data and that might be useful for the safety section, I suppose; but it's not as good for that purpose. Eubulides (talk) 08:18, 1 March 2008 (UTC)

It seems like risk/benefit is all tied up together. If massage works as well as manipulation, why take any risk? Why are physical therapists becoming hesitant to do manipulations, or at least, recommending consent and caution? 'Causes of complications from cervical manipulation', Mann and Refshauge, 2001,CynRNCynRN (talk) 08:31, 1 March 2008 (UTC)

Yes, in the end they're all tied up together. We probably need 3 sections (or at least 3 paragraphs), one for safety (risk), one for efficacy (benefit), and one for risk-benefit. For now I'd like to start with safety, though (primarily because there's an existing section called "Safety"). Safety first, and all that.… Eubulides (talk) 08:42, 1 March 2008 (UTC)

What about citing textbooks on manual tx and chiropractic about safety, as references?CynRNCynRN (talk) 09:16, 1 March 2008 (UTC)

Depends on the textbook and the publisher. Some are quite good. The current list has one source from a textbook, namely Triano 2005. WP:MEDRS has a bit more on textbooks and sources. Eubulides (talk) 09:21, 1 March 2008 (UTC)

If someone has access to a copy (EBDCM?) I suggest the following book as a source. I do not think it is available online. "Current concepts in spinal manipulation and cervical arterial incidents" by Triano and Kawchuk. DigitalC (talk) 11:17, 1 March 2008 (UTC)

Thanks. That source is a little hard-to-find, and sounds like it would mostly just expand on the existing Triano source, but I added it since it should be more extensive and it was published a year later. Eubulides (talk) 19:22, 1 March 2008 (UTC)

It is extensive. There are over 700 references used in it. DigitalC (talk) 10:25, 2 March 2008 (UTC)

I'm sure this has been mentioned before, but CCGPC CCGPC -other-version DigitalC (talk) 11:56, 2 March 2008 (UTC)

That's limited to adult non-whiplash neck pain, which is a bit of a subset; also, it's a clinical practice guideline rather than being a study or review of safety. It's got relevant info, but is it up to the standard of the other references, which attempt to be directly on point? Let's put it another way: does it say something about safety that the WHO report doesn't? Eubulides (talk) 04:53, 3 March 2008 (UTC)

Eubulides, let's put it this way: the most comprehensive, evidence-based literature synthesis and review on ALL aspects of chiropractic treatment is done by the ccgpp. We will use those sources, it's done in 2007-2008. And, for the record, oh great one, if you even bothered to read the Canadian guidelines safety was well mentioned in there for neck manipulation which is really the only real source of controversy. Thanks for coming out! EBDCM (talk) 01:43, 4 March 2008 (UTC)

If the CCGPP work is higher-quality than the WHO's, then we should prefer it to the WHO's. That would be fine with me. Although neck manipulation is the only a real source of controversy over safety, I disagree that neck manipulation is the only real source of controversy; Ernst 2007 also cites adverse effects from chiropractic manipulation of the thoracic and lumbar spine. Eubulides (talk) 07:38, 4 March 2008 (UTC)

No further comment, so I added that guideline to the list of sources. It's not clear to me that both the WHO and CCA•CFCREAB-CPG guidelines will be needed, but it can't hurt to list both for now. Eubulides (talk) 21:47, 4 March 2008 (UTC)

Another example of Eubulides bulldozing his way through here. Thanks for waiting all of 4 hours for replies. Consensus moves fast with you, eh? Your previous comment does not make sense: though neck manipulation is the only real source of controversy over safety, I disagree that neck manipulation is the only real source of controversy; Ernst 2007 also cites adverse effects from chiropractic manipulation of the thoracic and lumbar spine.

Do you object to including the ccgpp sources? Previously you favored it. Sorry about the confusing typo about neck manipulation; I fixed it. Eubulides (talk) 07:19, 5 March 2008 (UTC)

My question is simple: If you state that neck SMT is the only real controversy in SAFETY why include other controversies in the safety section? Another example of your less than forthright editing here. Another example: Having 12 lines dedicated to the adverse effects of SMT (UNDUE WEIGHT) and 2 sources from Ernst (UNDUE WEIGHT) and a rather poor tone of the section via your choppy writing style and your creepingly negative bias and lack of understanding of the issues in chiropractic care and chiropractors. I wish you would work with me, as an evidence-based practitioner, who shares many of the same criticisms and skeptical attitudes towards dubious practices habits both within chiropractic and all health care. I am extending you an olive branch and I hope you take it :) EBDCM (talk) 03:58, 5 March 2008 (UTC)

It was a typo; sorry. I disagree that neck SMT is the only real controversy. Sorry about the typo. Like it or not, Ernst has 3 of the top 10 citations in Google Scholar on the query "chiropractic safety"; it's hardly undue weight to cite Ernst twice on the subject, when none of the other citations crack the top 10. Eubulides (talk) 07:19, 5 March 2008 (UTC)

[Re PMID 17178922]:

Here is a rebuttal of this study and outlines many flaws in it: http://www.fcer.org/html/News/pediatrics107.htm EBDCM (talk) 01:12, 3 March 2008 (UTC)

PMID 17178922 contains pointers to rebuttals that address points mentioned in that press release (other than its touting of the effectiveness of spinal manipulation to treat ear infections, which is irrelevant to safety). We can rely on those rebuttals rather than on that press release. Eubulides (talk) 07:26, 3 March 2008 (UTC)

God, I mean, Eubulides, are you ever wrong? I mean, why bother having other editors here when you can a) find all the relevant literature, b)review all the relevant literature c) synthesize and come up with appropriate conclusions of the literature and d) make an edit here using said literature. Gimme a break. Many, many editors here have disagreed with you yet you keep pushing through ignoring their points or concerns. The double standard applies here too; effectiveness has not been established for 85% of medical interventions yet we need a massive section here on chiropractic, eh? What BS. I'm with Levine2112 on this one, more double standards and fear mongering supported by Eubulides and Quack Guru. 208.101.89.150 (talk) 17:02, 3 March 2008 (UTC)

I often make mistakes; for example, I missed some high quality sources, which other editors suggested later (thanks, by the way), and which I added to the list. However, a press release is not a high-quality source. When higher-quality sources are available, as is the case here, we should prefer them. As for your other point: effectiveness is an important topic, and should be addressed, but I'd rather address Chiropractic #Safety's problems first. Eubulides (talk) 17:50, 3 March 2008 (UTC)

We are going to stick with the reliable sources and NOT the chiropractic advocacy press release reference. QuackGuru (talk) 07:43, 3 March 2008 (UTC)

This coming from a guy who brings quackwatch and stephen barrett articles to the table. Nice. Regardless, Rosner a PhD, has waaaaaaaaaaay more research background that barrett and his "press releases" are used here. Sorry, same standards apply; this goes both ways, unless, of course, we take out every single press release from chirobase, quackwatch and stephen barrett. 208.101.89.150 (talk) 17:02, 3 March 2008 (UTC)

The French Society of Orthopedic and Osteopathic Manual Medicine has a paper, well referenced, concluding with 5 cautions regarding cervical thrust manipulations, inluding: "No cervical thrust in rotation in females less than 50 years. No cervical thrust in rotation in males less than 50 years at the first visit (but allowed at the 2nd visit if the first treatment was not efficient). Instead of rotational thrust, it is highly recommended to use mobilisations, MET (muscle energy techniques), soft tissue cervical techniques and upper thoracic spine thrust manipulations (which certainly act on the cervico thoracic muscles)." I think it is worth mentioning that several physiotherapy and osteopathic associations are studying the issue.CynRNCynRN (talk) 00:16, 4 March 2008 (UTC)

What is the reliable source for "several physiotherapy and osteopathic associations are studying the issue"? I'm asking because I'm wondering whether it is that big a deal. All other things being equal, I'd prefer to simply report the results that are in; it's not that useful to say "further studies are underway". (Further studies are always underway.…) Eubulides (talk) 07:09, 4 March 2008 (UTC)

I mispoke. PTs have been studying this issue for a decade or so.

ref>http://www.accessmylibrary.com/coms2/summary_0286-12484328_ITM</ref> CynRNCynRN (talk) 08:14, 4 March 2008 (UTC) And Grieve's Modern Manual Tx talks about Grimmer in Australia, Michaeli in South Africa and Rivett in New Zealand with data on cervical manip. pgs 257 on, Google books. CynRNCynRN (talk) 08:26, 4 March 2008 (UTC)

That comment has a few formatting problems, but what appears to be the first source mentions only one chiropractic case, one I imagine our existing sources address. What appears to be the second source does not mention chiropractic. The third source, Grieve's (ISBN 0443071551, OCLC 56659290) looks like it's high quality but (alas) the online version is so redacted that it's hard for me to follow. Eubulides (talk) 09:24, 4 March 2008 (UTC)

I was trying to make the point that PTs, who are licensed to do cervical manipulation, have taken a very cautious approach to it. I guess it's not a point we need to go into here in this article. Yes, too bad the Grieve's ref. is so limited.CynRN17:33, 4 March 2008 (UTC) —Preceding unsigned comment added by CynRN (talk • contribs)

If I took weekend courses and learned how to adjust necks, I'd be cautious too. A PT who practices "orthopedic manual physica therapy" is really practicing chiropractic at its core. EBDCM (talk) 00:26, 5 March 2008 (UTC)

French osteopaths and PTs are not chiropractors and their manipulations are not chiropractic manipulations. More fear mongering. 0.0000002%. Let's put this in. Also, why is everyone here ducking the fact that there's a double standard here; no other med article or profession has such a section on safety or efficacy. Since we have begun the slippery slope I vote we kill this section entirely until there is a fair balance occuring at other articles. Eubulides can start and go back to his vaccination article and start there FIRST before attempting to force upon us his interpretation of the events, ditto for CynRN who does not seem to understand the conclusions of the Neck Pain Task Force and resorts to comparing physio and osteo manipulations and trying to pidgeon toe chiropractic with it. EBDCM (talk) 01:26, 4 March 2008 (UTC)

• I agree that the FSOOMM source is of lower quality than the ones we already have. It's less on point, and I don't think it adds much.
• It's not true that no other medical article has a section on safety. For example, Ozone therapy has a long section "Studies of the toxicity and side effects of blood ozonation". Gene therapy has a long section "Problems and ethics" that covers safety issues and mentions deaths that have occurred with gene therapy. Phage therapy has a "Safety" section. Megavitamin therapy has a long "Criticisms and side effects" section. There are many other examples.

Ozone therapy? Are you kidding me? Lol! Get back to me when we are talking about the same thing, not apples and oranges. What an intellectually dishonest comment. EBDCM (talk) 00:26, 5 March 2008 (UTC)

Who said ozone therapy is the same as chiropractic? It's a completely different form of therapy. It has safety issues, just as chiropractic does. Gene therapy is similar: it's quite different from chiropractic, but it also has safety issues. Similarly for phage therapy and megavitamin therapy. Safety issues are important and relevant for nearly every kind of therapy, chiropractic included. Eubulides (talk) 00:32, 5 March 2008 (UTC)

• Vaccine safety is a topic best raised in Talk:Vaccine and Talk:Vaccination; unless I'm missing something (in which case an explanation would be helpful), it's not that relevant here.
• It is not realistic to remove all discussion of safety from Chiropractic. As mentioned in #Comments on sources for safety and risk-benefit, more than 10% of articles in Google Scholar that mention chiropractic also mention safety. This is just a rough measure, but it indicates that safety is a valid and important subtopic of chiropractic.

Eubulides (talk) 07:09, 4 March 2008 (UTC)

Who cares what google scholar says? Is that your research? That mainstream medicine still doubts SMT its efficacy? That's why there's so many bloody articles its yet another attempt to discredit the chiropractic profession. Don't lecture me about Ernst, he is without credibility anymore and has been rebutted severely in JMPT for his less than thorough review of SMT. EBDCM (talk) 00:26, 5 March 2008 (UTC)

Google Scholar is just a rough measure, but it is better than nothing, and it is an indication of the importance of safety. For example, Google Scholar also indicates that safety is an important issue in surgery (a point made below). Of course, one hardly needs Google Scholar to prove that for surgery; still, it does make the point that the rough measure has some validity. Eubulides (talk) 00:36, 5 March 2008 (UTC)

Actually no, it's a weasel technique and you're using it here on chiropractic. EBDCM (talk) 00:49, 5 March 2008 (UTC)

Feel free to propose a more-reliable technique. In the meantime the Google Scholar query results remains as evidence that safety is a valid topic within chiropractic. Eubulides (talk) 07:19, 5 March 2008 (UTC)

I understand your frustration, EBDCM, about having a 'safety' section. I realize the risk is very small. The thing is, when a person decides to have surgery, it's a last resort option and the risks are well-known, in general. (I did find risk of death discussed in Wikipedia Gastric Bypass.) It seems that a great deal of attention is given to risk of cervical manipulation by conventional medical researchers in the past few years, so maybe countering this or explaining the chiropractic viewpoint in the article is worthwhile?CynRNCynRN (talk) 17:53, 4 March 2008 (UTC)

I will work with CynRN on this one; but suggesting that surgery as a last resort? Yeah right. How many unnecessary back surgeries per year? What about carpal tunnel releases? These are both wayyyyy move amenable to soft tissue and joint manipulation I don't see most MDs recommending manual therapy for this stuff. Again, the most comprehensive, in depth review we've had so far re: neck manips is the Task Force report. It's co-authored by MDs and many various researchers and top-notch universities and notable health organizations. Yet it still gets dismissed summarily by most of allopathic practitioners. EBDCM (talk) 00:26, 5 March 2008 (UTC)

Surgery is not directly related to spinal manipulation. Non-surgical therapies, such as massage is related. By the way, surgery is not always the last resort. Doctors have routinely performed unnecessary surgury to get the insurance money. Doctors do not always inform the patients about the risk of surgury. Moreover, they do not tell the patient to get a second opinion. However, if reliable sources make a direct comparison we can consider using it in this article. QuackGuru (talk) 21:17, 4 March 2008 (UTC)

The point isn't that surgery is realted to manipulation. The point is that it is a violation of WP:UNDUE to mention safety in the chiropractic article. Especially, when looking at other medical articles it is not mentioned. Eubulides, you mention that 10% of chiropractic articles on google scholar mention safety. A comparable search reveals that 13% of surgery articles on google scholar mention safety, yet again it is not listed on the surgery article. As for the risks being well known, the last (minor) surgery that I had, I had to sign a consent form that I had discussed the risks with the attending and resident. However, I had to sign this before I even got to see the attending and the resident. I don't think that risks are well-known in general. 121.44.227.79 (talk) 00:06, 5 March 2008 (UTC)

I fully support adding a safety section to Surgery. That article lacks a safety section now, which greatly weakens it, and helps to explain why Surgery is rated only at the Start-Class (i.e., just barely above stub quality) on the Wikipedia:WikiProject Medicine/Assessment #Quality scale. If you have the time and inclination to do so, please improve Surgery. In the meantime, Surgery's shortcomings should not distract from the topic at hand, which is the POV issue with Chiropractic #Safety. Clearly safety is an important subtopic of chiropractic, just as it is an important subtopic of surgery, and Chiropractic should cover it. Eubulides (talk) 00:29, 5 March 2008 (UTC)

Finally someone calls a spade a spade. Eubulides parades around here with his medical hat lecturing evidence-based DCs about the profession through his warped lens. I've already said that there is a massive double standard going on here and Eubulides never addresses this point. He also fails to address the fact that I have asked him to "man up" and including the reference I provided regarding medical safety. Hush hush, it's so quiet now I hear crickets chirping in the background. So, I'll ask Eubulides again: as a sign of good faith collaboration, will you include the references I provided you and address the safety issue (or lack thereof) in the medicine article? If not, then why? Also, why not apply the same standard to the vaccination article? I'm just trying to follow your logic. EBDCM (talk) 00:26, 5 March 2008 (UTC)

As I mentioned, proposed changes to other articles are best discussed on the other articles' talk pages. Please take up those discussions there. I fully support adding safety sections to other medical articles where appropriate. However, right now the topic is Chiropractic. Eubulides (talk) 00:40, 5 March 2008 (UTC)

No, Eubulides, I want you to address my concerns NOW and stop ducking them. You recent safety 3 proposal is possibly the worst fear mongering I've ever seen and I'm no longer inclined to give you any more benefit of the doubt. Your qualifier where appropriate is BS. Your response telling me that ozone therapy also has a safety section is a low point in our discussions. You think I'm retarded or something? Because I'm a DC I can't seem through a weak argument and weak logic. You have shown nothing but contempt for DCs so far in your talk discussions and you keep ducking my questions. Why should the chiropractic article even mention safety when medicine and surgery does not? Which risk is greater, surgery for mechanical neck pain or SMT for mechanical neck pain? Please think carefully before you reply. Thanks. EBDCM (talk) 00:49, 5 March 2008 (UTC)

