Talk:Chiropractic/Archive 31

"Review conclusions by Ernst and Canter regarding spinal manipulation refuted"
Somebody has been removing the Ernst reference from the lede, claiming "The linked comment has been widely discredited" and "The cited article has been discredited and this is not a true statement". They linked to, which is an interesting short document, but doesn't actually falsify any of Ernst's claims (rather, making methodological criticisms without actually performing a new analysis with what they would consider better methodology). It certainly doesn't touch on fatalities or risks of chiropractic interventions. So, I think it's reasonable to retain the Ernstism in the lede - but should this new document by Bronfort et al get more discussion? bobrayner (talk) 11:16, 1 July 2010 (UTC)
 * It's a comment in a chiro journal. Doesn't seem to warrant the delete of the strong WP:MEDRS and doesn't on it's own offer much to the article. Verbal chat

The comments made are based on a single refuted study. There is a large body of evidence and studies, many already quoted on the page that support the other side of the discussion. Therefore is is erroneous to make such a sweeping statement for the page, it may be appropriate to state "There is a study that states....". It isn't helpful to provide such a sweeping quote as it was to the readers - it simply does not add to the body of information. —Preceding unsigned comment added by 219.89.84.122 (talk) 22:11, 1 July 2010 (UTC)


 * It's been refuted? Could you give details, please? If you have a stronger source than Ernst, we would love to see it. As it stands, it's a reliable source which clearly supports the text in the lede.
 * Please let's not get into an edit war.
 * bobrayner (talk) 22:39, 1 July 2010 (UTC)

There are some good references that refute the study the following link being one: http://www.ncbi.nlm.nih.gov/pmc/articles/PMC1563471/. I agree with you comments about a possible war, a war is usually the result of intractability on both sides, you will note that I did suggest a middle way.

Any statement about a whole profession (in fact two in the study) for a lede would ideally include a wider research base. The comment is simply to black and white to be a fair representation and I therefore suggest it is modified. —Preceding unsigned comment added by 219.89.84.122 (talk) 00:20, 2 July 2010 (UTC)


 * As said above, the document at is a comment in a journal, not a fully fledged study; the writers criticise the methodology of Ernst's paper but do not perform their own analysis, do not produce their own results, do not say what the outcome would be if their preferred methodology were used; they don't even mention deaths at all. This must be some meaning of the word "refuted" of which I was previously unaware.
 * How might be "refuted"? Is there some other paper which proves that these supposed victims of back-cracking quacks are, in fact, alive and well?
 * Can you explain how the text has been "widely discredited" or is "defamatory"?
 * I think it would be a good idea to bear in mind WP:3RR.
 * bobrayner (talk) 00:57, 2 July 2010 (UTC)


 * Has our article been mentioned on some internet forum again? Someone please request semi-protection of the page if this keeps up. There seem to be a large number of accounts dropping in to have their say on this relatively minor issue. Also, in case it was not clear from my edits - the Ernst source looks fine, the comment does not pass WP:MEDRS or WP:LEAD. - 2/0 (cont.) 03:25, 3 July 2010 (UTC)

Bob, what was that about not wanting an edit war... and then you go on to refer to chiropractors as "back-cracking quacks"... how amusing. You might want to take a chill pill. Javsav (talk) 01:08, 4 August 2010 (UTC)

Redirection
Why is this page the redirect for Chhh? EJBH (talk) 17:57, 27 July 2010 (UTC)


 * No idea. The google brings up a circularly named Facebook page (based on the Wiki article), and a Community Home Health and Heart organization in Canada.  Maybe check the page-log for the redirect? Ocaasi (talk) 02:02, 4 August 2010 (UTC)

Sentence needing to be removed/revised?
"Death has occurred following chiropractic spinal manipulation, and the risks surpass its benefit.[23]"

The above sentence really seems more like an opinion than a statement of fact and might be worth removing or at least revising in some way. I followed the cited reference and met a dead webpage. Thoughts? —Preceding unsigned comment added by Alikaalex (talk • contribs) 15:44, 27 July 2010 (UTC)
 * The sentence is supported by the conclusions of the paper cited. The links given (one to an abstract, the other to a pdf of the whole paper) are currently working fine.  I've rephrased it slightly to fit better with what it follows.  Brunton (talk) 12:08, 3 August 2010 (UTC)


 * Actually, that statement is an opinion, by the author of that article; yes that article had a sole author. In fact the author of that article has not reviewed the benefits of chiropractic. It is an opinion statement. Furthermore, that article refers to only upper spinal adjustments (of the neck). I am a medical student by the way; I can just plainly see that this is an opinion statement Javsav (talk) 00:40, 4 August 2010 (UTC)


 * It's not the place of Wikipedia to make a blanket declaration without attributing the source in the text. For example, we could say that "Ernst concludes that the risks are not worth the benefits"; or (if there was support for it) "The majority of doctors argue the risk is not worth the benefits."  However, without changing to a more specific statement or finding broader support, the claim cannot be left as is.  Not because of anything having to do with chiropractic, but because of basic encyclopedic methods regarding presenting claims.


 * (Ocaasi's) Although spinal manipulation can have serious or even fatal complications in rare cases,[20][21] chiropractic care is generally safe when employed skillfully and appropriately.[22]
 * (Brunton's) However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or even fatal complications in rare cases,[21][22] and the risks outweigh the benefits.[23]
 * (Javsav's) However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or even fatal complications in rare cases,[21][22] and the risks of manipulations to the neck outweigh the benefits. Ocaasi (talk) 04:59, 4 August 2010 (UTC) updated from below

I changed mine to "However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or even fatal complications in rare cases,[21][22] and the risks of manipulations to the neck outweigh the benefits." However, I agree that it is not the place to make this kind of statement. When I changed mine, Brunton's was: Chiropractic care is generally safe when employed skillfully and appropriately.[20] However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or even fatal complications in rare cases,[21][22] and the risks outweigh the benefits.[23]" - what you have described as 'the current' was not what the current was when I changed it. I personally believe that the statement about the risks outweighing the benefits should be removed, but I adjusted it to make it slightly more fair. Javsav (talk) 03:58, 5 August 2010 (UTC)
 * Great. Obviously the point is not to compare dead drafts, but just propose options and come to a better consensus.  If it's ok with you, I'm going to paste your new draft where the old one was, so it's easier to compare.Ocaasi (talk) 04:15, 5 August 2010 (UTC)


 * Your fix is more narrowly constructed, but still the same kind of issue, because it makes a blanket statement. I'm going to try again, but I'd be happy to just work out a group draft on talk if it doesn't work. Ocaasi (talk) 06:40, 5 August 2010 (UTC)

I think the new revision is good Javsav (talk) 09:57, 5 August 2010 (UTC)

NPOV dispute: "the risks outweigh the benefits"
The issue concerns a review of literature conducted by E. Ernst published by the International Journal of Clinical Practice. He looked at medical papers since 1934 and found 26 instances where death had followed chiropractic manipulation. The paper concluded that the risks of short-thrust, high-velocity manipulations to the neck outweigh the benefits.