A safety section is appropriate for any medical treatment that can cause serious injury or death. That certainly includes Surgery. It also includes Chiropractic. A safety section is not necessary for all treatments. I wrote "appropriate" only because a safety section is not needed for something like Homeopathy (though I just now checked and saw that Homeopathy has a lengthy safety section!). I chose ozone therapy only because it came up in the first page on the Google search, right next to gene therapy, chelation therapy, etc. I know little about ozone therapy, don't know whether it's safe or not, and don't know why mentioning it would be a low point. Again, the shortcomings of Surgery are not a good argument that Chiropractic should also have shortcomings; we should be striving for a high-quality article, and should not use a start-class article Surgery as a model. Again, right now I want to focus on chiropractic safety, as that's the topic of this section; I would rather defer issues like efficacy and comparative safety for later sections. There will be plenty of time to discuss those controversial issues later; let's not get bogged down with them now. Eubulides (talk) 07:38, 5 March 2008 (UTC)

Struck out sources that are disputed due to a) methodological/conclusion flaws b) strong bias against someone/something c) is disputed by an editor here for another reason (age, tone, content, etc)

It is not reasonable to strike out all critical sources, leaving only sources relatively favorable to chiropractic. Wikipedia should cover all sides. I made this change to unstrike those sources and reorganized the section to categorize the other sources added. Eubulides (talk) 18:32, 7 March 2008 (UTC)

Safety and Efficacy

As stated above, I do not believe that efficacy belongs in the safety section. IF we are going to have sections for safety and efficacy, they should be dealt with in their own subsections. That is, the other efficacy section should not mention safety, and the safety section should not mention efficacy. In addition, since it seems that the focus is on safety right now, could we hold off on discussing the inclusion of efficacy until we have created a NPOV section for safety? The talk page is confusing enough as it is without adding another completely different conversation to it. DigitalC (talk) 07:59, 1 March 2008 (UTC)

I like the idea of focusing on safety first here. My suggestion for the final order of presentation would be: efficacy; then safety; then risk-benefit and/or cost-benefit. That's a logical order. Eubulides (talk) 09:28, 1 March 2008 (UTC)

Efficacy, Safety, and Risk-benefit are all related. Me thinks it is okay if a bit of overlap occurs among the sections. Now, what is the next step? QuackGuru (talk) 00:46, 2 March 2008 (UTC)

I agree there's overlap but it's a big job to do it all and I'd like to focus on safety first. If there is a reasonable agreement on the sources listed in #Sources for safety, the next step would be to draft a safety section based on them. The current draft in #Safety 2 doesn't do that. (Also, it's way too long for Chiropractic.) If you like, I could give it a stab. Eubulides (talk) 07:38, 2 March 2008 (UTC)

Please edit away. Be very very WP:BOLD. QuackGuru (talk) 07:45, 2 March 2008 (UTC)

OK, but first I'll have to read the sources carefully. That's going to take days rather than hours, I'm afraid, as I have other responsibilities. But you are welcome to draft something yourself, if you've read the sources in question. Eubulides (talk) 09:09, 2 March 2008 (UTC)

I agree with Levine re: undue weight and this is attributed primarily to the medical profession continuing to sandbag the chiropractic profession (i.e. Ernst et al). What other med article has this as well? Does Eubulides own baby, vaccination, have this as well? Again, we are going to compare SMT to other conv. med modalities for similar conditions (i.e. neck pain) and look at the risks, benefits and efficacies of those as well (i.e. surgery for neck pain) so we can put all this into perspective and context. I doubt surgery for mechanical neck pain has a .000002% odds of serious effects. Ten bucks that's not even mentioned in those articles. Double standards again and we're going to make sure that our resident medical editors here are not going push through any spin or fear mongering tone. The evidence is clearly in favour of SMT; if this persistent whining about safety is beyond bogus. Name one other modality that has been studied as extensively for SMT and I'll drop $100 in your bank account tomorrow. EBDCM (talk) 00:41, 3 March 2008 (UTC)

• Sandbagging is something one does to oneself, so I'm not sure what is meant by "the medical profession continuing to sandbag the chiropractic profession".
• The concern about adverse effects is genuine, and Ernst 2007 (PMID 17606755) is a reliable and recent secondary source.
• Comparing SMT's cost-benefits to those of other therapies is a different topic, one that would logically follow the cost-effectiveness topic already mentioned. For now, I'd rather focus on safety, since the POV dispute is over Chiropractic #Safety.
• I agree that Vaccination (or actually Vaccine, which it should be merged into) could have better coverage of safety. I suggest following up this part of the discussion on Talk:Vaccine or Talk:Vaccination or both; they are better venues for that topic.

Eubulides (talk) 02:53, 3 March 2008 (UTC)

Railroading, sandbagging, using straw mans fallacies, surely you've studied up on these since you so cleverly employ these and hide behind policy. At least I can respect Quack Guru and Mccready because they're direct with their positions whereas you constantly take cheap shots at the profession and have purged any contrast to conventional medical treatment because a lot of times chiropractic care is equal to or superior to med care for NMS conditions and some non NMS conditions. Anyways, here's a link to a 2004 WSIB (workmans comp from Ontario contrast DC and PT efficacy. [20]. We will include this and get rid of some of the more ancient references are start synthesizing them together to establish accurate trends. EBDCM (talk) 01:48, 4 March 2008 (UTC)

I am unaware of any attempt by any recent editor of this page to use the techniques you describe. Certainly I have not intended to use them. Please assume good faith. Compared to what's in #Sources for safety, the WSIB source is relatively low quality, as it does not mention safety, and it does not appear in a refereed journal. Let's strive for higher-quality sources that are on-topic, using WP:MEDRS as a guide. Eubulides (talk) 07:48, 4 March 2008 (UTC)

It's about efficacy and its notable and reliable. Chiropractic care was 2x as effective as PT care. WSIB is notable and reliable and use evidence-based protocols. If you lecture me one more time about "higher quality sources"..... Anyways, good faith has long gone out the window, in fact I have NEVER seen you backdown from any single point you've ever made here. You're always right and when editors disagree with you, you cite your interpretation of policy. No more MEDRS as a guideline. Chiropractic is not medicine; and it cannot be expected to have the same amount of high quality secondary sources because research culture is relatively new and there are many DC journals that are simply not indexed at PubMed, for example. You know absolutely NOTHING about chiropractic which is why your edits suck. You lack insight and sensitivity to this topic and article, because you're an MD and do not understand chiropractic culture, chiropractic philosophy, chiropractic styles of practice and chiropractic research. You think you "get it" if you read an article or a textbook? Sorry you do not. The best source who would understand the whole chiropractic spectrum from straight to reform is either a chiropractic historian or an actual DC, preferably a reformer who understands research methodology and is strong in clinical and biological sciences.

If the source is about efficacy then I'm sorry that I misunderstood it to be about safety; but then we can defer this discussion until later. Right now I'd rather get safety finished. As for the other comments, the threshold for inclusion in Wikipedia is verifiability, not truth. This means reliable, third-party published sources. The unpublished thoughts of someone, no matter how eminently qualified and no matter how insightful, do not count as sources. Eubulides (talk) 07:47, 5 March 2008 (UTC)

Hello again, Eubulides. Before we proceed any further we should perhaps take into account the scope of chiropractic (aka SMT) safety vs. mainstream medicine safety.

http://www.ourcivilisation.com/medicine/usamed/deaths.htm Now, you said above that you've made mistakes and I would opine that you would be making a big one by not reviewing and including this in the most appropriate article, you know, as a sign of NPOV editing and a sign of good faith. My experience with you as an editor has been a mixed one; on one hand you are excellent with formatting the citations and coming up with a few good papers; yet on the other, your edits on chiropractic both here and at vaccine controversy have, in my opinion, unneccessarily "biting" language with respect to chiropractic and an editing style here that really does not understand the complexities of the profession itself to appreciate how difficult it will be to really getting the appropriate NPOV, something both Dematt and Fyslee would attest to. Hopefully we can constructively move forward here but I know one thing for sure it would be best to find another team-mate (I'm looking at you, Quack Guru) that is more objective and is more educated with respect to acceptable literature standards and proper writing style. EBDCM (talk) 04:15, 4 March 2008 (UTC)

That web page is not suitable for citing in Chiropractic, as it doesn't mention chiropractic. Are you suggesting that it be cited in some other article? If so, the appropriate venue would be the talk page for that article. Eubulides (talk) 08:00, 4 March 2008 (UTC)

I'm suggesting you look at the WEIGHT of what you are proposing and the double standard you are endorsing. EBDCM (talk) 01:02, 5 March 2008 (UTC)

I am not endorsing any double standard. I am agreeing with you that safety ought to be covered better in other medical therapy articles. That is not a double standard. I have tried hard to make the safety section short, appropriately for the weight of the topic. The section I proposed was shorter than what's currently in Chiropractic#Safety. Eubulides (talk) 07:50, 5 March 2008 (UTC)

Where does the .0000002%(or is it .0000002) come from? Is it the 1 in 5 million risk from the malpractice study? Do you maintain that there is zero risk, as the Bone and Joint task force would indicate? That strokes only happen to people that were going to have one anyway? In any case, let's report the 'hypothetical' risks in the usual 1/1000 form instead of mind-numbing decimals. CynRNCynRN (talk) 07:53, 4 March 2008 (UTC)

A better format can be found in phrases like this one, taken from Thiel et al. 2007 (PMID 17906581): "This translates to an estimated risk of a serious adverse event of, at worse ≈1 per 10,000 treatment consultations immediately after cervical spine manipulation, ≈2 per 10,000 treatment consultations up to 7 days after treatment and ≈6 per 100,000 cervical spine manipulations." This sort of presentation is fairly standard in epidemiology. The format "1 per 17,000" is also used, but many readers find it harder to interpret. Eubulides (talk) 08:21, 4 March 2008 (UTC)

I have included all the available info. Now it can be adjusted to fit this specific article as needed. Just edit away. QuackGuru (talk) 08:51, 4 March 2008 (UTC)

Another redraft of "safety"

I read the sources in #Sources for safety. I looked at what's in Chiropractic #Safety now: as already mentioned, it has real POV problems and also it can be shortened. I also looked at what's proposed in the Safety subsection of #Safety 2 now; it's even longer, suffers from a too-many-quotes problem, and has POV problems of its own: for example, it doesn't lead with the point that chiropractic care is regarded as safe. So I propose the following new draft below. It's shorter than the alternatives, it covers the bases of the #Sources for safety, and it attempts to address the POV problems. Comments are welcome (I'm sure there will be some…). Please comment in #Comments on safety 3 below. Eubulides (talk) 00:15, 5 March 2008 (UTC)

Attempts to address POV problems? Your whole proposal is a POV problem. What exactly to you have a problem with? Are contraindications not listed? Is the stroke issue not mentioned even though there is no increased incidence? Is it not mentioned that critics think that SMT is dangerous? Do we not list common side effects? I mean, give me a break Eubulides, This is getting beyond pathetic now. If you thought philosophy was a rough go, buckle up. EBDCM (talk)

This thread continues in #Comments on safety 3 below. Eubulides (talk) 04:01, 9 March 2008 (UTC)

Safety 3

Chiropractic care in general, and chiropractic manipulation in particular, are safe when employed skilfully and appropriately. As with all treatments, complications can arise and there are known contraindications and risks.

Absolute contraindications, such as rheumatoid arthritis, prohibit employing manipulation. Relative complications, such as osteoporosis, mean the increased risk is acceptable under some conditions. Although most contraindications apply only to manipulation of the affected region, a few emergency conditions, such as visual field defects, absolutely contraindicate all chiropractic treatment.

Risks can reasonably be considered slight when compared to all forms of medical treatment. Spinal manipulation is statistically associated with frequent, mild and temporary adverse effects; they have been estimated to occur in 34% to 55% of patients, with 80% of them disappearing within 24 hours. The most common minor side effects reported in a 2007 study of cervical spine manipulation were new or worsening pain in the head, neck, arm or upper back; and stiffness of the neck, shoulder or arm. Spinal manipulation, particularly on the upper spine, can also result in rare complications that can lead to permanent disability or death; these can occur in adults and children. The incidence of these complications is unknown, due to rarity, high levels of underreporting, and difficulty of linking manipulation to adverse effects. Vertebrobasilar artery stroke, the most commonly reported serious complication, is 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.

---

(End of redraft for Chiropractic #Safety.)

Eubulides (talk) 00:15, 5 March 2008 (UTC)

Please edit responsibly

The initial response to the above draft was a complete strikeout of the entire draft. This is not constructive. Please be responsible in editing comments on the talk page. I have reverted that change. Eubulides (talk) 00:45, 5 March 2008 (UTC)

It was mostly crap. Here we go. EBDCM (talk)

There's a START. More to go after dinner. EBDCM (talk) 01:10, 5 March 2008 (UTC)

That edit, which crossed out half the draft, was justified only by the change log entry "not so much melena now, just stool". I'm afraid that sort of commentary is not helpful. Please discuss each part of a change and why it is necessary. Among other things, I disagree with the change's replacement of statistics like "7.3%" with a vague "relatively common". All other things being equal, it's better to give some numbers when available, so that readers can judge for themselves how common an effect is. For now, I'm going to remove the strikeouts and the vaguely-worded replacement. Eubulides (talk) 08:29, 5 March 2008 (UTC)

What gives? Why do you revert strikeouts and concerns raised when more editors disagree with you? Please address my question directly: why do you 1)misrepresent other editors views and 2)continue to insist using hard numbers when they vary (sometimes drastically) from study to study and cite a general conclusion or trend? DigitalCs edit is much better than yours and address a fundamental concern that myself and other have REPEATEDLY raise but which you IGNORE. Please desist from doing so in the future, Dr. Eubulides, MD. 208.101.89.150 (talk) 20:53, 6 March 2008 (UTC)

• This is a controversial area, and will require extensive discussion before anything resembling a consensus can be reached. Simply striking out material with unhelpful changelog entries will not help to achieve consensus, because other editors will not know why the changes are needed. Please discuss edits; don't just make them unilaterally.
• I have attempted to represent other editors' views accurately, and am not aware of errors I have made in that department (although, in such a long discussion, I would not be surprised if errors are present; they can be corrected if someone points them out specifically).
• It is better to give some numbers than to use vague words. If the numbers are approximate, or even vary drastically, the article can simply say so.
• Isn't this point moot, to some extent? I accepted the removal of the 7.3% etc. statistics.

Eubulides (talk) 19:16, 7 March 2008 (UTC)

I absolutely disagree with you that using numbers from a small amount of studies is better than summarizing the data. DigitalC (talk) 22:35, 7 March 2008 (UTC)

First, the current strikeouts have omitted not only all the numbers, but also the summarizing word "frequent". So they are not even summarizing the data. Second, there is nothing wrong with using a range of numbers to summarize available studies. Eubulides (talk) 23:38, 7 March 2008 (UTC)

Struck out (do not revert me again, Eubulides or I will report you) unncessary fear mongering tactics and language. Current text is more apropos and better done. UNDUE weight with Ernst. Improper claims made by Ernst which was refuted and questionable methodology as described in JMPT but not mentioned here (Ernst POV only). These stats are from one paper only and are disputed by other numbers in other papers which is why general statements must be used rather than specifics from one small paper. UNDUE weight on Ernst, no weight on Task Force report (biggest neck pain study EVER) is amongst the many things that are completely wrong with this proposal and is why the current text (also writing style) is much better.

EBDCM (talk) 15:56, 5 March 2008 (UTC)

The following comments assume this version of #Safety 3, i.e., that the struck-out material is retained rather than being eliminated.

• Chiropractic#Safety is not at all apropos. It's a 500-word section that devotes only 30 words to critics and spends the rest of its time demolishing the criticism. This is clearly POV. Also, the section does not address the topic of mild adverse effects. That is a real limitation. Also, it does not address adverse effects to the practitioner (a less-serious issue, admittedly). Safety 3 fixes these problems.

This is a bold faced lie. 30 words about safety? Yeah right. Contraindications are listed, VBA is mentioned, controversy is acknowledged, side effects are listed. Your edit is heavily POV which seems like it was written by a medical physcian who opposes SMT. It's hardly NPOV and your tone and writing style leave much to be desired. EBDCM (talk) 23:25, 5 March 2008 (UTC)

I did not write "30 words about safety". I wrote "devotes only 30 words to critics". Which is what the current section does. This is clearly POV. I welcome constructive comments on the style and tone for the draft in #Safety 3. Eubulides (talk) 23:41, 5 March 2008 (UTC)

That is 30 more than is devoted to proponents. Your edit is clearly POV but much, much worse. The comments I state are indeed factual and shared by other editors here as well. You have not addressed any of my concerns in any meaningful way and seem to be stalling for your tag-team of CynRN and Quack Guru to jump in.

No, the vast majority of Chiropractic #Safety is devoted to material supported by proponents of chiropractic. This is way out of line for NPOV. Eubulides (talk) 00:10, 6 March 2008 (UTC)

No it is not. You're simply out of touch with the majority of the editors here, Eubulides. You're wrong yet again. The current section acknowledges a) controversy b) stroke/VBA, c) contradindications and d) side effects. All this for a one in 5 million chance of serious adverse effect. Your edit is a fear mongering attempt to scare the readers and spin stats from a discredited "researcher" (aka Ernst).

The current section briefly mentions criticism, in a way that disparages the critics, and then spends the vast majority of its space presenting the view that chiropractic is safe. It is POV to rely entirely on material other than the critics' own work to state their case. The critics should be give some space of their own. I'm not saying they should get the whole section (far from it) but currently the section is written almost entirely from the chiropractic viewpoint, which is POV and does not provide proper weight to the criticsm. Eubulides (talk) 17:32, 6 March 2008 (UTC)

Disparages critics? You are projecting again, Eubulides. Please explain how a)acknoledging adverse effects b)acknowledging critics and skeptics c)acknowledging and listing contraindications and d)acknowledging the 0.000002% risk of VBA stroke is POV in "favour" of chiropractors? The evidence and safety DOES favour SMT practitioners, chiropractors being by far the largest segment (90%+). When you say chiropractic, do you mean SMT? Chiropractic is a profession, not a modality. In your edit critics, contraindications and adverse events forms 80% of your edit despite the 0.000002 chance of a serious complication. When contrasted with NSAIDs, for example, this section and the weight given to it, is by far one of the biggest UNDUE WEIGHTs on any wikipedia page, period. EBDCM (talk) 18:16, 6 March 2008 (UTC)

• Chiropractic #Safety briefly acknowledges adverse effects and critics, but devotes the vast majority of its space to defend the proposition that chiropractic treatment is safe. There is nothing wrong with saying chiropractic is safe (that's what #Safety 3 does as well); but adequate space should be given to critics who have legitimate concerns about rare adverse effects, and the Chiropractic #Safety does not do that.
• I try to use "chiropractic" to refer to all chiropractic treatments, and "spinal manipulation" to refer to spinal manipulation. Sometimes I make mistakes, though, because most safety concerns about chiropractic are related to SMT.
• This is a section on safety, so naturally it should focus on contraindications and potential adverse effects, as those are the primary safety concerns. It should also lead with the point that chiropractic is safe, and say that the serious adverse effects are rare. #Safety 3 does that.
• This is a section on chiropractic safety, not on the safety of other treatments. Other treatments are best discussed in a later section (not yet written) that talks about relative cost-benefits of chiropractic versus other treatment forms.

Eubulides (talk) 19:28, 7 March 2008 (UTC)

It isn't way out of line with NPOV because the "proponents of chiropractic" that are being quoted are saying the same thing that NPOV sources such as the WHO are saying. Sure, we could did up articles that say there are no risks associated with chiropractic, but then we wouldn't be working towards an NPOV article. Just because the "proponents" have an inherent bias, does not mean that their contributions are not NPOV. In fact, EBDCM has pointed out reasons why the Ernst article and the Pediatrics article are NOT NPOV. DigitalC (talk) 00:17, 6 March 2008 (UTC)

Sorry, I didn't quite follow that first sentence, but the point remains that the current text is too strongly dominated by a proponent viewpoint. The argument about bias cuts both ways: just because "critics" have an inherent bias, does not mean that their contributions are not NPOV. The Ernst and Pediatrics article reflect opinion by mainstream critics; this opinion is severely underrepresented in the Chiropractic #Safety. Eubulides (talk) 00:28, 6 March 2008 (UTC)

The first sentence is saying that the "proponents of chiropractic" are saying the same thing as unbiased sources such as the WHO. I agree with you that 'just because "critis" have an inherent bias, does not mean that their contribution are not NPOV'. However, those sources have been shown not to be NPOV by way of rebuttal. DigitalC (talk) 01:46, 6 March 2008 (UTC)

The rebuttals do not show the sources to be POV; they merely show that the sources are controversial. The two are not the same thing. When a genuine controversy exists, as one does here, it's Wikipedia's responsibility to give all sides of the controversy. Ignoring one side, or giving it just a few words in a sea of disagreement, is not a neutral presentation. Eubulides (talk) 07:38, 6 March 2008 (UTC)

All sides are represented, controversy is acknoledged. Your edit is simply a chiropractic hit-piece masqueraded as thorough synthesis of pertinent info. Your INTENT behind it is grossly inappropriate; and I will ask you again to please desist with this despite a majority of editors disagree with your safety3 edit. EBDCM (talk) 18:16, 6 March 2008 (UTC)

That is YOUR interpretation of it. This controversy is a hyped up; mostly by you and the research has spoken. We cannot give Ernst the same weight as a 6 year study, I would figure that our self declared "expert" in research and writing med articles (which this is not) would know better. Apparently not. EBDCM (talk) 15:40, 6 March 2008 (UTC)

#Safety 3 (with strikeouts restored) does not give critics the same weight as proponents of chiropractic. It gives Ernst only about 25% of the text. Again, Ernst is not the only critic; he's just the one that has most-recently reviewed the subject with an on-point article. If anything, #Safety 3 underplays criticism; more critics could be brought in. A #Safety 3 that devotes a minority of its text to critics' arguments hardly seems like given undue weight to criticism. Eubulides (talk) 17:37, 6 March 2008 (UTC)

Ernst and safety

<outdent>Why are you restoring strikeouts when DigitalC and myself have provided a specific critic and rebuttal of it? This is not in good faith anymore. Ernst does not merit 25% of the text; his point is already made: cervical spine SMT is associated with strokes, but so is MD care (pills and surgery). So, there is no causation but an association which is explained at length in Haldeman. Safety3 hardly underplays criticism, and to suggest this is delusional. Critics arguments have nothing to do with the inherent safety of SMT, and the weight you're giving it is UNDUE and it's already UNDUE in the current version as well. Here's sentences in the current text that already prove there already may be undue weight

1. the most common modality in chiropractic care, has been increasingly studied in recent years as critics and proponents debate the merits of its efficacy and safety.
2. Cervical spine manipulation (upper cervical specifically) has been a source of controversy. Critics have suggested that spinal manipulation is of limited benefit and a risk factor for vertebral basilar stroke
3. Despite the numerous studies which demonstrates the clinical and cost effectiviness of spinal manipulation, there are still calls for more research by skeptics in the scientific and medical communities
4. The authors concluded that the risk of serious adverse effects was, at worst, 6 per 100,000 manipulations. The most common minor side effect was fainting, dizziness, and/or light-headedness, which occurred after, at worst, 16 in 1,000 treatments
5. Prior to the administration of spinal maniopulative therapy, absolute contraindications must be screened out. These include inflammatory arthritides, fractures, dislocations, instabilities, bone weakening disorders, tumours, infections, acute trauma as well as various circulatory and neurological disorders

That's already 11 lines of 21, and the other 10 are not in "favour" of "proponents" but rather provide a minor intro, outro, context and present the opposing argument. By suggesting that critics, safety, and the other POV is not mentioned really is no more than a lie; from an editor who is crying wolf now. Time to call a spade a spade, Eubulides edits here now at Talk are becoming increasingly counter-productive and are going against any attempts to move the debate forward by working on the current text which Cyn, myself, DigitalC, Levine2112 and Dematt have contributed towards. EBDCM (talk) 18:16, 6 March 2008 (UTC)

• For strikeouts that were accompanied by discussion, I have attempted to continue discussing and have altered the text as part of that discussion. Some of it remains struck out while discussion continues. Obviously there needs to be some give-and-take in this area. However, just striking out without discussion is not helpful, and those are the strikeouts I have restored.
• It is certainly reasonable to give critics 25% of the section on chiropractic safety. Their criticism is motivating a large chunk of the section. It doesn't have to be Ernst, but Ernst has done the most-cited work in this area and is the most-reasonable choice.
• The critics talk about causation. Supporters of chiropractic talk about association. Both issues should be covered. #Safety 3 does that, but Chiropractic #Safety does not, which is part of why Chiropractic #Safety has a POV problem: it is not fairly presenting the critical point of view.
• The above-quoted extracts from Chiropractic #Safety demonstrate the POV in that section. The extracts personalize the controversy, and immediately talk about "critics" and "skeptics", implicitly casting doubt on their motivation, when they should just state the points without personalizing things. The extracts make it sound like critics are being unreasonable and are asking for more and more safety studies despite the "numerous studies which demonstrates" that they're wrong. There are numerous studies on both sides; it's not reasonable to just mention the numerous studies on one side. The extracts don't even mention the most common adverse side effects, which are minor. And these is just part of Chiropractic #Safety; there are several other problems.
• I have not said that critics and safety are "not mentioned" in Chiropractic #Safety. I've said that the section gives too short a shrift to them, in a way that does not present the controversy neutrally.

Eubulides (talk) 19:53, 7 March 2008 (UTC)

• It's not undue weight to give Ernst four lines out of 20. On the contrary, Google Scholar gives Ernst the 3 of the top 10 hits for "chiropractic safety", indicating that, if anything, Safety 3 is underweighting Ernst. Ernst's criticisms are controversial, but Safety 3 gives both sides, and gives less weight to Ernst than to the other side.

Ernst is not the end-all be all you make it seem to be. Also, again, you are being intellectually dishonest and referring to google scholar as some kind of barometer as to what is acceptable. Ernst publishes an anti-chiropractic hit piece YEARLY perhaps that would explain why google lists him so high. Regardless there are many better critics than Ernst who are much more objective and raise better points though they are not as infamous as Ernst. As a medical doctor, I find it astounding that you cannot seem to agree with your colleagues on the most comprehensive review of neck pain and safety ever. This again is more evidence that your intentions editing here is less than forthright. If you really cared about making this article good you would not be introducing a hit piece in the guise of safety especially when there is a double standard being applied and the acknowledged risk is infinitismal. Levine2112 said it best when he suggested anything more than 1 line for safety really is undue weight. EBDCM (talk) 23:49, 5 March 2008 (UTC)

• Ernst is not the only critic; there are others. It's just that Ernst's work is the best-quality critical source we've identified. No other critical review on chiropractic safety was suggested when sources were being asked for.

If that's all you've got Eubulides then we will be here for a long time debating this. EBDCM (talk) 15:40, 6 March 2008 (UTC)

Like it or not, Ernst 2007 is the highest-quality review article that we have identified that is devoted entirely to the subject of the safety of chiropractic. It's recent, it covers the whole subject, and it's published in a refereed journal. No one has proposed any better source. Ernst 2007 is a critical work, and needs to be balanced by others; but it is high-quality and cannot be ignored in an NPOV discussion of chiropractic safety. Eubulides (talk) 17:40, 6 March 2008 (UTC)

• Again, #Safety 3 emphasizes "the most comprehensive review of neck pain and safety ever" as much as the source itself does: every point that source says about safety is given in #Safety 3, and the source is credited.

The edit is crap; there is insufficient weight and context dedicated to the findings of Task Force; the text which you provided is incomplete, the points you make are actually bordering WP:SMACKSPOINT particularly with your incessant pushing of Ernst on us here. EBDCM (talk) 15:40, 6 March 2008 (UTC)

The Task Force source says only this about chiropractic safety:

"There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke."

The draft summarizes it this way:

"Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association, suggesting that these associations are likely explained by preexisting conditions."

This is a fair and accurate summary of what the task force says. No points are missing. If the wording can be improved, please propose it. "This edit is crap" is not a proposal.Eubulides (talk) 17:45, 6 March 2008 (UTC)

• #Safety 3 says that serious adverse effects are rare.
• 1 line for safety is clearly insufficient. Google Scholar is not the be-all and end-all here, but it provides suggestive evidence that safety is important; no evidence to the contrary has been presented.

There is hardly one line dedicated to safety you are lying when you suggest this. That statement is nowhere near factual and is starting to sound like a desperate plea to round up the troops. Like I've mentioned many, many times now (which you ignore) the current text devotes attention to 1) VBA/stroke b) controversy/skepticism c) contraindications to manipulation d) adverse effects. And you say 1 line for safety? Not a chance. You are rapidly losing credibility, Eubulides, by making these false insinuations. I strongly suggest that you please desist from perpetuating inaccuracies, trying to validate Google Scholar when most of us think that's not an appropriate barometer, use citations that have been strongly criticized and rebutted (in peer reviewed journals no less!) and forcing your poorly written safety3 section which has been analyzed and rejected in large part. EBDCM (talk) 15:40, 6 March 2008 (UTC)

The remark "1 line for safety" was responding to the earlier comment "Levine2112 said it best when he suggested anything more than 1 line for safety really is undue weight." The remaining comments seem to be inspired by a misapprehension about where the "1 line for safety" came from, so let's bring this part of the thread to a rest. Eubulides (talk) 17:49, 6 March 2008 (UTC)

Eubulides (talk) 09:01, 6 March 2008 (UTC)

It's 6 of 14. Your intro and outro paragraph don't count as they are not dealing with patient safety per say. 45% of your edit is dedicated to the OPINION of one man, Ernst. This is undue weight. EBDCM (talk) 23:25, 5 March 2008 (UTC)

• Obviously if one focuses on just the critical part, the proportion devoted to Ernst will increase, as Ernst is the main source for the critical comments.
• Ernst is the best critical source identified.
• Some of the text attributed to him is not even that controversial, e.g., that mild adverse effects are more common and are transient.
• Even counting the noncontroversial part, Ernst supports only 93 of the 366 words by my count, which is about a quarter of the text; this is a lower fraction than the top 3 of 10 that Google Scholar gives to Ernst. (The text in question is: "Spinal manipulation is associated with frequent, mild and transient adverse effects, which two prospective studies reported occur in 30% to 61% of patients.", "Spinal manipulation, particularly on the upper spine, can also result in rare, serious complications that can lead to permanent disability or death. The most commonly reported serious adverse effect is vertebral artery dissection, a tear in the artery that can lead to stroke. The incidence of severe effects is unknown, due to their rarity, to high levels of underreporting, and to the difficulty of linking manipulation to its adverse effects.").
• This text summarizes not just Ernst's opinion, but the opinion of many critics; this criticism should not be ignored.

Eubulides (talk) 00:00, 6 March 2008 (UTC)

[21] Please review this for your facts on VBA stroke and cervical spine manipulation Eubulides. It's way more credible than Ernst. 61% of patients have adverse effects? Not a chance. This is a medical hit piece article. Why do you not acknowledge that Ernst' review was severely criticized for methodological and conclusion flaws? This is your "reliable secondary source?" Surely you can do better. You are fear mongering with your edit and your writing style on chiropractic lacks is callous at worst and lacks an understanding of the issues of the profession at best, but this is attributed in part, to the fact that you're a medical doctor who has a negative bias towards chiropractic (see your vaccination hit piece as well). Lastly criticism has NOT been ignored, VBA has been addressed and underreporting is at best speculative. Let's go with the best, most recent and most comprehensive study which is Cassidy et al. Feb 2008. EBDCM (talk) 00:19, 6 March 2008 (UTC)

• The central point of Cassidy et al. 2008 (PMID 18204390) is summarized in #Safety 3, as follows: "Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association, suggesting that these associations are likely explained by preexisting conditions." This statement cites Haldeman et al (PMID 18204390), a secondary source that cites Cassidy et al. There is no need to cite the primary source directly when a secondary source summarizes its central point and is cited to that.

You are omitting many of Cassidy et al.'s findings and do not provide anywhere near the appropriate context or weight. This is a huge flaw with your proposed edit.EBDCM (talk) 16:19, 6 March 2008 (UTC)

The wording relies heavily on the Task Force source's characterization of Cassidy's work. It is appropriate, and even preferred, to rely on secondary sources to summarize findings of primary sources and place them in context. 17:51, 6 March 2008 (UTC)

• Yes, Ernst's review was criticized. Ernst also replied to the criticisms. The net sum of the criticisms and the reply do not affect the brief summary of Ernst's results in #Safety 3. Eubulides (talk) 07:56, 6 March 2008 (UTC)

Oh did he? Did you talk to him, Eubulides? Did he say so himself or is this conjecture and speculation on your part? If he responded to the criticisms then why are the same fallacious arguments being raised again in his most recent paper? The reason is simple; Ersnt has an agenda; has intent is to fear monger and discredit chiropractic by spinning stats and making unfounded claims (much like a straight DC!) and you're hanging your hat on this guy? That's lamentable. EBDCM (talk) 16:19, 6 March 2008 (UTC)

The criticisms and Ernst's reply were published in the same journal that published his original article. They can be found by following the PMID for Ernst 2007. Again, Ernst is not alone in making criticisms. Eubulides (talk) 17:53, 6 March 2008 (UTC)

Do you not think it would be more appropriate to use a different critic who has not been rebutted several times throughout the years and has a reputation as a chiropractic fear mongerer? Ernst "plays up" the numbers and he is the ONLY ONE who suggests the adverse effects rate is common (30-61%) which is out of line with every major study which investigated the safety of SMT (and chiropractic care). And what do you do? You want us to publish a 30-61% adverse reaction rate. It's garbage. Garbage in=garbage out. DigitalC, myself and CynRN feel that it's unncessary to use stats because they are easily spun, can be used out of context, ignores historical trends and are refuted by other investigations (ie. Anglo-European CC 2007). Anyways, rather than constantly have to correct your inappropriate and inflammatory edits, I will focus on improving the current text by integrating the agreed sources and using language that is suitable to all parties, not just yourself. 208.101.89.150 (talk) 20:48, 6 March 2008 (UTC)

It's not appropriate to avoid citing the most prominent critic, who's recently published a systematic review on this topic, simply because proponents of chiropractic dislike his conclusions. The figures he's quoting do not come from his studies; they come from primary studies done by other groups, also published in reliable journals. If another reliable review has different estimates for the rate of minor adverse effects, by all means let's see it; but in the meantime why not publish the best figures we have, noting that they are approximate? It's better to give numbers, even if approximate and over a wide range, than to use vague words like "common" or "frequent". Eubulides (talk) 20:32, 7 March 2008 (UTC)

Again, I proposed an edit that paraphrases the strikeout of Ernst and adds it to what is not struck out. I am not attempting to censor Ernst. Rather, I am attempting to keep the section concise, and prevent WP:UNDUE. If we include Ernst in more detail than what has been proposed below, then we need to include the criticsms of the study, and then we get into a section that has much more weight than it needs to, and we end up with WP:UNDUE violations. DigitalC (talk) 23:24, 7 March 2008 (UTC)

I assume you're referring to the proposal in #Strikeout 2 to change "Chiropractic services are associated with subsequent vertebrobasilar artery stroke..." to "Spinal manipulation, particularly of the upper spine, is associated with vertebrobasilar artery stroke..."? That discussion is still continuing (I just checked, and you asked for more time there) so I'll follow up there. Let's see if we can resolve it there. Eubulides (talk) 23:50, 7 March 2008 (UTC)

• It is completely out of place for Wikipedia to censor Ernst's points entirely, as the strikeouts do. That is untenable in a reliable survey of the topic. Ernst's review of chiropractic safety is by far the best available in the critical literature, and appears in a high-quality journal. It cannot be simply ignored.