The question is how to incorporate that into the article. Here are two versions:


 * (As fact) However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or even fatal complications in rare cases, and the risks of manipulations to the neck outweigh the benefits.


 * (With attribution) However, chiropractic manipulation has also been associated with mild to moderate adverse effects including, in rare cases, serious or even fatal complications: a review of literature by the International Journal of Clinical Practice collected published reports of 26 deaths following chiropractic care since 1934 and concluded that the risks of high-velocity, short-thrust manipulations to the neck outweigh the benefits.

QuackGuru prefers the first, stating the conclusion of the paper as a fact. He cites NPOV: A simple formulation (ASF) as support.

I, and Javsav, prefer the second, believing that the study's conclusion must be differentiated from a mere fact through in-text attribution.

Argument for attribution

It is indeed a fact that Ernst comes to the conclusion that the risks outweigh the benefits. This, however, is not equivalent to the risks factually, "simply" outweighing the benefits. A single study does not make a fact, particularly in the field of medical research, particularly in the assertion of a cost-benefit analysis, which is inherently subjective.

More to the point, QuackGuru has previously claimed that ASF applies where no serious difference of opinions among reliable sources exist. Yet the sentence in dispute immediately follows a citation by the World Health Organization and the text: "Chiropractic care is generally safe when employed skillfully and appropriately."

The WHO article goes further in disputing the perception that manipulation is inherently dangerous:
 * "Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that 'critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical manipulation. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects'. In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which, almost by chance, results in a very serious consequence..."

It seems there is a contradiction in QuackGuru's argument that requires one of the following: either the WHO is not a reliable source, or a simple formulation does not apply.

The solution is provided by the same ASF policy, which states:


 * That Plato was a philosopher is a fact... Facts can be asserted in Wikipedia's voice (e.g. "Mars is a planet."), but remain subject to Wikipedia's policy on verifiability and may require citation. By "opinion", on the other hand, we mean a statement which expresses a value judgment, or a statement construed as factual that does not reflect the consensus in other reliable sources...That The Beatles were the greatest band in history is an opinion... Values or opinions must not be written as if they were in Wikipedia's voice.


 * When we want to present an opinion, we do so factually by attributing the opinion in the text to a person, organization, group of persons, or percentage of persons, and state as a fact that they have this opinion, citing a reliable source for the fact that the person, organization, group or percentage of persons holds the particular opinion. For instance, rather than asserting that "The Beatles were the greatest band ever", locate a source such as Rolling Stone magazine and say: "Rolling Stone said that the Beatles were the greatest band ever", and include a reference to the issue in which that statement was made.

ASF addresses the issue of 'borderline' cases: "However, there are bound to be borderline cases where careful editorial judgment needs to be exercised – either because a statement is part way between a fact and an opinion, or because it is not clear whether there is a serious dispute – editorial consideration of undue weight will determine whether a particular disagreement between sources is significant enough to be acknowledged."

If this is one of those cases, then let it be discussed thoroughly and not in edit summaries. Ocaasi (talk) 03:48, 7 August 2010 (UTC)

Argument for fact

A study from a WP:MEDRS source does make it as asserting it as fact when no other systematic review contradicts the risk-benefit particularly in the field of medical research which relies on reviews. You don't need multiple studies to make it a statement a fact. This is the first review of neck manipulation like this. There is no serious dispute. The sentence "Chiropractic care is generally safe when employed skillfully and appropriately." does not dispute the risks outweight there benefits. The WHO source makes a different point. The edit summary was "The wording "the practice" is vague. The word "frequently" is sourced. The wording "by the International Journal of Clinical Practice..." is a major policy violation of WP:ASF and too much detail." No systematic review disputes the conclusion of this MEDRS source. It is also a WP:LEAD violation to have that much detail added by Ocaasi to the lead to undermine the text. In the body of the article there is attribution in the text.

Requiring an inline qualifier for widespread consensus of reliable sources on the grounds that it is "opinion" would allow a contrarian reader to insist on an inline qualifier for material about which there is no serious dispute, using the argument that the material is an "opinion". This would mean, in the end, that all material in Wikipedia would require an inline qualifier, even if only one Wikipedia editor insisted on it, which is not the goal of ASF. Presenting a "fact" as an "opinion" is needlessly attributing uncontroversial statements, and so creating the appearance of doubt or disagreement where there is none. There is no serious dispute (WP:ASF) among reviews and it was too much in-the-text detail added to the WP:LEAD. QuackGuru (talk) 04:21, 7 August 2010 (UTC)


 * It is top quality evidence by international acclaimed researcher thus should be presented as fact as it represents the opinion of the mainstream medical community. Yes some chiropractic literature disagree however most physiotherapists do not do cervical manipulations due to these concerns. Doc James  (talk · contribs · email) 00:01, 10 August 2010 (UTC)

Comments

 * I would say that, in most borderline cases, it is better on our part to take the attribution route. And in this specific case, I would also say that the second choice is better, as there are certainly opposing viewpoints to the subject at hand, as shown by Ocaasi. It is far better to attribute the statement to a source than to try and state it as a fact. Silver  seren C 03:53, 7 August 2010 (UTC)