It won't be ignored; I agree that Ernst has a place and Ernst is cited in the current text. It's the language, tone and writing style you use that is severely POV. Why don't you acknowledge the severe methodological flaws and inaccurate conclusions as dicussed in JMPT? Scared? EBDCM (talk) 23:25, 5 March 2008 (UTC)

• Ernst 2007 (PMID 17606755) is not cited in Chiropractic#Safety; a less on-point citation is used, which talks about chiropractic in general, not chiropractic safety in particular.

He criticizes chiropractic and suggest cervical SMT causes strokes. This what he says, this is what is written. EBDCM (talk) 00:36, 6 March 2008 (UTC)

Ernst 2007 is the more on-point source for chiropractic safety. It is a better source for #Safety. It mentions things other than cervical SMT and strokes. Chiropractic#Safety should use the most on-point source for safety, which is Ernst 2007. Eubulides (talk) 08:01, 6 March 2008 (UTC)

Using a fear mongering researcher who is NOT an expert in chiropractic safety, who is nowhere near objective in his assessment of chiropractic care, who has been rebutted and criticized strongly for his op-ed pieces on chiropractic hardly qualifies as a legitimate "on point" source. If you are attaching your anchor to Ernst, I'm afraid you will sink to the bottom with him.

Again, Ernst ranks as a top critic in this area; he is often cited and other researchers agree with his main points. Clearly Ernst is not the only critical source on chiropractic safety, but he is a leading and substantial one and Chiropractic#Safety should not censor or belittle substantial criticism in this area. Eubulides (talk) 21:39, 6 March 2008 (UTC)

What in particular, does Ernst have to say that is not already covered in the current text? EBDCM (talk)

• Chiropractic#Safety does not mention frequent, mild, and transient adverse effects, and provides no estimates for their frequencies.
• It does not mention permanent disability or death as complications.
• It does not say what vertebrobasilar artery stroke is. We can't expect typical readers to know what it is.
• It does not say that the incidence of severe effects is unknown.
• It does not mention high rates of underreporting.
• It does not mention that it is difficult to link manipulation to its adverse effects.

What it does emphasize is that there is "a consensus of the top experts in the world" that says, essentially, that it's likely not chiropractic's fault. This is a consensus of a committee that is heavily weighted towards chiropractic. It is not reasonable to present it as a worldwide consensus. The current section is strongly POV, and needs to get fixed. Eubulides (talk) 21:39, 6 March 2008 (UTC)

The WORLD HEALTH ORGANIZATION Task Force is a CONSENSUS report from MANY health professional INCLUDING MDs and GLOBAL universities and GLOBAL public health organizations. The commitee is not weighted towards chiropractic, it's investigating SMT. Moreover, the commitee in question includes a variety of health care professions whereas Ernst and Miley do not. They're simply MD POV which are much less notable and weight worthy (if any) than Haldeman et al. EBDCM (talk) 02:09, 7 March 2008 (UTC)

Chiropractic #Safety uses the phrase "consensus of the top experts in the world" to talk about the Bone and Joint Decade 2000-2010 Task Force. Its head and scientific secretaries are chiropractors. It indeed has made a laudable effort to reach out to the mainstream community and has many MDs on its committees, but one would hardly expect a committee so heavily weighted towards chiropractors to react favorably to critics of chiropractic. It is of course reasonable to publish and even emphasize WHO sources, which #Safety 3 does, but it is not reasonable to shut out critics or to limit their concerns to a few brief words that are immediately dismissed. Eubulides (talk) 20:55, 7 March 2008 (UTC)

• All citations to Ernst have been struck from #Safety 3; this is clearly inappropriate.

What is inappropriate is the tone and language you use. Pick an Ernst study and go with it since he regurgitates the same stuff in different journals every year.

See below re language and tone. Eubulides (talk) 08:01, 6 March 2008 (UTC)

Problems with tone, etc.

• If there is a problem with language, tone, and writing style, let's fix it. What is the problem? Just saying "language, tone, and writing style" is not enough to isolate the problem.

I don't even know where to begin; but the writing sucks; the statistics you quote are refuted in other papers, the length and dedication to stroke and adverse effects is undue and the tone of the article is one of fear mongering. Other editors have agreed with me and yet your 3 takes at rewriting safety are not different in tone or content then the other 2 which were wiped out. 3 strikes you're out, Eubulides.

"Writing sucks" is not a useful criticism. The writing accurately summarizes the sources; it is not Shakespeare, but if there are specific suggestions for improvement please make them. How are the statistic "refuted"? What other papers refute them and how? Please be specific; vague criticisms are not useful. Eubulides (talk) 08:01, 6 March 2008 (UTC)

Well, I'm just giving you my rather blunt assessment since my earlier attempts to gingerly suggest to you that the writing was not up to par was passed over and/or neglected. You don't need to tell us it's not Shakespeare, it's there for the world to see. Why do you not use the ccgpp lit review synthesis which is much more accurate, encompassing and recent? Evidence-based papers, like the ccgpp is a much more constructive means of obtaining consensus. EBDCM (talk) 16:19, 6 March 2008 (UTC)

Please don't treat the wording gingerly. Please bluntly suggest specific improvements to the wording, and say why those improvements are needed. "Writing sucks" is neither specific nor justified. #Safety 3 (with strikeouts restored) cites the CCGPP so I'm not sure what that commentis about. Eubulides (talk) 21:42, 6 March 2008 (UTC)

• The summary in #Safety 3 should not be affected by the material in the letters to the editor and author's response in the paper; it's intended to be a high level summary that is independent of those details. If it fails in that, please explain why.

00:24, 6 March 2008 (UTC)

If there are flaws in a study or paper, which there is with your Ernst citation they should be noted. When a group of editors band together and dispute the findings and publish it like in JMPT there's its notable and moreso because it appears in a refereed journal. If it's not a high level summary then why do you insist on using a low level source? Because it technically meets secondary source standards? It's a weak paper and has been rebutted numerous times by numerous individuals in numerous physical medicine professions. EBDCM (talk) 00:36, 6 March 2008 (UTC)

Flaws need to be noted only if they are material enough to affect the main points summarized here. That is not the case here. Ernst's replies addressed the criticisms made. And other authors have cited his review approvingly. Eubulides (talk) 08:10, 6 March 2008 (UTC)

Which other authors is that? More anti-chiropractic researchers? Your making stuff up too now, the inclusion for wikipedia is verifiability, not truth, remember, Eubulides? This came from you. Ernst replies have hardly addressed the severe methodological and conclusion flaws and the his paper reflects a lack of understanding of the profession, SMT and safety in general for chiropractic care. The fact that you are perpetuating these inaccuracies (which have been noted by several studies) is disconcerning and severely affects your credibility, Eubulides, MD. EBDCM (talk) 15:47, 6 March 2008 (UTC)

As mentioned before, Ernst 2007 is too new to be cited by many other reviews (the review cycle time is too long), but Miley, Wellik, Wingerchuk, and Demaerschalk 2008 (PMID 18195663) cite Ernst 2007 and rely on its results. Miley et al. 2008 is a recent high-quality review of whether cervical manipulative therapy causes vertebral artery dissection and stroke. Eubulides (talk) 21:46, 6 March 2008 (UTC)

Does the Miley et al. study trump Task Force in terms of depth, breadth, citations, number of researchers involved, have a representation of various health care professionals (DC, MD, PhD, etc), have the support of over 100 universities and public health agencies? This is where your studies fail the litmus test. They are very, very biased against chiropractic (SMT) and lack the diversity of professionals required to achieve a consensus. Otherwise, it's an MD hit piece a la Ernst. PS: is Miley et al. available to the public? EBDCM (talk) 22:52, 6 March 2008 (UTC)

Miley et al. is an evidence-based clinical neurologic practice review. It does not have as many authors as the task force report, obviously, but it addresses the question of causation more extensively and more carefully than the task force report does. (The task force report focuses on association, not causation.) I see no evidence of bias in Miley et al.; perhaps you could be more specific about any claims of its being an "MD hit piece"? Eubulides (talk) 00:02, 8 March 2008 (UTC)

• The statistics (e.g., 7.3%) are clearly labeled as being from one recent primary study. They are representative from the literature; they are not out of line. If you prefer a better source for statistics for mild adverse events, please discuss it.

Stats can always be countered or rebutted with stats. That's why they are generally not as useful as either a)trends b)generalizations. You don't seem to get this, Dr. Eubulides. Your intent here is questionable, and a majority of editors disagree with you and yet you always, always, always push, push, push. This is bad etiquette despite your civil tone. It's time to desist once in a while Eubulides. EBDCM (talk) 00:36, 6 March 2008 (UTC)

Again, you are ignoring my point. It's easy to pull up stats from various papers and I have many that disagree with the stats you've listed. Rather, it's better to use general statements that aren't so easily refuted. EBDCM (talk) 23:25, 5 March 2008 (UTC)

If it's easy to pull up stats on minor adverse effects from various papers, let's see them. Please show statistics from sources as reliable as those given in #Safety 3. There is no harm in giving representative statistics, and there is benefit in giving the reader specific numbers rather than vague generalities. Eubulides (talk) 08:15, 6 March 2008 (UTC)

Uh, no. See my previous comments. Stats can be spun, trends and generalizations, cannot. Generalizations are not vague, they're just generalizations. Your intent is to scare the reader via using disputed stats from a disputed author. There is definite harm when you provide information the way you are; and that is seemingly the intent of the edit. To fear monger rather than inform. Besides, neither Cyn, myself, DigitalC, Levine nor Dematt agree with your point. Let's move on. EBDCM (talk) 16:19, 6 March 2008 (UTC)

So far we have seen no other statistics than the ones in (unstruck) #Safety 3. They are more concrete than vague generalizations like "frequent" (and even that word, is currently struck; I don't know why). I fail to see why it's helpful to water down the article so that no indication is given for how frequent the mild side effects are. Please don't assume a particular intent on my part. I attempted to find the best sources I could, listed them with input from others here, and then wrote what they said. Obviously it's a controversial area, but it is not harmful to briefly summarize the frequency of mild side effects. Eubulides (talk) 00:09, 8 March 2008 (UTC)

Also, I don't see where Cyn, DigitalC, Levine and Dematt have weighed in on this point. Dematt, for example, hasn't written in this talk page since this edit a week ago; how could he have agreed about a topic that didn't come up until much more recently than that? Eubulides (talk) 00:17, 8 March 2008 (UTC)

• Safety 3 weights the Task Force source as strongly as it can. It reports everything that source has to say about safety. In contrast, it fails to report much of what Ernst has to say. If anything, this is bias against Ernst.

Are you kidding me? The task force came out AFTER Ernst and has a broad variety of health professionals and researchers (including many MDs) who are authors and contributors. Ernst is one dude, the Task Force had reports from over 500 respected authors, researchers and clinicians. Task Force trumps Ernst easily in both quality, content, weight and notability. Please stop being intellectually dishonest. EBDCM (talk) 23:25, 5 March 2008 (UTC)

This does not address the point made above, which is that Safety 3 weights the Task Force source as strongly as it can. Eubulides (talk) 08:15, 6 March 2008 (UTC)

This is disputed by myself, Cyn, Digital C and Levine. You are going against a majority of editors here. How can we assuem good faith when you NEVER BACK DOWN DESPITE CONSENSUS AGAINST YOUR POINT? Giving a major paper like that 2 lines and Ernst 6 is simply bad faith editing at worst and a gross error in judgement at best. EBDCM (talk) 16:19, 6 March 2008 (UTC)

I don't see where the other editors you mention have weighed in on the question whether Safety 3 weights the Task Force source as strongly as it can. How could it be weighed more strongly than to repeat everything the source says about safety? #Safety 3 has been revised in response to constructive comments, e.g, this edit and this edit were made in response to DigitalC's helpful comments. Eubulides (talk) 22:28, 6 March 2008 (UTC)

Well, the current version and findings of the task force is apropos given it's notability, breadth and depth. EBDCM (talk) 22:52, 6 March 2008 (UTC)

This subthread is about #Safety 3, no? I'm not sure why the subject should change to Chiropractic #Safety. That discussion is better left for another subthread. Eubulides (talk) 00:24, 8 March 2008 (UTC)

• It is not responsible to simply X out the other side's claims in one's edits. Chiropractic #Safety needs to cover both sides.

Eubulides (talk) 21:50, 5 March 2008 (UTC)

The citations are good, the writing, tone and language is not. You are fear mongering and this has been agreed by 2 other editors. EBDCM (talk) 23:25, 5 March 2008 (UTC)

The writing accurately summarizes the citations. No specific complaints have been made about specific wording; just vague complaints about tone. It would be more helpful to be specific. Eubulides (talk) 08:17, 6 March 2008 (UTC)

Are you wearing your glasses? DigitalC made specific complaints about specific wording in your edit. As have I. These are hardly vague. You are misrepresenting the comments of your fellow editors to further your point which is bad judgment. Please refrain from making inaccurate, misrepresenting statements when there is clearly evidence to the contrary. Thanks. EBDCM (talk) 16:19, 6 March 2008 (UTC)

DigitalC made specific comments, with justifications, and these have all been responded to, in #Strikeouts of Safety 3 explained. In some cases the responses included further edits attempting to address DigitalC's concerns; in other cases (the 4th paragraph on further questions were asked, and we are still awaiting DigitalC's input. Specific comments with justifications are helpful; vague comments like "the writing sucks" are not. Eubulides (talk) 22:32, 6 March 2008 (UTC)

Comments on safety 3

(Please put comments on #Safety 3 here.)

This will NEVER see the light of day as it is. FEAR MONGERING BY EUBULIDES! FEAR MONGERING BY EUBULIDES! Run, run, before the DCs kill you with their manipulations. Let's only find med articles that list the most severe reactions and frequencies. Hey eubulides, how come in 2 years of practice and 1 year of internship that I have NEVER had one adverse reaction to any adjustment I've given? It's because you don't know jack about the art and science of manipulation and you have to listen to quack guru. 0.0000002% yet let's have an entire paragraph about this. What a joke. My vote is to kill the whole section again we have begun the slippery slope and Eubulides editing now has hit a new low. EBDCM (talk) 00:31, 5 March 2008 (UTC)

Perhaps cervical manipulation has an inherent risk, but bad outcomes usually happen with practitioners who are less apt. IOW, we all know that some dentists can do restorations of better quality than others; some people can start IVs or draw blood more skillfully than others....It's all in the hands. That said, please calm down, EBDCM, this section can be worked into something that 'everyone is unhappy with' as a wise person here once said.CynRNCynRN (talk) 04:39, 5 March 2008 (UTC)

Here's why I'm pissed at Eubulides edit and moreso the meaning and INTENT behind his edit. Ernst review critical of SMT (which was severely throttled by JMPT and physical medicine specialists) is quoted 3 separate times for a total in 5 lines of 14, yet the biggest most intensive, comprehensive study, literally in the history of neck pain, which deems cervical SMT and chiropractic care to be safe (i.e. no increased risk of stroke) gets a little over 1 line. And Eubulides tries to pass himself off as NPOV, as good faith as an expert really, in the writing of "medical" articles on Wikipedia including "Chiropractic". It's really a farce is what it is, and I would much prefer to work with you on the current version, insert some of the good references by Eubulides and respectfully address some serious moral issues here regarding WEIGHT, TONE and TRENDS and TRUTHFULNESS. Lastly, cervical manipulation in of itself does not carry ANY inherent risk, rather it lies in the skill of the practitioner and the structural integrity of the joint being manipulated. EBDCM (talk) 05:31, 5 March 2008 (UTC)

• Ernst 2007 (PMID 17606755) is not quoted three times. It's cited twice. This is not undue weight for an author that occupies 3 of the top 10 slots in a Google Scholar query on "chiropractic safety". Ernst 2007 is a reliable secondary source. It was not "severely throttled"; it had the usual critical comments which the author replied to. Obviously a Chiropractic #Safety that cited only Ernst would be biased; but one that ignored Ernst would be biased as well. The #Safety 3 draft cites Ernst and other sources and gives to Ernst's opponents most of the citations and the place of honor at the lead. This hardly constitutes undue weight in favor of Ernst.
• I assume that "biggest most intensive, comprehensive study" refers to Haldeman et al. 2008 (PMID 18204400)? If so, the only thing I found that source says about safety is "There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke." That topic is covered extensively #Safety 3, which says "Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association, suggesting that these associations are likely explained by preexisting conditions." Unless I'm missing something, this is a fair summary of that source.
• In rare cases, cervical manipulation by a chiropractor has resulted in severe injuries. That counts as a risk.