 * That review is by only one author, Ernst, who has published many anti-chiropractic studies. Additionally, in that review he does not discuss the benefits of chiropractic, he only looks at the fatalities. It is his opinion that the risks outweigh the benefits in that article. I think this statement is too definitive to be making in the lead, especially when that review had only one, biased author; it can potentially negatively affect a whole profession - of those 26 fatalities, 23 of them are before 2000, and they are all before 2003, even though this review was published in 2010. That would indicate that chiropractors have learned from their mistakes as well. Javsav (talk) 04:31, 7 August 2010 (UTC)


 * @Quackguru I already removed "practice" since it was ambiguous. I am willing to put "frequently" back in, and to shorten the attribution to comply with WP:LEAD.  However, attribution is necessary.  The reason WP:MEDRS does not apply is because while one review of the literature is sufficient to assert a fact discovered in that research, the statement at issue was secondary to the research.  It is Ernst's own reasoned conclusion about the data.  It would be one thing if he had argued that "spinal manipulation involves potentially fatal consequences".  That follows directly from his research.  However, Ernst goes further to extrapolate the studies towards a global declaration.  This does not follow directly from his research--it is interpreted entirely by Ernst; he does not cite a standardized model for his cost-benefit analysis, he doesn't reference any logic for how he determined the conclusion.  Even if he did, it would still be an "argument" based on medical research and not a fact. Ocaasi (talk) 04:39, 7 August 2010 (UTC)


 * The review stated" The article is the first systematic review of all fatalities reported in the medical literature. Twenty six deaths are on record and many more seem to have remained unpublished." There is no serious dispute with any other review. The is no valid reason to ignore WP:MEDRS. Editors should not argue against MEDRS are judge the source or judge who wrote it as long as it was not written a chiropractic organisation. The source does explain the research anyhow. There is no serious dispute with any other review. See WP:ASF. QuackGuru (talk) 04:54, 7 August 2010 (UTC)
 * I tried a compromise but I still think it violated WP:ASF. There is no dispute with any other review. QuackGuru (talk) 05:02, 7 August 2010 (UTC)
 * 1) I think your compromise ("a systematic review concluded") is *much* closer to what I would prefer. 2) Do you see my point about the difference between the data in Ernst's results and the argument in his conclusions?  3) Though I don't find it necessary, if I found another medical source which asserted a different outlook on spinal manipulations, would that change your stance?  How narrow is the category for which an opposing view must fit:  must it be based on a "systematic review"?  It seems that medical claims are not excluded from serious consideration solely because they are or are not.  4) I hope you don't mind the talk page refactoring I'm doing.  It's only for ease of discussion. Ocaasi (talk) 05:30, 7 August 2010 (UTC)
 * "Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition (32). Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive."
 * This is another point the source makes to draw the conclusion. Another source would have to be specifically about neck manipulation and fatalities. We can't put a primary source on the same level as a MEDRS source. So there is in fact no serious dispute. Do editors prefer we comply with MEDRS and ASF or ignore all rules? QuackGuru (talk) 05:46, 7 August 2010 (UTC)
 * Your first point clarifies Ernst's argument but not does not settle the issue of attribution.
 * Other reviews may make conflicting claims even with a different scope. Explaining the variety of views would require nuance and likely attribution.  Ernst's review was not solely of neck manipulations, but rather included all deaths following chiropractic care.  At the least, if the other source must be about neck manipulation and fatalities, then the Wikipedia text must refer to the risk outweighing the benefits only in the context of neck manipulations.
 * ASF is not proof but a policy which must be applied in context: I dispute your application of ASF in this context because the conclusion of a systematic review is being presented as a fact.  The types of facts mentioned in ASF are "Plato is a philosopher" and "Mars is a planet".  "Spinal manipulations have more risk than benefit" is almost obviously a different kind of statement.   Your argument depends on a particular and narrow reading of ASF and MEDRS that other editors can and indeed do disagree with.  The difference of opinion is in no way an endorsement of ignoring all rules any more than going 56 miles per hour in a 55 mph zone is an endorsement of going 160. Ocaasi (talk) 06:09, 7 August 2010 (UTC)
 * ASF is a policy which can be ignored according to you. I am waiting for you to show a serious dispute with another systematic review. You can't reach down into primary sources to argue against reviews. QuackGuru (talk) 06:20, 7 August 2010 (UTC)
 * ASF is a policy which states that facts should be asserted and opinions attributed; everything in between requires editorial discretion. My argument is indeed based on ASF, just a different reading and application of it.  I dispute that Ernst's claim is a fact as described in ASF.   Please do not characterize my position falsely.
 * If there are competing reviews it is a bonus but not necessary to require attribution of his finding. I have not even mentioned a primary source, so you need not address it. Ocaasi (talk) 06:47, 7 August 2010 (UTC)

Ernst's claim is not a fact as described in ASF - this much should be obvious to anyone. As such, it should be attributed. Javsav (talk) 19:36, 7 August 2010 (UTC)
 * I support the view that the text in the lead should say that the risks by far outweigh the benefits. This is because it is supported by systematic review and is very recent (2010) paper. Additionally Doc James has pulled up a couple of other references which come to a similar conclusion, i.e., that there is little to no data to demonstrate benefit and a small but significant risk of severe harm/adverse effects. There is no valid reason in my view for excluding this content from the lead or the article. It should be included.-- Literature geek |  T@1k?  19:30, 11 August 2010 (UTC)

References Supporting Ernst
If Ernst was the only paper that has these concerns than maybe attribution would be needed but we have others that state the same/similar thing.

Ernst's conclusions are fairly clear

Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit... Spinal manipulation, particularly when performed on the upper spine, is frequently associated with mild to moderate adverse effects. It can also result in serious complications such as vertebral artery dissection followed by stroke. Currently, the incidence of such events is not known. In the interest of patient safety we should reconsider our policy towards the routine use of spinal manipulation.

Another paper PMID:17330693 states:

Since there is a large amount of evidence from many reports regarding an association between neurologic damage and cervical manipulation, and because there are no identifiable risk factors, anyone who receives CSMT can be at risk of neurologic damage. It is important for patients to be well informed before undergoing this kind of procedure and for physicians to recognize the early symptoms of this complication so that catastrophic consequences can be avoided. Despite the fact that sometimes studies report slight benefit of CSMT for pain miinagement,"' composite data from high quality prospective studies and randomized controlled trials is needed before definitive practice recommendations are outlined and public advice is given regarding the risk, benefits and incidence of serious complications after CSMT. For the time being, this article reinforces the need for extreme caution when recommending CSMT for patients suffering neck pain and headiichc.

This paper reiterates the same points:

Although cervical spine thrust manipulation has been advocated as an intervention appropriate for the care of patients with neck disorders, clinicians must consider the benefits relative to the potential risks, especially vertebral artery insult.7,8 The lack of evidence for premanipulative screening to identify which patients may be at risk has caused some authors to suggest that serious complications, although rare, are unpredictable and that the potential benefits of cervical spine thrust manipulation do not outweigh the inherent risks.8,9

Finnally we have this 2009 Cochrane paper that concludes:

"Cervical manipulation and mobilisation produced similar changes. Either may provide immediate- or short-term change; no long-term data are available. Thoracic manipulation may improve pain and function."

So to conclude: 1) We know that cervical manipulation has rare but potentially fatal outcomes.  2) That evidence does not show cervical manipulation is better than mobilization. So why would we be doing it when it has not been proven to be better than a safer treatment? Doc James (talk · contribs · email) 20:29, 9 August 2010 (UTC)

References Disputing Ernst
These are worth taking into account:
 * Spine: 1 October 2007 - Volume 32 - Issue 21 - pp 2375-2378 http://chiropractorvancouver.files.wordpress.com/2008/11/chiropractic-safety.pdf
 * "Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events. 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. Minor side effects with a possible neurologic involvement were more common."
 * "Although minor side effects following cervical spine manipulation were relatively common, the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low."


 * Spine: 15 May 2009 - Volume 34 - Issue 11 - pp E405-E413 http://journals.lww.com/spinejournal/Abstract/2009/05150/Safety_of_Chiropractic_Interventions__A_Systematic.26.aspx
 * "There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue."


 * World Health Organization (2005) (PDF). http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf
 * "Understandably, vascular accidents are responsible for the major criticism of spinal manipulative therapy. However, it has been pointed out that 'critics of manipulative therapy emphasize the possibility of serious injury, especially at the brain stem, due to arterial trauma after cervical manipulation. It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects'. In very rare instances, the manipulative adjustment to the cervical spine of a vulnerable patient becomes the final intrusive act which, almost by chance, results in a very serious consequence..."


 * J Manipulative Physiol Ther. 2005 Jan;28(1):57-63. http://www.ncbi.nlm.nih.gov/pubmed/15726036
 * "CONCLUSIONS: Perceived causation of reported cases of cervical artery dissection is more frequently attributed to chiropractic manipulative therapy procedures than to motor vehicle collision related injuries, even though the comparative biomechanical evidence makes such causation unlikely. The direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures."


 * The Journal of Alternative and Complementary Medicine. February 2001, 7(1): 65-78 http://www.liebertonline.com/doi/abs/10.1089%2F107555301300004547
 * "Ernst et al.'s publication on chiropractic include repeated misuse of references, misleading statements, highly selective use of certain published papers, failure to refer to relevant literature, inaccurate reporting of the contents of published work, and errors in citation. Meticulous analysis of some influential negative reviews has been carried out to determine the objectivity of the data reported. The misrepresentation that became evident deserves full debate and raises serious questions about the integrity of the peer-review process and the nature of academic misconduct."

(re: stroke)
 * Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S176-83. http://www.ncbi.nlm.nih.gov/pubmed/18204390
 * "The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care."


 * JMTP Volume 32, Issue 2, Supplement, Pages S201-S208 (February 2009) http://www.jmptonline.org/article/S0161-4754%2808%2900347-3/abstract
 * "VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care."

There's no question that Ernst's analysis is important and that his concern for the risks of chiropractic is warranted. It's the claim that his review stands alone as fact which needs addressing. These links provide context. Ocaasi (talk) 13:56, 11 August 2010 (UTC)


 * The review is not asserted as fact. The review does have attribution in the text. Please tell us which reference in accordance with WP:MEDRS says the risk of death from neck manipulation is worth the benefit from a recent review. QuackGuru (talk) 17:44, 12 August 2010 (UTC)
 * The review is not balanced with opposing or contextualizing views in reliable sources. Ernst's broad conclusions as well as the assumptions on which it is based are challenged by reliable medical sources and therefore must be described as such per WP:NPOV, WP:ASF, WP:UNDUE, WP:PARITY, and WP:MEDRS The dispute must be accurately described so readers can make appropriate determinations themselves. All sources identified below qualify under WP:MEDRS.


 * "The risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low (Spine 2007). There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic (Spine 2009). It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects (WHO 2005). The direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures (JMTP 2005). 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 (Spine 2008). We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care (JMTP 2009)." Ocaasi (talk) 01:28, 13 August 2010 (UTC)


 * This reference is not even specifically about neck manipulation and risk of death. Again which source says the risk of death from neck manipulation is worth the benefit from a recent review. QuackGuru (talk) 03:42, 13 August 2010 (UTC)
 * This is the first sysematic review that summarises all cases in which chiropractic spinal manipulation was followed by death. QuackGuru (talk) 03:47, 13 August 2010 (UTC)


 * Ernst is not the only one to have stated this risk. See : "A correlation between stroke and cervical manipulation has been reported with increasing frequency, and each new report seems to reignite debate between neurologists and manual therapists ... Patients undergoing spinal manipulative therapy need to consent to the possible risk of stroke or vascular injury from the procedure." Fences  &amp;  Windows  23:02, 15 August 2010 (UTC)
 * There is material in the article about safety of spinal manipulation and neck manipulation. I agree Ernst is not the only one to have stated this risk. But that is not the issue. The issue in not safety in general but about risk-benefit specifically. If there are recent reviews about risk-benefit we can use those references for more views for the Risk-benefit section. QuackGuru (talk) 01:04, 16 August 2010 (UTC)

Attempt at consensus
These modified versions are approaching consensus. Can they get closer?


 * (As fact) However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or even fatal complications in rare cases, and a systematic review concluded the risks of manipulations to the neck outweigh the benefits.


 * (With attribution) Spinal manipulation has also been associated with mild to moderate adverse effects including, in rare cases, serious or even fatal complications. In a systematic review of literature since 1934, the author concluded that the risks of high-velocity, short-thrust manipulations to the neck outweigh the benefits.