Eubulides (talk) 08:16, 5 March 2008 (UTC)

Google scholar is not a valid form of identifying notability. Ernst is the most anti-chiropractic researcher out there and he has been soundly rebutted by many physical medicine specialists in many journals. He is but one man with one opinion which is the same regurgitation as always. His work is suspect as are his conclusions. Undue weight means that Ernst should not occupy 6 of 14 lines (i.e. 45%). Your Haldeman interpretation is grossly inadequate and does not provide any context. Your pediatrics edit is really amounts to "we don't know" so it is not worthy of inclusion. Your edits are inflammatory, are poorly written, has negative and a bland tone associated with it and you team up with Quack Guru who has been banned and or blocked for disruptive and unethical editing standards. Your credibillity has been affected, Eubulides, MD. Ernst does not have "opponents" it's not a battle like you suggest, rather there is much more literature in favour of the safety of SMT. You are making this personal again, and your statements verifies this. In summary, your safety 3 is an unncessary provocation of many professionals using SMT daily to help people get out of pain in a safe alternative to meds and surgery. If you want readers to know the risks involved lets contrast it with conv med approaches so they can get the whole picture and they can see for themselves. This will not be flattering Eubulides, MD. But then again, you've gone and stirred the hornets nest.... EBDCM (talk) 16:07, 5 March 2008 (UTC)

• Google Scholar is not perfect of course, but it is a reasonable rough measure. It will tell you, for example, that "Abraham Lincoln" (45,900 hits) is more-prominent than "Millard Fillmore" (3,610 hits).
• There are many critics; Ernst is merely the best-cited. He does not stand alone.
• Ernst's work has been criticized but it's POV to claim that those criticisms are rebutted. His work is published in high-quality refereed journals, and he is widely cited by others. For example, Google Scholar says his 2001 book on evidence-based CAM has been cited by 288 other scholarly works, and that Stevinson & Ernst's 2002 paper "Risks association with spinal manipulation" is cited by 41 other scholarly works. Ernst 2007 is so new that one wouldn't expect many citations to have emerged from the pipeline; other than the letters to the editor alluded to above, Google Scholar reports one citation to Ernst 2007 by other authors, namely Miley et al. 2008 (PMID 18195663) who cite Ernst 2007 multiple times (among 27 other sources) and conclude, "In summary, we have found the burden of evidence to support a cause-and-effect relationship between CMT with VAD and subsequent stroke." So Ernst is clearly not alone in thinking cervical manipulative therapy causes vertebral artery dissection and stroke.
• The draft uses Ernst to support, by my count, 93 out of 366 words. Many of these words are about topics that are not actually controversial, e.g., SMT is associated with frequent, mild, and transient adverse effects. But even if the topics were controversial, it's hardly undue weight to give Ernst (3 of 10 the top Google Scholar works on chiropractic safety) about 25% of the wording.
• The Haldeman citation adequately covers the point in question, namely, the safety for chiropractors. I did not find anything in that citation that was higher-quality vis-a-vis patient safety than the sources already used. If you see something there, please let us know.
• It is important to summarize lack of knowledge too, when the topic is important, as it is with the safety of spinal manipulation on children.
• Clearly there is opposition to Ernst's points; if "Ernst's opponents" is not a good way to talk about this opposition, then "Ernst's opposition" or "Ernst's critics" will do. Obviously there is a dispute here, no matter what words are used to describe it.
• Controversy should not prevent Chiropractic#Safety from covering the topic of chiropractic safety. It is possible to cover a controversial topic neutrally, by presenting both sides fairly.

Eubulides (talk) 09:06, 6 March 2008 (UTC)

This version is a bit short. So I expanded it and put it in the body of the article. Enjoy reading the NPOV version. Cheers, QuackGuru (talk) 17:52, 5 March 2008 (UTC)

In what sense is #Safety 3 a bit short? Let's discuss this here before putting it into the body of the article. Thanks. Eubulides (talk) 08:18, 6 March 2008 (UTC)

We don't need to continue discussing this. Just NPOV the section. QuackGuru (talk) 18:20, 5 March 2008 (UTC)

QG please desist from reverting. This is an ongoing discussion which is nowhere near completion. To repeatedly insert this inflammatory piece displays a lack of good faith and wikipedia etiquette. We are missing the valuable input from highly respected senior editors so you cannot steamroll this until we achieve a consensus much like the philosophy section. Considering you were blocked yesterday for edit warring, I would hope that you would learn your lesson but clearly further remedial measures might need to be taken as you have not heeded the message. EBDCM (talk) 18:26, 5 March 2008 (UTC)

Please respect NPOV. QuackGuru (talk) 18:28, 5 March 2008 (UTC)

Please respect that there are discussions continuing on the talk page. We do need to continue discussing this. Furthermore, the section is LONG if anything, not short. DigitalC (talk) 00:05, 6 March 2008 (UTC)

I would have to agree with EBDCM that Google scholar is not a good measure of how much weight should be given to an author in the section. Without the strikeouts, there is too much weight towards Ernst. DigitalC (talk) 00:07, 6 March 2008 (UTC)

What measure would be better? Approximately what percentage of the text would be appropriate? With the strikouts, there is zero weight devoted to Ernst; surely that is too small. Eubulides (talk) 00:15, 6 March 2008 (UTC)

I don't think DigitalC (he will answer) nor myself are again including Ernst, but lets paraphrase and keep it level headed. A lot of stuff he writes has been disputed and refuted so we can keep his message (chiro causes strokes) and then we can counter this with an appropriate study. I don't even think of %, it just "feels" and "looks" right. Just because Ernst shows up at a certain slot on google scholar does not mean that much weight should be given in the article. This is quite arbitrary and lacks a good editing approach, IMO. The citations of Ernst is not what is being disputed it's rather how you are writing it, word for word, much of which has been rebutted and is not even mentioned to equalize things out. Now, if you want to include the JMPT commentary and critique, for example, than we can start using specifics, but it's best to keep things generalized as to not provoke either side. EBDCM (talk) 00:48, 6 March 2008 (UTC)

[22] Here is the NPOV version in case anyone wants to read it. It is not short like the draft version. QuackGuru (talk) 08:26, 6 March 2008 (UTC)

I would prefer a shorter version. There is a limit as to how much space should be devoted to chiropractic safety in a general-purpose chiropractic article. If more length is needed to do the topic justice, I suppose a new article Safety of chiropractic could be created, with the longer version put there. But for now I just want to get the POV out of Chiropractic #Safety; a new article is not necessary for that. Eubulides (talk) 09:08, 6 March 2008 (UTC)

That's a bit vague on proportion, so vague that it could mean give critics 30 words out of 500 (the current proportion, which is clearly POV). Giving Ernst 25% is not at all out of line given how often he's cited by scholarly sources on this topic. If it's merely the tone of the 25%, then let's work on the tone. It is not neutral to insist that commentary and critique of Ernst be included, as that makes Ernst a special case (none of the other sources are treated that way; why single Ernst out?). There is a controversy: both sides should be presented fairly; that ought to be good enough; the article should not make a special effort to critique one side. Eubulides (talk) 08:28, 6 March

2008 (UTC) (outdent)I don't think it's necessary to have the risk to the practitioner at the end.CynRNCynRN (talk) 17:25, 6 March 2008 (UTC)

Do you mean that risk should be covered somewhere other than at the end, or that it shouldn't be covered at all? Eubulides (talk) 00:26, 8 March 2008 (UTC)

I don't think it's necessary to cover it. It kind of detracts from the whole section on patient safety. If risk to the practitioner is notable, then maybe it should be in the article somewhere else. I'm sure it's a requirement for the job to exert oneself physically, but are injuries to chiropractors common?.CynRNCynRN (talk) 06:16, 10 March 2008 (UTC)

• The source says the risks to chiropractors have not been quantified.
• The section is titled "Safety", not just "Patient safety".
• My impression is that far fewer sources talk about the safety risks to chiropractors, so in that sense it is less notable, yes.
• Does anyone else have an opinion about covering the risk to the practitioner? If editors would prefer omitting that paragraph from #Safety 3, that'd be OK with me.

Eubulides (talk) 06:53, 10 March 2008 (UTC)

No further comment. This section is already a bit long, so when in doubt it's better to be brief, and I removed the paragraph on risks to the practitioner. Eubulides (talk) 17:10, 11 March 2008 (UTC)

Strikeouts of Safety 3 explained

Strikeout 1

In regards to my strikeout of "Spinal manipulation is common among children; serious adverse events have been identified, but their incidence is unknown", we have already mentioned in the introduction that complications and risks are known. It is a violation of WP:UNDUE to mention it again. Furthermore, although chiropractic and spinal manipulation are linked, this article includes many adverse events from spinal manipulation NOT delivered by chiropractors. DigitalC (talk) 01:54, 6 March 2008 (UTC)

The introduction did not mention children. But this point can be combined with that (or some other) earlier point so as to shorten the discussion and avoid WP:UNDUE issues. Eubulides (talk) 08:52, 6 March 2008 (UTC)

It doesn't have to mention children. There s no reason to mention that there are risks in children, because we have already stated that complications and risks are known. DigitalC (talk) 23:11, 6 March 2008 (UTC)

Chiropractic #Safety doesn't have to mention children, but it should mention children. A reader who is not an expert in the field might think that risks of stroke are limited to older adults, since they are at most risk for stroke more generally. Google Scholar has 5610 hits for "chiropractic safety children", compared to 7910 hits for "chiropractic safety"; this suggests (although it of course does not prove) that concern about safety for children is real here, and should be addressed, albeit if only briefly. Eubulides (talk) 23:44, 6 March 2008 (UTC)

I don't think those google scholar searches suggest anything. A google scholar search for "Chiropractic safety apple" brings up 725 hits, and yet chiropractic safety has nothing to do with apples. There is absolutely nothing in the article that would suggest that risks only pertain to adults, and there is no need to explictly mention that there is risk in treatment of children as well as adults. DigitalC (talk) 00:04, 7 March 2008 (UTC)

The difference is that "chiropractic safety apple" gets a much smaller number of hits, none of which (in the first page of results) are relevant to the combination, whereas "chiropractic safety children" gets many more hits, many of which (again, in the first page) are relevant. Relevant hits on the first page include Lee et al. 2000 and Ernst 2003 doi:10.1007/s00431-002-1113-7; there are others. Eubulides (talk) 00:39, 8 March 2008 (UTC)

You missed the point. The point is that google scholar is an inaccurate gauge as to whether something should or should not be mentioned in the article. Lee et al is NOT a relevant hit. Again, I don't have access to Ernst 2003, but it doesn't look relevant either from the abstract. Again, not quite the same number of hits, but "Chiropractic Water Safety" brings up 3860 hits, and we aren't mentioning anything to do with Safety of Chiropractic in Water, or Chiropractic water safety messages. I agree that the article in pediatrics is a high-quality source. However, it doesn't add anything to the article. DigitalC (talk) 06:40, 9 March 2008 (UTC)

• Google Scholar is not a precise measure, agreed, but its results are suggestive. The abstract of Lee et al. concludes "National studies are needed to assess the safety, efficacy, and cost of chiropractic care for children", which certainly suggests that safety of chiropractic care on children is a matter worth concern. There are other relevant citations in the first page; I just listed two. In contrast, there are zero relevant citations for the first page of "chiropractic water safety" results, which indicate it is not a relevant combination.
• Currently, Chiropractic does not mention children at all, even though spinal manipulation is common on children. The ordinary reader cannot be expected to know that serious adverse effects happen to children, unless this is mentioned. Mentioning children would add to the article.

Eubulides (talk) 07:08, 9 March 2008 (UTC)

Why does children need a special mention? I disagree that it should and this is another attempt by Eubulides to really slant (fear mongering, anyone?) the safety section and repeat the same point twice in a slightly different context which is a POINT and WEIGHT violation. Again, this google scholar as a barometer of what is reliable, relevant and valid is really an exercise in faulty logic which DigitalC has demonstrated above. EBDCM (talk) 01:32, 7 March 2008 (UTC)

I think the mention of children can be summarized in #Safety 3 down to a handful of words. It is worth mentioning children, because we have a recent review of the subject published in a high-quality source, and because the topic is evidently of interest to scholars and others. I'll think about how to reword the mention of children to make it shorter. Eubulides (talk) 00:42, 8 March 2008 (UTC)

This edit made the change described above, among other changes. Also see #Strikeout 2, the next section. Eubulides (talk) 08:27, 9 March 2008 (UTC)

I am happy with that wording as a compromise. I still don't think that it needs mentioning at all, but the way that it had been inserted does not seemed to give it undue weight. DigitalC (talk) 05:55, 10 March 2008 (UTC)

Strikeout 2

In regards to the strikeout of "Spinal manipulation, particularly on the upper spine, can also result in rare, serious complications that can lead to permanent disability or death. The most commonly reported serious adverse effect is vertebral artery dissection, a tear in the artery that can lead to stroke". This strikeout should be maintained, as the next sentence is again stating that SMT can be associated with vertebral artery dissection. In addition, the next sentence uses much better language. It is absolutely not NPOV to state the spinal manipulation can RESULT in complications that LEAD to disability or death. As shown in the Haldeman/Cassidy article, the ASSOCIATION between the spinal manipulation and the stroke can be explained by the fact that the patient is presenting with a stroke in progress. The wording used in the struckout section implies that the SMT is causing the stroke. In fact there is another paper (citation EBDCM?) that shows that the force of a cervical spine manipulation CANNOT cause a tear in the vertebral artery. tl;dr summary - gross violation of NPOV & UNDUE. DigitalC (talk) 02:04, 6 March 2008 (UTC)

No, the strikeout makes several important points that the next sentence does not.

• It explains that the upper spine is of greater concern.
• It explains that complications are rare and serious.
• It mentions that complications can lead to permanent disability and death.
• It mentions vertebral artery dissection, and explains what it is. The average reader cannot be expected to know what vertebral artery dissection is, or what vertebrobasilar artery strokes are.
• It says that the incidence of severe effects is unknown.
• It explains why they are unknown: the effects are so rare, there is much underreporting, and it's hard to link manipulation to adverse effects
• It is not talking about the association, as Cassidy et al. does. It talks about causation.
• Ernst et al. is not the only reliable source that concludes that spinal manipulation causes vertebral artery dissection.

Admittedly this is a controversial area, but the important points made by critics (and this is clearly one) deserve to be heard. Striking out Ernst is not the answer; he makes important points, even if we might disagree with him. 08:52, 6 March 2008 (UTC)

Please cease being argumentative, Eubulides. All the points you've listed are already in the current text without the inflammatory tone that your edit carries. Underreporting is a speculative at best, VAD is already mentioned though so extremely remote that you are giving it more undue weight; it is already mentioned that upper cervical manipulation theoretically carries the most risk and is the most controversial, there has NEVER been any study done that proves CAUSATION so your edit is factually wrong. EBDCM (talk) 17:36, 6 March 2008 (UTC)

Ernst's review gives examples of very high underreporting rates; underreporting does exist to some extent, and is not speculative. We are trying to reword the discussion of VAD and stroke to avoid duplication. We have multiple secondary sources saying causation exists in rare cases; I am not aware of any reliable secondary source saying that causation cannot occur. Eubulides (talk) 00:47, 8 March 2008 (UTC)

• Could we change "Chiropractic services are associated with subsequent vertebrobasilar artery stroke..." to "Spinal manipulation, particularly of the upper spine, is associated with vertebrobasilar artery stroke..." "...[58,[59]" with a inline link to vertebrobasilar insufficiency? This "explains" what a vertebrobasilar artery stroke is better than the previous "explanation" of what a vertebral artery dissection is. Everyone knows that strokes are serious, can lead to permanent disability, and death; we do not need to mention this for them - lets be concise, this section is longer than it needs to be. We could then move The incidence of severe effects is unknown, due to their rarity, to high levels of underreporting, and to the difficulty of linking manipulation to its adverse effects. to the beginning of the 1st paragraph where it is more relevant.