Are either of these acceptable? Can they be combined? Ocaasi (talk) 07:38, 7 August 2010 (UTC)

I think Including some indication of the attribution for this statement in the lead is a definite improvement. Either version is acceptable as far as I'm concerned (both include the information that it is a specific review that concluded this rather than a general consensus), and which is used perhaps should just depend on the current length of the lead, which is supposed to briefly summarise the article. The more detailed version originally proposed at the start of the NPOV dispute: "the risks outweigh the benefits" section should be integrated into the appropriate part of the main body of the article. The word "frequently" is adequately sourced. Brunton (talk) 09:09, 7 August 2010 (UTC)

Agreed. It simply can not be stated that "the risks outweigh the benefits" - this is far too definitive a statement to make about an entire profession, when it is really one man (Ernst's) opinion. I agree with Brunton that more information should be put in later in the article.Javsav (talk) 19:33, 7 August 2010 (UTC)

"I still don't think that either of those is completely fair - it wasn't the review that concluded this, it was the reviewerJavsav (talk) 19:39, 7 August 2010 (UTC)
 * I agree that it's technically incorrect to personify a study; reviews can't conclude. But this is mainly semantic, and I bet it's not an uncommon convention in science/medicine to talk about the results as if the study 'showed' them.  What would you write instead?  (Here's part of the difficultly: "The finding of a systematic review of literature since 1934 was that the risks of high-velocity, short-thrust manipulations to the neck outweigh the benefits"--doesn't sound very good.)  I've updated it, using a different variation, but I think it moves farther away from consensus. Ocaasi (talk) 20:55, 7 August 2010 (UTC)

This edit is a lead violation because it is to much detail added to the lead and it does not summarise the body. The added extra attribution is not an improvement.

(With attribution) However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or even fatal complications in rare cases, and a systematic review concluded the risks of manipulations to the neck outweigh the benefits.

The text is attributed with "a systematic review concluded" and no reason has been given to add even more attribution. QuackGuru (talk) 03:20, 8 August 2010 (UTC)

I moved the extra attribution to the body to keep the lead a summary and added a new sentence to the article. QuackGuru (talk) 03:47, 8 August 2010 (UTC)
 * Consensus is still elusive. Three editors have made concerted efforts to address the lead so that it accurately characterizes the status of Ernst's conclusion.  We too can cite NPOV, ASF, and MEDRS in support of attribution in the case of a statement that does not directly follow from the results of a study but is instead the author's interpretation of the data.  It holds weight, but does not warrant treatment as a plain fact per ASF.  The effort at concision proposed by LEAD is secondary to the imperative of NPOV, which suggests we give appropriate weight to Ernst's conclusion, erring on the side of clear attribution rather than presenting a single medical opinion as fact.  Please show me where in MEDRS it suggests that a single author's conclusion deserves the same treatment as "Mars is a planet".  I believe that is a policy synthesis for which there is neither textual support nor consensus. Ocaasi (talk) 07:52, 8 August 2010 (UTC)


 * We need to be particularly careful with this sentence. It is the final sentence of the introduction, the last word in the paragrah summarizing the mix of risks, benefits, support, and criticism.  This sentence must be phrased so that it is unambiguous that Ernst's review did not suggest all chiropractic manipulations were not worth the risk, and that Ernst's opinion regarding risk is not reflective of a broader consensus in the medical community. Ocaasi (talk) 07:55, 8 August 2010 (UTC)


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


 * The effort at concision proposed by LEAD is secondary to the imperative of NPOV? The lead is a summary of the body. But is instead the author's interpretation of the data? It is not for editors to decide this. You have not shown the source's interpretation of the data is incorrect in the medical community. This reference is a review. It is not an unreliable opinion per WP:MEDRS. The risk is not reflective of a broader consensus in the medical community? This systematic review is not disputed in the medical community. The dispute is among reliable sources, not with editors disagreeing with the conclusions. I am sure we have both looked for a similar review about neck manipulation and fatalities but no other review exists becuase this is the first review of its kind. But this does not warrant treatment as a plain fact per ASF? We previously explained "The text is attributed with "a systematic review concluded" and no reason has been given to add even more attribution." So in fact the text does have attribution in the text. Including even more attribution in the text implies the text is disputed where there is none. MEDRS is clear in that we rely on reviews. The sentence is clear in that it is not a blanket declaration about spinal manipulation in general. It is specifically about neck manipulation which does include attribution as a compromise against ASF. After you got what you wanted with "a systematic review concluded" in the text you are still not satisifed? QuackGuru (talk) 03:00, 9 August 2010 (UTC)

I am not satisfied, because the review did not conclude that, the author did. The only thing the review concluded was that there were 26 deaths reported since 1937 - or whenever it was. The review did not even assess the benefits of chiropractic. Ideally, I think it should say "an author of a systematic review concluded that the risk of manipulations to the neck outweigh the benefits" Javsav (talk) 04:53, 9 August 2010 (UTC)


 * The review did explain the risk-benefit balance. "Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition (32). Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive."
 * The review was written by a researcher. The review did conclude the risks by far outweight the benefit. The researcher did not attach a separate paper to go along with the review. QuackGuru (talk) 05:09, 9 August 2010 (UTC)
 * I added by far to the sentence because it is more accurate to the conclusion of the MEDRS source. QuackGuru (talk) 05:34, 9 August 2010 (UTC)
 * Since editors seem to not be satisified by saying concluded I changed it to determined while maintaining a neutral tone per NPOV. QuackGuru (talk) 05:50, 9 August 2010 (UTC)
 * For a peer-reviewed source, it isn't (or at least shouldn't be) just the author's view. The reviewers should also have determined that the conclusions are supported by the data in the review.  Brunton (talk) 07:59, 9 August 2010 (UTC)

Ok, I am satisfied with the result, however, I'm not sure that "by far" is necessary Javsav (talk) 10:58, 9 August 2010 (UTC)


 * Javsav: the wording "by far" is closer to the source. Is there an argument to remove it I missed. QuackGuru (talk) 00:24, 10 August 2010 (UTC)