• Vertebrobasilar insufficiency is not the same as vertebrobasilar artery stroke, and Vertebrobasilar insufficiency does not explain the mechanism or effects of vertebrobasilar artery stroke. I disagree that everybody knows that vertebrobasilar artery strokes are serious; a nonexpert reader won't know what they are. However, a wikilink to Vertebrobasilar artery stroke is appropriate, so I added one. Eubulides (talk) 00:12, 7 March 2008 (UTC)

No it's not appropriate, in fact its not even correct. This is becoming a farce, Eubulides. Let's wikilink to a stroke? Your kind of editing is by far the worst I have ever seen on wikipedia and the mechanism or effects of VBI/VBA is not even relevant or within the scope of the safety section. Eubulides, please answer me this: why do you keep pushing your fear mongering edits and agenda and seem to ignore the valid concerns of other editors? Also, I'm becoming increasingly concerned with your arrogant tone as you seem to believe you are the only one who can decide what source is appropriate but also how it should be written. You are really demonstrating a gross lack of collaboration and I plead with you to please change your approach. EBDCM (talk) 01:45, 7 March 2008 (UTC)

What is incorrect about wikilinking to Vertebrobasilar artery stroke? Haldemen et al. 2008 (PMID 18204400) say "vertebrobasilar artery stroke". They do not say "vertebrobasilar insufficiency". It would be inaccurate to replace the source's wording with different wording that talks about a different condition. Eubulides (talk) 00:57, 8 March 2008 (UTC)

Eubulides, are you seriously suggesting that the average reader would not know that a stroke is a serious adverse event? A reader does not have to be an expert to know what a stroke is. DigitalC (talk) 23:45, 7 March 2008 (UTC)

The vast majority of readers won't know what vertebrobasilar artery strokes are, and they won't know how serious they are. Readers might plausibly think that such events effect only the vertebral column, for example. Also, many readers won't even know what strokes are; Wikipedia has many youthful readers. Eubulides (talk) 01:06, 8 March 2008 (UTC)

• The evidence for spinal manipulation causing the stroke is minimal at best. There is a temporal association, that has SINCE been explained. Talking about causation will result in a POV section, and ongoing NPOV complaints. Full stop. DigitalC (talk) 23:01, 6 March 2008 (UTC)

• We have two recent reviews published in high-quality journals that talk about causation, not temporal association. As far as I know, none of our current high-quality sources in #Safety sources say causation is impossible. So I don't see the POV issue here. #Safety 3 makes the point that association exists but is likely due to other factors, but association is not causation; they are different things. Eubulides (talk) 00:27, 7 March 2008 (UTC)

I agree, association is NOT causation. I will have to look over some of the articles again (time please), because other than a temporal association, which has been explained, I don't see what evidence there is to support a claim of causation. DigitalC (talk) 00:39, 7 March 2008 (UTC)

• Perhaps linking to "verteobrasilar artery stroke would be more appropriate. DigitalC (talk) 23:09, 6 March 2008 (UTC)

There is no evidence for causation, Eubulides. This has been debunked most recently by Haldeman et al. and Cassidy et al. Just because something is not stated as impossible does not mean it deserves mention. What weak logic for inclusion. The reviews selected by Eubulides, MD are nothing more that medical hitpieces that are written exclusively by MDs with no DC participation so the bias is enormous (which seems to be why Eubulides wants it in so bad) unlike TaskForce which is also written by MDs, but has the input of DCs, PhDs,, PTs and over 100 university and public health organizations giving input, research and support. To imply causation now, after all that has been done simply demonstrates that you have no credibility whatsoever and, consequently, your edits and inputs will have little to no value. EBDCM (talk) 01:45, 7 March 2008 (UTC)

Those sources have not "debunked" causation. Haldeman et al. 2008 (PMID 18204400) does not mention causation; it mentions association, which is not the same thing. Cassidy et al. 2008 (PMID 18204390) is also about association not causation; it explicitly says "We have not ruled out neck manipulation as a potential cause of some VBA strokes." In contrast, we have three recent reviews that say that in rare cases causation does occur; these are Ernst 2007 (PMID 17606755), Vohra et al. 2007 (PMID 17178922), and Miley et al. 2008 (PMID 18195663). Eubulides (talk) 07:50, 8 March 2008 (UTC)

After reviewing some more literature, the criteria for causation uses association as the first item. In fact, this criteria for causation is used inappropriately, as far as I can tell, as it is supposed to be used in an occupational setting. Furthermore there is no way to prove the causation. I can't seem to get access to Miley at el unfortunately. However, Cassidy et al ALSO says "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" (as in, it is likely not caused by chiropractic). DigitalC (talk) 06:30, 9 March 2008 (UTC)

Miley et al. used Austin Bradford Hill's criteria; I assume that's what you're talking about? You're quite right that there is no absolute proof (or disproof) for causation, a point Miley et al. also make; all one can do is have greater or lesser confidence in causation. One possible explanation consistent with both Ernst 2007 and with Cassidy et al. (and this is sheer speculation; I am not proposing it for the article) is that the incidence of strokes caused by SMT is much smaller than the increase of incidence Cassidy et al. measured as being associated with chiropractic care. Another possible explanation (again, sheer speculation) is that some forms of chiropractic care increase the likelihood of stroke and other forms decrease it. Obviously we can't include speculation like that in the article, but what we can do is give both sides in a neutral way, which is what #Safety 3 attempts to do. Eubulides (talk) 07:24, 9 March 2008 (UTC)

As requested, Herzog et al. (2002) [23]. Again, it seems like Dr. Eubulides cannot comprehend that true nature of spinal manipulation and seems to defend and rely heavily on Ernst and Quack Guru, a POV team if I've ever seen one. EBDCM (talk) 04:41, 6 March 2008 (UTC)

Read the fine print of the above reference. Supported by grants from the Canadian Chiropractic Association and the Chiropractic Foundation for Spinal Research. It was a cadaveric study supported by grants from two chiropractic advocacy groups. Hmm. QuackGuru (talk) 05:00, 6 March 2008 (UTC)

Yes it is a cadaveric study. I seem to have missed your point? Do you have a study that refutes Herzog's findings? 121.44.227.79 (talk) 05:54, 6 March 2008 (UTC)

I was anticipating QGs response. DCs want to learn and validate their healing art, SMT. This includes research into safety and mechanisms of action. It's perfectly fine if a national chiropractic association (CCA) and a research foundation provide grant money. Chiropractors are the primary providers of SMT. It makes sense that chiropractors and chiropractic associations and chiropractic research foundations want to participate in these studies. Furthermore, this was declared on the paper as a potential source for conflict of interest. The fact that is was cadeveric is the only ETHICAL thing to do. It's also the only way to accurately measure forces on verebrae during manual manipulation procedures. Going further, the fact that the adjustments were being given to old, frail specimens with questionable structural integrity and STILL the forces were grossly insufficient to generate any amount of tension of the VA illustrates this point even moreso. The study basically said you get more tension/compression of the vertebral artery from looking over your shoulder when backing up your car than you do from a typical diversified manipulation given by a typical chiropractor. EBDCM (talk) 06:22, 6 March 2008 (UTC)

The Herzog study is discussed by Miley et al. 2008 (PMID 18195663), who note that the study may not match real life for several reasons:

• Vertebral arterial dissection (VAD) associated with cervical manipulative therapy (CMT) most commonly occurs at the C1–C2 level, but Herzog et al. did not measure the forces in this location.
• Stretch by tensile forces may not reflect the type of artery deformation suspected to occur after CMT.
• The range of motion of elderly patient cadavers is likely more restrictive than that in younger patients undergoing CMT.
• VAD may come from multiple insults to the artery, instead of from just a single event.

All good points. Therefore the Herzog study's results do not rule out the possibility that CMT causes VAD. Incidentally, now that I've read Miley et al., I'm going add it to the list of sources on chiropractic safety; it is a recent reliable review that I was unaware of until today. Eubulides (talk) 09:21, 6 March 2008 (UTC)

Of course, you will, Eubulides. Of course you will add more negative hit pieces. MORE undue weight. This is MORE proof that you are not objective enough to be editing this section and article. The ROM in an spinal adjustment is LESS than rotation looking behind your shoulder doing a lane check. Anyways, the study you listed is speculative at best and is another example how you are disingeniously approaching this section and article. Tensile forces are the ONLY forces which can result in a dissection. If you knew ANYTHING about biomechanics and structural engineering you would see this. You should refer to McGill for a proper review of tissue loads and tolerances. VAD MAY come from... VAD associated with SMT has already been explained by Haldeman et al. with epidemiological data and is stronger than Miley. Herzog's study does not rule out the possibility but it quantifies the tissue loads necessary to cause a traumatic dissection which is very, very, very, very, rare (1 in 1-5 million aka 0.000002% risk) and yet your edit pushes more UNDUE weight on this. Why can't you face the fact Eubulides, that your edits are a poorly written fear mongering attempt from the perspective of a mainstream medical doctor who simply wants to paint SMT (and chiropractic) in an unfavourable (hardly NPOV) light? Because over the past month that's been your TREND. EBDCM (talk) 17:36, 6 March 2008 (UTC)

Miley et al. 2008 (PMID 18195663) is a structured evidence-based clinical neurological practic review of causation; it is not speculative. As mentioned above, Haldeman et al. 2008 (PMID 18204400) address association, not causation. The Herzog study's quantifications may not match real life for the reasons discussed above. Those risk estimates are debatable; the risks are hard to quantify. Eubulides (talk) 08:10, 8 March 2008 (UTC)

I am afraid I think the Ernst study must be included. I do not think a lot of emphasis needs to be given to the transient side effects, even though they seem to have a neurologic basis in many cases due to interference with blood flow. What about the studies of living people and vertebral artery circulation? I don't think cadaver studies are too convincing, since #1,they are elderly, #2, "live" is very different from "cadaver"!CynRNCynRN (talk) 18:33, 7 March 2008 (UTC)

I had proposed an edit (above) paraphrasing the two sources, and citing them both. I am not trying to strike out Ernst as a source. DigitalC (talk) 22:38, 7 March 2008 (UTC)

Thanks. That edit is still under discussion; see "time please" above. I hope we can come up with a good paraphrase. Eubulides (talk) 08:13, 8 March 2008 (UTC)

I made this change to try to come up with a reasonable paraphase, to address issues brought up both here and in #Strikeout 1. No doubt it can be further improved. Eubulides (talk) 08:29, 9 March 2008 (UTC)

Here is a review of literature of vertebral artery blood flow studies, which concludes that 'there is no consensus' one way or the otherCynRNCynRN (talk) 21:13, 7 March 2008 (UTC)

Thanks for the pointer. That review is about vertebrobasilar insufficiency, though, whereas this discussion focuses on vertebral artery dissection; they certainly related topics but they are not the same thing. Eubulides (talk) 08:21, 8 March 2008 (UTC)

Strikeout 3

In regards to the strikeout of "Spinal manipulation is associated with frequent, mild and transient adverse effects, which two prospective studies reported occur in 30% to 61% of patients.[58] The most common minor side effects reported in a 2007 study of cervical spine manipulation were new or worsening neck pain (reported for about 7.3% of consultations during the follow-up period), shoulder or arm pain (4.8%), reduced movement or stiffness of neck, shoulder, or arm (3.9%), headache (3.9%), upper, mid back pain (2.5%), numb or tingling upper limbs (1.3%), and fainting, dizziness, or light-headedness (1.1%)". This strikeout should not be maintained (IMHO), however should definitely be reworded. I propose something along the lines of "Spinal manipulation of the neck may be associated with frequent, mild, and self-resolving adverse effects.[58] The most common minor side effects reported in a 2007 study were new or worsening pain in the head, neck, arm or upper back; and stiffness of the neck, shoulder or arm; This encompasses the majority of the mild adverse effects, leaving out only effects reported in less than 2.4% which isn't really COMMON. The benefit of this re-wording is that it increases readability dramatically. DigitalC (talk) 02:15, 6 March 2008 (UTC)

Thanks, the summary of the symptoms (rather than listing them one by one) and omitting their percentages is fine and does help readability, but there are some problems with the other part of the newly proposed wording:

• It waters down "is associated with" to "may be associated with". But the source says "is associated with". There's no real doubt the association exists, so why water it down?
• It changes the source's "transient" to "self-resolving". Why the change? No source is given for "self-resolving". I'd rather stick to what the source says.
• It leaves out the fact that the 2007 study was of CMT only. That's an important qualification.
• It omits all percentages, which leaves one with a vague feel. Better to leave some in. I think it's OK to omit the percentages from the one primary study (7.3% etc), so long as we included the overall percentages from the secondary review (30% to 61%).

Eubulides (talk) 09:34, 6 March 2008 (UTC)

Yet another terrible edit by Eubulides with respect to safety. No one is watering anything down, association exists with MD care for neck pain too. Why the special mention? Double standard again that you are promoting. It's called paraphrasing Eubulides and editing, a concept which you do not seem able to grasp. It's about language which will arrive at a NPOV view and consensus. Also, why not mention the misattribution which is rampant through mainstream medical literature with respect to CMT? [24]. Your edits and logic is so brazenly bad now it's getting difficult to tolerate some of your nonsensical claims. EBDCM (talk) 17:44, 6 March 2008 (UTC)

• "There's no real doubt the association exists". The problem I have with "Spinal manipulation of the neck is associated with..."is that it implies that it always happens. Spinal manipulation may be associated with adverse effects, but more often it ISN'T associated with adverse effects.

• Thanks for that clarifying question. This use of "association" is its statistical sense; see Association (statistics), not in the informal sense you're using. I added a wikilink to Association (statistics) in #Safety 3 to attempt to clarify this point. Eubulides (talk) 22:43, 6 March 2008 (UTC)

Exactly, but what will the average reader of the article be thinking when they read it? How will they interpret it? DigitalC (talk) 00:15, 7 March 2008 (UTC)

I changed "associated" to "statistically associated" to try to help clear this up. Eubulides (talk) 00:22, 7 March 2008 (UTC)

• Just because the source uses the word transient, doesn't mean we have to. The change increases readability, and clarity. It is more clear to the average reader what self-resolving means than transient. If we need a source for it, it is mentioned in the CGP. DigitalC (talk) 00:08, 7 March 2008 (UTC)

• I don't see why "self-resolving" is a lot more readable and clear than "transient". The word "transient" is used far more often in English than the word "self-resolving".
• "Transient" does not mean the same thing as "self-resolving". Transient merely means the problem is temporary; it does not necessarily mean the problem resolves itself. It is important in a controversial area like this to stick closely to choices of words that are made by the source, rather than using words that mean something different.
• The CGP uses "transient" when talking about some mild side-effects ("Regarding manipulation; benign and transient unforeseen-Tx-AEs, or none, have been reported in …") and "self-resolving" when talking about others ("Reports ranged from none to those considered minor and self-resolving among a small fraction of study subjects, or minor." (note that this says "self-resolving" only for a small fraction). So it supports the use of "transient", as well as "self-resolving" for some cases. We could add something also mentioning "self-resolving" and cite the CGP, but it would be tricky to do so accurately without adding a lot of verbiage.

Eubulides (talk) 23:00, 6 March 2008 (UTC)

I am trying to AGF here, but this is pedantic. The reason that the problem is temporary (perhaps that is even the best word to use?) is because they resolve on their own. In fact, perhaps we should mention that over 80% resolve within 24 hours? The reason why the CGP uses both words, is because they mean the same thing. They are transient because they resolve. DigitalC (talk) 00:10, 7 March 2008 (UTC)

Do we have a reliable source supporting the 80% and 24-hour claim? If so, that detail would be good to add. As for the wording choice, "self-resolving" does not imply "transient" and likewise "transient" does not imply "self-resolving". A problem might be transient but require further treatment to correct; conversely a problem might resolve itself but take a long time to do so. The source says mild adverse effects are "transient"; we don't have a source saying mild adverse effects are "self-resolving". I'm still leery of departing from the source. It'd of course be OK to add "self-resolving" if we can get a good source that supports "self-resolving". The CGP's use of "self-resolving" isn't good enough, since its quote uses that word only when talking about a "small fraction of study subjects". Eubulides (talk) 08:36, 8 March 2008 (UTC)

The 80% in 24 hours comes from the CGP. Given that you think that youthful readers don't know what a stroke is, I would say the same thing for transient. As editors, we are allowed to paraphrase. What do you think about using the word "temporary" instead? Now, you might be thinking what does this person have against the word transient. I just want it to be clear in the article that these are not permanent effects, and that that fact may be buried by using technical terms. DigitalC (talk) 07:05, 9 March 2008 (UTC)

Thanks for the citation for the 80% in 24 hours statistic. And for the suggestion of "temporary", which sounds fine. Also, the CGP provides an estimate of 34% to 55% incidence rate, which I hope is more acceptable than Ernst's 30% to 61%. I made this change to incorporate all three ideas. Eubulides (talk) 07:42, 9 March 2008 (UTC)

This has been my experience with Eubulides as well. Pedantic is a good, soft word for it... I can think of a few better words that would cut to the chase more... Regardless, Eubulides edits have a history of highlighting negative information, choosing very biased sources, being uncooperative and uncompromising. In general, Eubulides paternalistic and arrogant and condecending tone is not winning him any favours and further damages his credibility, which, IMO, is shot now. EBDCM (talk) 02:33, 7 March 2008 (UTC)

• I'm not sure that mentioning that it is a study of CMT is and important qualification, as similar adverse effects are noted with other treatments.