I also think it's an improvement from where it started but I think more questions were raised by QuackGuru's argument that we should flesh out below. I'm particularly concerned that the Ernst paper does not deserve the prominence it currently is getting, that its claims are not in fact undisputed, and that ASF and MEDRS do not clearly apply to this specific type of conclusion and/or when there are no disputes because there are no other systematic reviews at all. If we're going to talk policy, we should at least get it right. Ocaasi (talk) 13:00, 9 August 2010 (UTC)


 * Ocaasi, its claims are undisputed. No editor has provided another MEDRS source that dipsuted the conclusions. QuackGuru (talk) 00:24, 10 August 2010 (UTC)

Okay, a different question. The current article says "systematic review determined the risks of manipulations to the neck by far outweigh the benefits." This word "determined" is strange, since it implies specific comparison between benefits and risks. The only risk noticed by the review was death. How did he compare the benefits to death? What I'm wondering is, given that this conclusion is headline-worthy but isn't quantifiable in any way, how does it fit in with evidence-based medical science, and how is it worthy of such a statement in Wikipedia? Rather, shouldn't we say "systematic review determined numerous deaths have been associated with chiropractic neck manipulation." rather than what is there now? This seems to be a justified sentence, whereas the current version is only someone's opinion. BE——Critical __Talk 23:04, 9 August 2010 (UTC)


 * The review goes beyond "numerous deaths have been associated with chiropractic neck manipulation" I did change the sentence to make it clear that the risk is death to make it more understandable. QuackGuru (talk) 00:24, 10 August 2010 (UTC)
 * Sure it does, but such a statement is a personal conclusion of the author, not part of the study, and it would seem attribution is necessary if we are going to quote his intuitive assessment in an encyclopedia instead of letting the facts speak for themselves. BE——Critical __Talk 00:39, 10 August 2010 (UTC)
 * Also, your use of the word "determined" indicates evidence rather than intuition. BE——Critical __Talk 00:43, 10 August 2010 (UTC)
 * There was not a separate conclusion with a separate attached paper. We don't have two conclusions. This was not an opinion assessment. The facts did speak for themselves before the attribution in the text was added as a compromise. QuackGuru (talk) 00:55, 10 August 2010 (UTC)
 * Can you give me a diff of the version you favor? BE——Critical __Talk 00:59, 10 August 2010 (UTC)
 * [with attribution in the text] ...and a systematic review determined the risk of death of manipulations to the neck by far outweigh the benefit.[23]
 * [assert the text as non-controversial] ...the risk of death of manipulations to the neck by far outweigh the benefit.[23]
 * I think the version without attribution is the one I favor but the version with attribution is the version I think editors can live with. QuackGuru (talk) 05:25, 10 August 2010 (UTC)

Firstly, it should be "the risk of death FROM manipulations to the neck far OUTWEIGHS the benefits" secondly, even with this better wording, it doesn't sound right and i'm going to revert it or change it a bit - Javsav (talk) 07:42, 10 August 2010 (UTC)

Secondly, I'm agreeing with critical in that this is an opinion of the author. This author, Ernst, is clearly antichiropractic (look at his other papers), and in fact when he claims that there have been no benefits, he is referencing another of his OWN papers, which was shown to have some methodological flaws. You can't say that the study "determined" or "concluded" that the risks outweigh the benefits, because a study can't really conclude that. All it can conclude was that there were 26 deaths in the literature since 1937. Whether or not the risks outweigh the benefits is completely subjective - for example, this is a huge exaggeration for the case of proving a point, but to a suicidal person, death would actually be a benefit - and I'm saying this just to show how completely subjective this conclusion is. If you find out how many deaths medicine has caused since 1937, as a percentage per patient treated compared with chiropractic, it will be higher. And yes I know that the potential benefits of medicine are much higher, but as I said before, the study can't really conclude that, only a PERSON can. By the way, I'll again point out that I am a medical student - I have no bias here. Javsav (talk) 07:54, 10 August 2010 (UTC)
 * Yes, well put. Using the word "determined" is wrong for a subjective conclusion.  There isn't even an attempt at quantification of how risks outweigh benefits.  I would have the same, though smaller, objection to the word "concluded."  But the same impression can be given without violating NPOV by simply stating what was actually determined, that is the number of deaths. The reader can then draw their own conclusions.  BE——Critical __Talk 19:58, 10 August 2010 (UTC)


 * I suggest this: "a systematic review determined that 26 or more deaths have been associated with chiropractic neck manipulation since 1934." BE——Critical __Talk 20:05, 10 August 2010 (UTC)


 * The lead is supposed to be a summary and the proposal does not summarise the body. QuackGuru (talk) 23:41, 10 August 2010 (UTC)
 * Ah, so this is only in the lead? Then why do we have it at all?  BE——Critical __Talk 02:47, 11 August 2010 (UTC)


 * We have a summary of the body in the WP:LEAD to summarise the body. QuackGuru (talk) 03:14, 11 August 2010 (UTC)

QuackGuru, if you are going to change the lead, at least use proper English. You have reverted it again back to "However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious complications in rare cases,[21][22] and a systematic review determined that the risks of death from manipulations to the neck by far outweigh the benefits.[23]" It should be: the RISK of death from manipulations to the neck by far OUTWEIGHS the benefits" furthermore, I have changed it to "However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious complications and fatalities in rare cases,[21][22] and a systematic review determined that the risk of manipulations to the neck by far outweigh the benefits.[23]" which is better sounding English, and encompasses the fatalities earlier in the sentence. Furthermore, your response does not negate the fact that a study can not conclude or determine something of this nature. As critical said, the readers can draw their own conclusions, which would be pretty easy, considering that the sentence before hand says that manipulation has not been shown to be effective for any condition with the possible exception of back pain58.96.105.189 (talk) 02:24, 11 August 2010 (UTC)


 * The conclusion of the review is summarised in the lead. Your change deleted part of the summary of the review. See Talk:Chiropractic. Futhermore, you are confounding different conclusions with fatalities in the ealier sentence. QuackGuru (talk) 03:14, 11 August 2010 (UTC)

Open questions
I think the issues are basically these:
 * Does every word of a systematic review of literature have equal weight--the results as well as the interpretation of the results as well as the conclusion of the review?


 * Are there parts of a systematic review which are refelective of only the author's opinion as opposed to carrying the weight of the entire literature with which it engages?


 * Do WP:NPOV, WP:ASF, and WP:MEDRS combine to mean that any statement from a systematic review which is not directly contradicted by another systematic review can be treated as fact, even if no other systematic review on the same subject has ever been conducted?


 * Does the fact that no other systematic review has ever been conducted on a similar subject make the finding of the one that does stronger or weaker (stronger, because it has no similar sources which dispute it; or weaker because it has no similar sources which confirm it)?


 * Should care be taken to contextualize a medical finding so that it does not suggest other members of the medical community share it's viewpoint or should medical findings be taken to represent consensus unless contradicted elsewhere?


 * Should care be taken in the lead to prevent readers from drawing conclusions based on a single source, even if that source is a systematic review of medical literature?


 * If a systematic review concludes that because X is true, Y is true, and a reliable outside source disputes X, but not Y directly, is it considered a "serious dispute" which would require attribution and a weighing of opposing viewpoints?


 * If a reliable outside source finds that X is generally safe, but a systematic review concludes that a specific part of X is unsafe, is it considered a "serious dispute" which would require attribution and a weighing of opposing viewpoints?


 * If a systematic review is criticized for its methodology by a reliable outside source, but that source does not perform a competing systematic review, is it considered a "serious dispute" which would require attribution and a weighing of opposing viewpoints? Ocaasi (talk) 10:37, 9 August 2010 (UTC)

There is attribution in the text against ASF as a compromise. I'm not sure your point. If another systematic review contradicted this systematic review we would not need to change the way it is currently attributed in the text. No serious dispute has been presented and this systematic review cites reliable sources (Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65.) like other systematic reviews do. QuackGuru (talk) 00:24, 10 August 2010 (UTC)
 * Attribution is an improvement. These are open questions related to the arguments you have used.  I think many of them exceed what policy actually supports or was intended to support, so I want to clarify them for future issues. Ocaasi (talk) 06:07, 11 August 2010 (UTC)
 * I think a new section in MEDRS covering ASF for medical information would clarify the issue for future content disputes. QuackGuru (talk) 06:19, 11 August 2010 (UTC)

Conclusion of the systematic review
PUBMED CONCLUSION: "Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit."

"In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly."

The article body is the conclusion of the systematic review. The WP:LEAD is a summary of the body and a summary of the conclusion. QuackGuru (talk) 00:17, 11 August 2010 (UTC)
 * The question is whether that conclusion is secondary to the review's quantitative results, if the conclusion is undisputed, how we should treat it in the article to reflect medical consensus, and if the lead mischaracterizes the body. These are valid questions which are not resolved by merely quoting Ernst's review.  (note: I edited your comment slightly, because I was confused by the heading.  Please revert if unhelpful or misleading, and I'll add back my comment). Ocaasi (talk) 05:57, 11 August 2010 (UTC)


 * We reflect the source and not argue whether there is medical consensus among other sources. QuackGuru (talk) 06:12, 11 August 2010 (UTC)
 * We reflect the source 'and argue whether there is medical consensus among other sources; otherwise, whether the statement is disputed cannot be determined. (my problem with this discussion's heading is that it sounds like its concluding the discussion rather than addressing the review) Ocaasi (talk) 06:20, 11 August 2010 (UTC)
 * We reflect the source per NPOV and debate whether there is a serious dispute among other reliable sources per ASF. QuackGuru (talk) 06:26, 11 August 2010 (UTC)
 * ASF is not the only relevant section. We reflect the source per NPOV and debate disputes among reliable sources per NPOV, and RS.  ASF is a guide for attribution of facts/opinions only.  It does not settle more complicated disputes, or clarify how many (or which) sources qualify in a dispute.  MEDRS is useful, but it is not welded to ASF and requires all of NPOV as well. Ocaasi (talk) 07:19, 11 August 2010 (UTC)


 * I'm going to kind of wash my hands of all this. I don't think that the sources are being properly represented in a way that gives the reader specific information (for instance, in the body of the article it just quotes the conclusion, leaving in the word "numerous" instead of quantifying).  Personally, I believe in being very specific especially when science is involved.  I just don't see why we can't be extremely specific in this case, especially since the word count would not have to go up significantly, per my suggestions above.  If people here want to argue over which non-specific phrasing is more NPOV, I wish them luck. BE——Critical __Talk 03:44, 11 August 2010 (UTC)


 * The body has now more specific information. The lead accurately summarises the body. QuackGuru (talk) 06:12, 11 August 2010 (UTC)
 * I edited both the intro and the body to reflect this discussion. The intro just has two sentences, because I thought it was easier to read.  The body has some minor cleanup for grammar, as well as a small expansion about Ernst's cost-benefit logic. Ocaasi (talk) 07:19, 11 August 2010 (UTC)
 * This and this make it a lot better (: It's pretty specific as to how things stand.  BE——Critical __Talk 07:32, 11 August 2010 (UTC)

Agreed. But hello, what about the lead? It is still not ok Javsav (talk) 09:07, 11 August 2010 (UTC)
 * Right. How do people want to fix that? BE——Critical __Talk 20:10, 11 August 2010 (UTC)


 * How is the text not properly summarises per WP:LEAD? When this systematic review is accurately summarises in the lead there is no problem. QuackGuru (talk) 17:44, 12 August 2010 (UTC)


 * We don't review the systematic review ourselves or interpret what we think the review was implying. That would be editorialising which is WP:OR. QuackGuru (talk) 17:44, 12 August 2010 (UTC)

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


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


 * Several case reports show temporal associations between manipulations and potentially serious complications. Vertebrobasilar artery stroke (VBA) is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions. Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.  'A crossover study found that increased risks of VBA stroke associated with chiropractic and general practitioner visits was likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. A literature synthesis found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.