• Studies of other forms of spinal manipulation could well yield a different set of most-common mild adverse effects. When in doubt it's better to accurately delimit what the source says. Eubulides (talk) 23:02, 6 March 2008 (UTC)

• I don't think it leaves a vague feel to it. The problem with the secondary review is that it is still relying on only 2 studies, leaving a huge range (there is a big difference between 30% and 60%). In addition, other sources have put it at closer to 34%, and 40% from my limited reading. 121.44.227.79 (talk) 22:29, 6 March 2008 (UTC)

• Which other studies are those? It would be fine to list figures in the 34% and 40% range. These numbers are approximate; the point is that we should convey the correct feel, and "frequent" is too vague. Eubulides (talk) 08:40, 8 March 2008 (UTC)

Ahhh, a voice of reason. Anonymous raises key points that I have tried (unsuccessfully) to convey to Eubulides. As editors, we can and should paraphrase, when possible, and use as neutral language and tone as possible. I feel that Dr. Eubulides does not have a firm grasp on this subtlety which is nicely illustrated in Anon's point. EBDCM (talk) 22:59, 6 March 2008 (UTC)

I made this change to incorporate the abovementioned comments on mild adverse effects. Hope this helps. Eubulides (talk) 10:12, 6 March 2008 (UTC)

I disagree. This would not be an improvement. I want sourced text for the readers to understand. Leaving out facts is an NPOV violation. We are here to improve Wikipedia. QuackGuru (talk) 03:21, 6 March 2008 (UTC)

You are welcome to disagree, but please expand on your reasons WHY. There is still sourced text for the readers to understand. Leaving out POV FINDINGS (not facts) is NOT a NPOV violation. As EBDCM stated, there are other articles that cite different numbers, and to only include these ones would be WP:UNDUE. I am also here to improve Wikipedia - AGF. DigitalC (talk) 04:09, 6 March 2008 (UTC)

Leaving out the sourced text is POV. The sources said it and we should follow the sources. Saying that the sources have POV findings makes no sense. The sources are the facts. QuackGuru (talk) 04:20, 6 March 2008 (UTC)

I agree with DigitalC and he's hitting the point I was trying to make earlier to both Eubulides, MD, and Quack Guru. Leaving out sourced text is routine, it's called editing and paraphrasing. That's what editing is all about. The strikeout was regarding the language Eubulides chooses to use but not the source being used. Also, please refrain from using the POV straw man argument. It's getting tiresome and it is not a valid claim. Furthermore, your frequent attempts to include YOUR PERSONAL EDIT (with snazzy referencing STYLE by Ebulides, your partner) without any discussion is inappropriate. What's even worse, you have probably attempted this same routine around 10 separate times and have been reverted each time and asked to get consensus. EBDCM (talk) 04:48, 6 March 2008 (UTC)

What was the POV findings? QuackGuru (talk) 05:00, 6 March 2008 (UTC)

The POV findings are that those percentages only pertain to that one paper, and we cannot reasonably put in the findings of every research paper - but including the percentages from only 1 paper is undue weight - so lets summarize and paraphrase. What is it that I have removed in my rewording that you specifically object to? DigitalC (talk) 06:07, 6 March 2008 (UTC)

Strikeout 4

In regards to the strikeout of "Although most contraindications apply only to manipulation of the affected region, there are a few exceptions, for example, all chiropractic cervical treatment is contraindicated by a sudden, severe and persistent headache unlike previously experienced headaches", I think this seems a little out of place for encyclopedic content. After looking at the reference, it is also only one of several absolutely contraindications, such as a heart attack in progress. It is mentioned as an absolutely contraindication, which means if needed we could put it in with the rest of the absolutely contraindications. More easily summarized, we could include emergency conditions in the absolute contraindications section. DigitalC (talk) 06:30, 6 March 2008 (UTC)

The distinction that's trying to be made here is that these emergency conditions contraindicate all chiropractic treatment, not just at the affected site. I took the wording "emergency conditions" from your comment, changed the headache example to a visual field example (much shorter), and made this change; will that do? Eubulides (talk) 09:46, 6 March 2008 (UTC)

Thanks for those helpful comments, DigitalC. I hope the current draft in #Safety 3 addresses most of the points made. The remaining problem area that I see is with the 4th ("rare, serious complications") paragraph, which contains struck-out material which needs to be unstruck and reworded/worked back into the text somehow, as described above. I can draft something along those lines later but figure that now is a good point to stop and wait for reactions to what I've done so far. Perhaps you see other remaining problems; if so, I'd like to work together to fix them. Thanks again. Eubulides (talk) 10:01, 6 March 2008 (UTC)

Strikeout 5

This change struck out the text "Relative complications, which mean the increased risk is acceptable under some conditions, include osteoporosis, double-jointedness, disk herniations, steroid or anticoagulant therapy, and many other factors." without commenting on the text, and I haven't seen any commentary about that text. Please discuss changes like these, as this is a controversial area and changes should not be done without discussion. To help get the discussion started, I restored the struck-out material; we can improve the text further as needed. Eubulides (talk) 19:05, 7 March 2008 (UTC)

Strikeout 6

This change struck out the word "frequent" from the phrase "frequent, mild and transient adverse effects". The change log entry says "frequency is suggest it is common, the way it is written suggest serious and moderate adverse effects is common (they are not)". I don't see how the phrase "frequent, mild, and transient adverse effects" can be misinterpreted to mean that serious adverse effects are common. If it can, can this be explained? For now, I restored "frequent"; if moving the words around would help then we can do that too. Eubulides (talk) 09:04, 8 March 2008 (UTC)

Strikeout 7

This change replaced:

"Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association …"

with:

"Chiropractic care, and spinal manipulation in general, is associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but medical practitioner services have a similar association …"

with no discussion other than the change log entry "fear mongering link removed; why are we working on this one why it's almost all struck out? What is left has been already incorporated in the current text. Strike 3, Eubulides". However, the cited source, the Bone and Joint Decade 2000–2010 Task Force, says this:

"There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services."

No reason was given for replacing "Chiropractic services" with "Chiropractic care, and spinal manipulation in general" when the source talked about services. Also, no reason was given for replacing "general practitioner" with "medical practitioner" when the source talked about general practitioners. Finally, I see no good reason to omit the wikilink to Vertebrobasilar artery stroke. We cannot expect ordinary readers to know what that term means. It is not fear-mongering to explain an unfamiliar term.

This change then struck out the word "subsequent", with the change log entry "we do not know that the stroke is actually subsuquent to the treatment". But the Bone and Joint Decade source says we do know there was an association with subsequent strokes. Let's keep "subsequent".

Good catch. DigitalC (talk) 09:35, 9 March 2008 (UTC)

I struck out the words that don't match the source and unstruck the original words; perhaps there is a better way to address whatever concerns led to these edits. Eubulides (talk) 09:42, 8 March 2008 (UTC)

Strikeout 8

Re this change: Here, the problem is that the source says only that visual field defects and similar emergency conditions contradict chiropractic cervical treatment. The source does not say they contraindicate all chiropractic treatment. Presumably this is because the source is only about cervical manipulation. Is a more-general source available on contraindications? That would let us supply the more general-phrase. But as things stand, I don't see how the text can say "visual field defects, absolutely contraindicate all chiropractic treatment" when the cited source talks about chiropractic cervical treatment. If we can't find a better source, perhaps there's a better way to reword the text to match the source? Eubulides (talk) 16:55, 11 March 2008 (UTC)

The source also says "...3 factors that are absolute contraindications that require immediate discontinuance of care and referral to emergency health services...". It does not specify discontinuance of cervical spine care. In fact, it also says "These are absolute contraindications to all treatment modalities". If someone is having an impending stroke, or has a subdural hematoma, etc., you're going to stop treating them and call an ambo. You wouldn't treat their low back while you wait. —Preceding unsigned comment added by 202.161.71.161 (talk) 01:42, 12 March 2008 (UTC)

Thanks for clarifying that. This change (not by me) removed the "cervical", so the problem is moot now. But I see that also changed "treatment" to "treatments"; "treatment" is shorter so I'll change that word back. Eubulides (talk) 05:02, 12 March 2008 (UTC)

Strikeout 9

The discussion of contraindications in one sense had too much detail (a list of several contraindications of each time) and in one sense had too little (the lists were just small samples). When in doubt it's better to be shorter, so I made this change to give just one example of each type of contraindication, with the idea that subarticles can go into more detail. This saves about 30 words. Comments are welcome of course. Eubulides (talk) 19:29, 11 March 2008 (UTC)

Looks good to me. I agree with you that it is better to be shorter when possible. 202.161.71.161 (talk) 02:00, 12 March 2008 (UTC)

Strikeout 10

I made this change to replace [[Vertebral artery dissection|Vertebrobasilar artery stroke]] with [[Vertebrobasilar artery stroke]]. Currently, Vertebrobasilar artery stroke redirects to Vertebral artery dissection, so this change makes little difference (if the link is followed it introduces a small extra load on Wikipedia's servers and shows the user the redirect in the header, both small actions). However, in the future, it's quite possible that Vertebrobasilar artery stroke will be a separate article rather than a redirect, and if that happens this section should refer to the separate article rather than to Vertebral artery dissection. The idea behind the change is that keeping things simple in the article now will ease its maintenance in the future. Eubulides (talk) 20:03, 11 March 2008 (UTC)

Additions to Safety 3 explained

Addition 1

When reading one of the sources noted in #Sources for effectiveness below, I discovered that it also had a safety section which seemed relevant; it made the point, already discussed elesewhere on this talk page, that chiropractic techniques' risk can reasonably be considered slight when compared to all forms of medical treatment. I made this change to incorporate this point and included the new citation in as a list of safety references. Eubulides (talk) 19:52, 11 March 2008 (UTC)

Addition 2

Another new source just came out, but it is not a review. I do not know whether it is worth including. Boyle E et al., Spine 2008; 33(4S): S170-75; discussion 2379. "Examining Vertebrobasilar Artery Stroke in Two Canadian Provinces". DigitalC (talk) 00:10, 13 March 2008 (UTC)

That primary source is summarized in both Haldeman et al. 2008 (PMID 18204400) and Hurwitz et al. 2008 (PMID 18204386), which appear in #Secondary sources on safety above. Eubulides (talk) 05:12, 13 March 2008 (UTC)

Changes to safety 3 explained

Reordering 1

In rereading the text I noticed that the discussion talked about risk, then contraindications, then risk again. It's simpler and cleaner to have one paragraph about contraindications and one about risk, so I made this change to reorder the text appropriately. This just changes text order and paragraphing; it doesn't change the words or citations used. Eubulides (talk) 19:57, 12 March 2008 (UTC)

Current Safety Text: Suggestions for improvement

Safety

Further information: Spinal adjustment § Safety, and Spinal manipulation § Safety

Spinal manipulation, the most common modality in chiropractic care, has been increasingly studied in recent years as critics and proponents debate the merits of its efficacy and safety. Spinal manipulation has generally regarded is a safe and effective procedure for the treatment of various mechanical low back pain syndromes. Cervical spine manipulation (particularly the upper cervical spine) has been a source of controversy. Critics have suggested that spinal manipulation is of limited benefit and a risk factor for vertebral basilar stroke and there needs to be more research to support its use whereas chiropractors have countered that cervical manipulation is a safe, effective and cost-effective alternate to conventional medical management for mechanical back and neck pain syndromes. Spinal manipulation poses a slight risk to the practitioner, particularly to the wrists, shoulder, and lumbar spine which may occur during the 'orientation' phase and the dynamic thrust phase of manipulation although these risk has not been quantified.

Spinal manipulation is a regulated/controlled medical intervention and can only be performed by chiropractors and a limited number of physical medicine professionals. Prior to the adminstration of spinal manipulative therapy, absolute contraindications must be screened out. These include inflammatory arthritides, fractures, dislocations, instabilities, bone weakening disorders, tumours, infections, acute trauma as well as various circulatory and neurological disorders. Although most contraindications apply only to spinal manipulation of the affected region, a few emergency conditions, such as visual field defects is an absolute contraindication spinal manipulative therapy. In February 2008, the World Health Organization sponsored Bone and Joint Decade 2000-2010 Task Force on Neck Pain and its Associated Disorders, the largest and most comprehensive study on neck pain, diagnosis, prognosis and safety to date. This included a consensus of the top experts in the world whose findings were collated using a best-evidence synthesis, which addresses risk, prevention, diagnosis, prognosis and treatment risks and benefits. With respect to the association of VBA stroke and cervical manipulation the study concluded:

1. Vertebrobasilar artery stroke is a rare event in the population.
2. There is an association between vertebrobasilar artery stroke and chiropractic visits in those under 45 years of age.
3. There is also an association between vertebrobasilar artery stroke and use of primary care physician visits in all age groups.
4. no evidence of excess risk of VBA stroke associated chiropractic care.
5. The increased risks of vertebrobasilar artery stroke associated with chiropractic and physician visits is likely explained by patients with vertebrobasilar dissection-related neck pain and headache consulting both chiropractors and primary care physicians before their VBA stroke."

A 2007 study which examined over 50 000 chiropractic spinal manipulations had no reports of serious adverse effects. The most common minor side effect was pain in the head, neck, arm or upper back; and stiffness of the neck, shoulder which occurred after, at worst, 16 in 1,000 (0.016%) treatments. Furthermore, the authors concluded that the risk of serious adverse effects was, at worst, 6 per 100,000 (0.006%) spinal manipulations. Despite the controversy and skepticism regarding chiropractic spinal manipulation, The World Health Organization states that "[when] employed skilfully and appropriately, chiropractic care is safe and effective for the prevention and management of a number of health problems."

Comments on current safety

The current rendition on safety acknowledges the following controversies: a) stroke/VBA, b)common side effects of SMT, c) critics claims d)contraindications to SMT. This all despite the relative risk of 0.000002% of serious injury which is far, far better than meds and surgery for the Tx of similar conditions. Yet Eubulides would have the readers believe that it's severely NPOV and because 1/2 the text is not dedicated Edzard Ernst it is severely lacking. DigitalC, myself, Levine2112 and Dematt feel that the current text is close to NPOV and can be tweaked whereas Eubulides and Quack Guru want a complete rewrite that is tantamount to fear mongering (which has not been addressed when asked). EBDCM (talk) 23:58, 5 March 2008 (UTC)

Where does this frequently mentioned stat come from? .0000002% is one in 500 million!CynRNCynRN (talk) 03:04, 6 March 2008 (UTC)

I would go along with DigitalC's rewrite of this part: Spinal manipulation of the neck may be associated with frequent, mild, and transient adverse effects.[58] The most common minor side effects reported in a 2007 study were new or worsening pain in the head, neck, arm or upper back; and stiffness of the neck, shoulder or armCynRNCynRN (talk) 03:03, 6 March 2008 (UTC)

Thanks, I made that change to #Safety 3, keeping the "transient" as you suggested. Eubulides (talk) 10:16, 6 March 2008 (UTC)

Sometimes a 0 or two gets tossed in there. That should be 1-5 million. My bad! EBDCM (talk) 05:05, 6 March 2008 (UTC)

Take the % off the end of it and you're OK!CynRNCynRN (talk) 06:15, 6 March 2008 (UTC)

This version should be deleted off of Wikipedia. It is not NPOV. QuackGuru (talk) 08:55, 6 March 2008 (UTC)

Thanks for your input Mr. Guru; however a majority here disagree with your assertion. EBDCM (talk) 15:21, 6 March 2008 (UTC)

I think we'll make better progress rewriting #Safety 3 instead. #Safety 3 does not devote 50% to Ernst; it's more like 25%, which is reasonable. Clearly Chiropractic #Safety is strongly POV against safety critics; minor patches will not fix this. Eubulides (talk) 10:16, 6 March 2008 (UTC)

You and quack guru are the only ones who think this. We will not allocate any arbitrary number; it makes for a dull, wooden entry that is easily contested. Safety 3 is a cooked goose, and we've already stuck a fork in it. We will focus on improving the current section which is closer to a consensus amongst the majority of editors here than your rewrite. EBDCM (talk) 15:21, 6 March 2008 (UTC)

I disagree with that claim about what the consensus is. No arbitrary number is being asked for; an approximate value will do, which will allow enough freedom to avoid woodenness. The current Chiropractic #Safety allots way too little space to critical comments, and devotes way too much space to refuting them. Eubulides (talk) 22:36, 6 March 2008 (UTC)

Please re-read my comment. I suggest that the current text (in modified version here) is closer to reaching a consensus than Safety3. Tell me what specific critical comments you want listed or expanded, let's come up with good phrasing and we'll add them in. What specific refutations are you talking about? Task Force and Anglo European? They're both large studies which seemingly debunks a lot of myths, addresses incidence rates for minor and major side effects and as far as I am aware contain the best synthesis of literature re: cervical spinal manipulation and adverse effects. Also, both these studies support the plethora of other studies (which I have not listed due to WEIGHT reasons) which suggest a 1 in a 1-5 million chance of serious, permanent neurological impairment. EBDCM (talk) 22:44, 6 March 2008 (UTC)

I have included another piece of Eubulides' safety3, namely the bit about visual defects as an absolute contraindication, a section now which is beginning to be a bit lengthy, IMO. Still, we will work to make sure we get it right and that all parties can live with it. EBDCM (talk) 23:17, 6 March 2008 (UTC)

There is consensus among Wikipedians for the current Safety section in mainspace to be replaced based on the recent discussions. QuackGuru (talk) 21:04, 9 March 2008 (UTC)

This version was rejected by the community and there is a new and concise version in mainspace. QuackGuru (talk) 02:02, 16 March 2008 (UTC)

Not necessarily, QG. In fact there were no comments from Mar 6-16 which suggests it was dormant. We can look at incorporating both this and the current text that addresses the concerns of both proponents and critics. EBDCM (talk) 04:58, 17 March 2008 (UTC)

There was a lot of work in Another redraft of "safety" (now archived) and in #More comments on safety #3 focusing on the "Safety 3" draft. My assumption, and I think the assumption on the part of others, was that this was to replace Chiropractic #Safety and that the approach of making relatively minor changes wasn't going to suffice. That would explain why this section was dormant: it wasn't the approach that was favored. That is not to say that the revised Chiropractic #Safety is perfect; it's not. But on the whole it's a big improvement on the old one, and a better place to start from. Eubulides (talk) 05:17, 17 March 2008 (UTC)

More comments on safety #3

Here is yet another version, with the contraindication part pared down:

Chiropractic care in general, and chiropractic manipulation in particular, are safe treatments when employed skillfully and appropriately. However, chiropractic treatment is contraindicated for some conditions, such as rheumatoid arthritis, broken bones, hematomas, vertebral dislocations or infection.

Ok, it's an honest mistake, I know Cyndy, but the wording is incorrect. I treat patients with RA. Do I manipulate their spine, no. Do I help improve their biomechanics, function, (soft tissue techniques, neuromuscular reeeducation techniques, medical acupuncture, inflammation levels via natural anti-inflammatories (Omega 3, green tea) and inflammation reducing diets (cut out fats, particularly from dairy and meat products). prescribe them exercises and or programs, etc. Anyways, "chiropractic treatment" is not contraindicated for an RA, but SMT is, particularly to C1 (increased ADI to due transverse ligament laxity/rupture) It is subtle, but it's an important difference to note. EBDCM (talk)

I didn't notice treatment vs manipulation there. BTW, have you followed Dr. John McDougall's work and writings re. diet and arthritis? I've been interested in the diet link to many chronic diseases for almost 20 years.CynRNCynRN (talk) 05:32, 6 March 2008 (UTC)

Actually no, Cyn, I had never heard of him but will look him up now. The diet recommendations for patients with inflammatory arthropathies or inflammation in general really just comes from an appreciation of physiological states and how we can manipulate our internal metabolic machinery by changing the "fuel" that it burns. By decreasing pro-inflammatory diet contents and increase anti-inflammatory compounds (when is the last time you heard an MD prescribe this(!) I know we can help manage symptoms. Inflammation is terrible for the nervous system. Many, many chronic pain states and syndromes have an underlying inflammatory component which munching on Flexerol is not going solve the problem. Patients must be pro-active, and the good doctor teaches them how to take care of themselves. Nature will take care of itself if you provide the right STIMULUS. I think DCs are way ahead of the game in their holistic approach towards health and I'm so glad that nurses have embraced this approach. It's such a fulfilling style of care and permeates to all aspects of the patients life. BTW, are you a nurse practitioner (they're called RN(EC) (extended class) here and I must say they do an excellent job and some deliver superior care than some of our MDs in town. (Disclaimer: I'm not against MDs, I highly respect their clinical skills and knowledge and they should be gatekeeper for most of medicine, but not neuromusculoskeletal medicine. )

McDougall wrote several books, referenced with good studies. I just checked his website...pretty flashy these days. I'll put a link on your user page. No, I'm not an NP, I work on a neuro unit.CynRNCynRN (talk) 06:27, 6 March 2008 (UTC)

Rarely, spinal manipulation of the neck can also result in complications that can lead to permanent disability or death. A serious adverse effect is vertebral artery dissection, a tear in the artery that can lead to stroke. The incidence of severe effects is unknown, due to their rarity, to high levels of underreporting, and to the difficulty of linking manipulation to its adverse effects, although estimates range from 1 in 200,000 to 1 in several million cervical spine manipulations(58)(thiel)

This statement implies (and even states) causation which is not the case. There is an association, but so is there for MD care. That's because as Haldeman et al. concluded, these were strokes in progress and they were seeing a health care provider for help with latent symptoms. Now I know you've stated before that you thought DCs were poor screeners for stroke but I would disagree. We are well taught (at least in Canada) in school for the many hard and soft neurological signs, know how to do a proper cranial nerve exam, screening techniques (5Ds, 3Ns, 1A) etc. We experience daily the benefits of spinal manipulation to the quality of life to patients but that does not mean we adjust indiscriminately (at least not mixers/reformers). There is a time and place for SMT (though that does not preclude one from adjusting a lumbar spine, for example) and most DCs know this well. EBDCM ([[User

talk:EBDCM|talk]]) 05:23, 6 March 2008 (UTC)

Case reports tell us some strokes were precipitated immediately by the manipulation. Some people didn't have neck pain presenting. The Haldeman study is great, but does not cancel out all the other research showing evidence of risk. That study also hints that both DCs and GPs were pretty poor at picking up prodromal s/s of stroke.CynRNCynRN (talk) 06:15, 6 March 2008 (UTC).

Case reports are anecdotal. I also have anecdotal evidence of a patient that had (his first) seizure on his first visit to a chiropractor. He had the seizure before being seen by the chiropractor, while in the treatment room. If the seizure had occured 15 minutes later, we would also be seeing case reports that some seizures were precipitated immediately by manipulation. It is a temporal assocation, from which we CANNOT imply causation. DigitalC (talk) 23:05, 6 March 2008 (UTC)

Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association, suggesting that these associations are likely explained by preexisting conditions.(59)

Chiropractic researchers emphasize that medical treatments for neck pain, such as ibuprofen or surgery, are much more dangerous than chiropractic treatment, and that benefits outweigh potential risks.(ref needed).

We don't need to unncessarily play this card and IMO, I would rather not do it. We cannot speak for all chiropractors and I doubt DC/PhDs are spending proving repetitive Tylenol use burns a hole in your stomach. We need to flesh out WHO Task Force more, the conclusions listed (5) go together as they're inter-related and are necessary for sufficient context. Also, we need to acknowledge the breadth of the study because otherwise why should we care about its conclusions? I don't think that you appreciate the magnitude of the study done. If you really are interested in cervical spinal manipulation and neck pain you must get the February isssue of Spine 2008; some of these projects were 6 years in length. The amount of citations, and meta-analyses is impressive. And yet Eubulides wants an Ernst paper (1 man's opinion) to get equal weight with the 500-1000 contributors of the WHO study and the entire Feb issue of Spine. It's ridiculous. Anyways, we are making some progress now and I will incorporate DigitalCs suggestion that you agreed with and attempt to get your edit in there as well. Language will be the key so let's focus on that. EBDCM (talk) 05:05, 6 March 2008 (UTC)

I was about to comment, before I saw your reply, that the Bone and Joint study should have more emphasis in the last paragraph of safety #3, as it is a notable study, as long as the critical studies are cited as well, earlier. Comparison to advil/surgery doesn't need to be there, OK.CynRNCynRN (talk) 05:26, 6 March 2008 (UTC)

How could it be emphasized more? Here is all that the main Task Force source (PMID 18204400) says about chiropractic safety:

"There was an association between chiropractic services and subsequent vertebrobasilar artery stroke in persons under 45 years of age, but a similar association was also observed among patients receiving general practitioner services. This is likely explained by patients with vertebrobasilar artery dissection-related neck pain or headache seeking care before having their stroke."

The unstruck #Safety 3 summarizes it this way:

"Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association, suggesting that these associations are likely explained by preexisting conditions."

How could this be rewritten to emphasize the task force results more? The intent here is only minor editing for brevity; it isn't supposed to omit any of the points of the original. But if something is missing, what is it? Eubulides (talk) 08:49, 8 March 2008 (UTC)

(I moved all this as it was about safety #3, not current safety.) Sorry.CynRNCynRN (talk) 07:06, 6 March 2008 (UTC)

x

Is there another word we can use than critics? It is a WP:WEASEL word. DigitalC (talk) 06:44, 6 March 2008 (UTC)

It's balanced by "proponents". Is it "weasel" to acknowledge that chiropractic has critics?CynRNCynRN (talk) 07:00, 6 March 2008 (UTC)

I agree with Cyn, I think critics is OK because it's balanced out. Perhaps skeptics could be substituted if there is a consensus for that. We just need to make sure that critics/skeptics, contraindications, adverse reactions, etc.. do not have too much weight; especially given the fact that is is much safer than NSAIDs and surgery neither of which have drummed up as much needless (IMO) controversy as SMT. EBDCM (talk) 23:22, 6 March 2008 (UTC)

There are different types of critics. For example, take a look at this website. http://www.vocact.com/index.php QuackGuru (talk) 07:12, 6 March 2008 (UTC)

Protected

I have protected the page due to ongoing edit warring. The protection lasts for one week. Please use that time to establish a consensus on what to include and not include on this talk page. If you come to a consensus before then, you can request earlier unprotection at WP:RFPP. Stifle (talk) 09:34, 6 March 2008 (UTC)

Removal of inappropriate warning tag

This has been discussed at length yesterday[25][26]. Whatever the problems here at Chiropractic, the extension of the Homeopathy warning tag to here is an aggression that would be a false and dangerous policy precedent. I am not involved in Homeopathy, Chiropractic or their articles, although I have voted in a few minor AfD/RfC matters distantly related to Chiro where other ongoing WP policy or POV problems were involved.--I'clast (talk) 18:00, 7 March 2008 (UTC)

I'm not aware of any good reason for a probation tag here. I support the use of the usual, objective remedies such as 3RR, and oppose giving admins extra powers to define users as disruptive according to subjective opinion. --Coppertwig (talk) 19:46, 9 March 2008 (UTC)

We need to give admins super powers to stop all the disruptive people on Wikipedia. QuackGuru (talk) 10:15, 10 March 2008 (UTC)

Safety (oh my)

Further information: Spinal adjustment § Safety, Spinal manipulation § Safety, and Scientific investigation of chiropractic § Safety

Chiropractic care in general, and chiropractic manipulation in particular, are safe treatments when employed skilfully and appropriately. As with all treatments, complications can arise and there are known contraindications and risks.

Absolute contraindications, which prohibit employing manipulation, include rheumatoid arthritis, broken bones resulting from one-time injuries, tumors, hematomas, dislocation of a vertebra, bone or joint infection, and many other factors. Relative complications, which mean the increased risk is acceptable under some conditions, include osteoporosis, double-jointedness, disk herniations, steroid or anticoagulant therapy, and many other factors. Although most contraindications apply only to manipulation of the affected region, there are a few exceptions, for example, all chiropractic cervical treatment is contraindicated by a sudden, severe and persistent headache unlike previously experienced headaches.

Spinal manipulation is statistically associated with frequent, mild and transient adverse effects, which two prospective studies reported occur in 30% to 61% of patients. The most common minor side effects reported in a 2007 study of cervical spine manipulation were new or worsening neck pain (reported for about 7.3% of consultations during the follow-up period), shoulder or arm pain (4.8%), reduced movement or stiffness of neck, shoulder, or arm (3.9%), headache (3.9%), upper, mid back pain (2.5%), numb or tingling upper limbs (1.3%), and fainting, dizziness, or light-headedness (1.1%).

Spinal manipulation, particularly on the upper spine, can also result in rare, serious complications that can lead to permanent disability or death. The most commonly reported serious adverse effect is vertebral artery dissection, a tear in the artery that can lead to stroke. The incidence of severe effects is unknown, due to their rarity, to high levels of underreporting, and to the difficulty of linking manipulation to its adverse effects. Chiropractic services are associated with subsequent vertebrobasilar artery stroke in persons under 45 years of age, but general practitioner services have a similar association, suggesting that these associations are likely explained by preexisting conditions. Spinal manipulation is common among children; serious adverse events have been identified, but their incidence is unknown.

Manipulation poses a minor risk to the chiropractor, particularly to the wrists, shoulder, and lumbar spine. The main risky activities seem to be transferring patients to positions and applying dynamic treatments. This risk has not been quantified.

A study concluded, "Initial studies have found massage to be effective for persistent back pain. Spinal manipulation has small clinical benefits that are equivalent to those of other commonly used therapies. The effectiveness of acupuncture remains unclear. All of these treatments seem to be relatively safe. Preliminary evidence suggests that massage, but not acupuncture or spinal manipulation, may reduce the costs of care after an initial course of therapy." Another study stated, "Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements)." Spinal manipulation for the lower back seems to be relatively cost-effective.

Safety (oh my) comments

Here is an expanded version. It is complete and not short. FYI, Neutral point of view is a fundamental Wikipedia principle. NPOV is absolute and non-negotiable. QuackGuru (talk) 05:50, 9 March 2008 (UTC)

My kneejerk reaction is that it's too long for Chiropractic. It is not that much shorter than Scientific investigation of chiropractic #Safety 2, for example. Its last paragraph is not just about safety, it's also about efficacy and cost-benefit, and the safety bit seems repetitive; it can go. Other ways to trim include removing some of the more-detailed statistics and some of the contraindications, and a few other phrases; but then we are approximating #Safety 3 (assuming no strikes), no? Let's put it this way: is there anything crucial in this version that is not in #Safety 3? Eubulides (talk) 08:09, 9 March 2008 (UTC)

I prefer Safety 3, as it is more concise. In addition, the last paragraph seems very out of place. Comments on massage and acupuncture belong on the safety sections of those articles. DigitalC (talk) 09:51, 9 March 2008 (UTC)

Efficacy and cost-benefit is related and this version is not vague. Perhaps bits of this version could be tightened. Please discuss. QuackGuru (talk) 20:02, 9 March 2008 (UTC)

I made some simple adjustments. This version is not too short and not too long and has the detailed facts. Removing the detailed facts creates vagueness. The safety 3 short and vague version is nonsensical. This version is concise as well as detailed. QuackGuru (talk) 20:39, 9 March 2008 (UTC)

• I agree that cost-benefit is related, but one problem at a time. This thread is about Chiropractic #Safety and a replacement for that section should focus on safety. Efficacy and cost-benefit are better left for another (yet-to-be-written) section. Perhaps we can start drafting that section now, but it is a different section.
• What is nonsensical about the #Safety 3 draft? I am referring to the current version, not to older versions that contained so many strikeouts that they were indeed nonsensical. What important points are missing in #Safety 3 but present in #Safety (oh my)? All other things being equal, shorter is better, and there is limited space in this article.

Eubulides (talk) 23:42, 9 March 2008 (UTC)

The safety 3 is a bit vague. For example, see the missing details of the children's study. The safety 3 does not mention risk-beneft or compares spinal manipulations versus other methods. Additions of efficacy and risk-benefit may help with the some of the missing pieces. QuackGuru (talk) 00:03, 10 March 2008 (UTC)

Which missing details are those? Here's what #Safety (oh my) says about children:

Spinal manipulation, particularly on the upper spine, can also result in rare, serious complications that can lead to permanent disability or death.… Spinal manipulation is common among children; serious adverse events have been identified, but their incidence is unknown.

Here's what #Safety 3 says:

Spinal manipulation, particularly on the upper spine, can also result in rare complications that can lead to permanent disability or death; these can occur in adults and children.

I don't see any details missing about adverse effects in children. Neither version gives any details about adverse effects on children in particular. #Safety (oh my) says only one thing about children that #Safety 3 doesn't, namely that spinal manipulation is common among children. But that is not a safety topic per se; it's more of a prevalance-of-chiropractic topic.

As for risk-benefit, if the intended topic of #Safety (oh my) also includes efficacy and cost-benefit, then the section needs to be retitled and a lot more emphasis needs to be placed on efficacy and cost-benefit (currently, it's almost all about safety, which is unbalanced). But that will be quite a bit of work. I'd rather get safety fixed, then worry about efficacy and cost-benefit in new (yet-to-be-written) sections. Eubulides (talk) 00:16, 10 March 2008 (UTC)

Spinal manipulation is common among children; serious adverse events have been identified, but their incidence is unknown.[44] Here is the complete sentence in this version above. Please review this sentence. QuackGuru (talk) 00:20, 10 March 2008 (UTC)

That 17-word sentence makes the following points:

1. Spinal manipulation is common among children.
2. Serious adverse events have been identified among children whose spines have been manipulated.
3. The incidence rate of these events is unknown.

#Safety 3 makes the last two points. It does not make the first one, but (1) is not really a safety issue; it is a prevalence issue, one that might better be made in some other section. #Safety 3 uses 2 words "and children" to make the last two points; that's far more compact than #Safety (oh my)'s 17 words. Let's keep it short. Eubulides (talk) 00:27, 10 March 2008 (UTC)

It is short but missing one point. QuackGuru (talk) 00:31, 10 March 2008 (UTC)

Maybe in introductory sentence to summarize the sections will work. Here is an example:

Spinal manipulation, the most common modality in chiropractic care for adults and children, has been increasingly studied in recent years as researchers evaluate its efficacy and safety. QuackGuru (talk) 00:53, 10 March 2008 (UTC)

• The first half of that sentence ("Spinal manipulation, the most common modality in chiropractic care for adults and children") needs a citation, and would be more appropriate for Chiropractic#Treatment procedures.
• The second half of that sentence is somewhat redundant ("studied" / "evaluated"), a bit questionable ("increasingly"? really? what's the source?), and focuses too much on researchers and too little on chiropractic. The article should focus on chiropractic, and mention researchers only in citations. The topic here is chiropractic, not researchers.

Eubulides (talk) 01:19, 10 March 2008 (UTC)

Okay. This can be archived now to focus on Safety 3. QuackGuru (talk) 10:10, 10 March 2008 (UTC)

Chiropractic#Treatment procedures

Spinal manipulation is the most common modality in chiropractic care.[27]

This might work. QuackGuru (talk) 05:21, 11 March 2008 (UTC)

I added it to the article. Please review. Thanks, QuackGuru (talk) 02:06, 16 March 2008 (UTC)

Can you find a peer-reviewed source instead, QG? I doubt this would be disputed as it is common knowledge, but I know for sure there's a reference out there that is "iron clad". EBDCM (talk) 02:13, 16 March 2008 (UTC)

We're already using the NBCE source for that; it's not published in a peer-reviewed journal, but it's more reliable than a random website, so to help improve things I substituted it. Eubulides (talk) 02:57, 16 March 2008 (UTC)

References

References