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

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

Comments

 * I think that works really well. You've done a great job at keeping the paragraphs balanced, with both sides being clearly shown and neither one receiving preferential wording. Great example of NPOV with opposing viewpoints. I don't see any problems with it at all. Good job. Silver  seren C 02:43, 14 August 2010 (UTC)
 * Please show how this meets MEDRS. QuackGuru (talk) 02:50, 14 August 2010 (UTC)
 * Please show how it doesn't. Besides ref #1, the rest all appear to be exactly the kind of sources that MEDRS asks for. Silver  seren C 03:01, 14 August 2010 (UTC)
 * I asked the question and now you are asking me a question. Please show how this meets MEDRS or I assume you are unable to show how they meet MEDRS. Which references are reviews per MEDRS. QuackGuru (talk) 03:03, 14 August 2010 (UTC)

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

Several case reports show temporal associations between manipulations and potentially serious complications. Vertebrobasilar artery stroke (VBA) is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions. Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke. A crossover study found that increased risks of VBA stroke associated with chiropractic and general practitioner visits was likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. A literature synthesis found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.'''

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

Here are the problems to begin with. This is a massive MEDRS violation. QuackGuru (talk) 03:20, 14 August 2010 (UTC)
 * ...*sighs* Here goes...
 * Ref #1 is from the Journal of Manipulative and Physiological Therapeutics, which fits under the Biomedical Journals section of MEDRS.
 * Ref #2 is obviously the systematic review that started this entire discussion in the first place.
 * Ref #3 is guidelines set forth by the World Health Organization (WHO), which fits under the Medical and scientific organizations banner of MEDRS.
 * Ref #4 is from the Journal of the Royal Society of Medicine, which fits under both the Journals and Organizations heading.
 * Ref #5 is from PEDIATRICS, which is, yet again, a Journal.
 * Ref #6 is from Spine, another Journal
 * Ref #7 is from Spine.
 * Ref #8 is from European Neurology, another Journal.
 * Ref #9 is from Neurologist, another Journal.
 * Ref #10 is also from Spine.
 * Refs #11, 12, and 14 are from the Journal of Manipulative and Physiological Therapeutics Journal.
 * Ref #13 is also from the WHO.
 * Ref #15 is also from Neurologist.
 * There, all covered...except for why 6 is blank. Silver  seren C 03:25, 14 August 2010 (UTC)
 * 6 just didn't copy-over for some reason. I updated it. It's also from Spine. Ocaasi (talk) 03:49, 14 August 2010 (UTC)
 * You have not shown how the newly proposed refs are reliable per MEDRS. QuackGuru (talk) 03:29, 14 August 2010 (UTC)


 * Assess evidence quality

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

I don't see even one of the newly proposed text using a systemetic review. QuackGuru (talk) 03:29, 14 August 2010 (UTC)
 * Then I suppose the first step would be to find out what type of studies the supplied references are. Though I will leave that up to Ocaasi to determine, since he is likely much better and more able at finding that out than I am. Silver  seren C 03:38, 14 August 2010 (UTC)
 * According to you previous argument any reference appearing in a journal is reliable. That is clearly not the intent of MEDRS. For medical information we rely on reviews for example. In this case we already have plenty of reviews in the safety section. The recent proposal uses any low-quality reference to argue against high-quality references. QuackGuru (talk) 03:45, 14 August 2010 (UTC)
 * You have yet to explain why the supplied references are "low-quality". Silver  seren C 03:54, 14 August 2010 (UTC)
 * I have already explained the newly proposed references are not systematic reviews. Any reference appearing in a journal is not reliable per MEDRS. QuackGuru (talk) 03:57, 14 August 2010 (UTC)
 * You are clearly misunderstanding what MEDRS means. Otherwise, there would be no section on Biomedical Journals on MEDRS. Yes, systematic reviews are the highest quality and the most reliable, but that doesn't mean that reviews in journals are non-reliable. s the section in MEDASSESS states...
 * "The best evidence comes from meta-analyses of randomised controlled trials (RCTs), and from systematic reviews of bodies of literature of overall good quality and consistency addressing the specific recommendation. Narrative reviews can help establish the context of evidence quality. Roughly in descending order of quality, lower-quality evidence in medical research comes from individual RCTs, other controlled studies, quasi-experimental studies, and non-experimental studies such as comparative, correlation, and case control studies. Although expert committee reports or opinions, along with clinical experience of respected authorities, are weaker evidence than the scientific studies themselves, they often provide helpful overviews of evidence quality. Case reports, whether in the popular press or a peer-reviewed medical journal, are a form of anecdote and generally fall below the minimum requirements of reliable medical sources."
 * Which shows that other types of material besides systematic reviews are seen as reliable, per MEDRS. And, as the section on Biomedical Journals states, "Peer-reviewed medical journals are a natural choice as a source for up-to-date medical information in Wikipedia articles. They contain a mixture of primary and secondary sources, as well as less technical material such as biographies. Although almost all such material will count as a reliable source, not all the material is equally useful." Thus, journal reviews can be used, as they are in the new proposal, to show opposite viewpoints to a systematic review. You do not have to have a systematic review to counter the views of another systematic review. That would be ridiculous and far too restrictive. Silver  seren C 04:05, 14 August 2010 (UTC)
 * You clearly did not show which references are reliable per MEDRS. According to your argument editors can cherry pick any reference as long as it is from a journal. This goes against WP:MEDASSESS. The intent of MEDRS is not to allow editors to reach down into primary studies to argue against high-quality reviews. You do have to have a systematic review to counter the views of another systematic review instead of using a primary study to argue against a systematic review. QuackGuru (talk) 04:15, 14 August 2010 (UTC)
 * You have yet to prove (or even explain how) that any of the supplied references are primary sources, which is why I stated above that we need to figure out what type of reviews they are so we know where they rnk on the scale of reliability. Silver  seren C 04:22, 14 August 2010 (UTC)
 * You think it is ridiculous and far too restrictive to have to have a systematic review to counter the views of another systematic review. Then you think MEDRS is ridiculous. QuackGuru (talk) 04:29, 14 August 2010 (UTC)

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

QuackGuru, you are either high, or stupid. What you are proposing is that in any article on wikipedia, the only references that can be used are systematic reviews. In order to do this, you would have to delete half of wikipedia. You are misunderstanding MEDRS - it says that systematic reviews are the highest quality - it does not say they are the ONLY thing acceptable. Controlled studies are also of high quality. You need a reality check Javsav (talk) 04:52, 14 August 2010 (UTC)
 * You can't use low-quality references to argue against systematic reviews. I did delete not half but all the lower quality references recently added against MEDRS. QuackGuru (talk) 05:00, 14 August 2010 (UTC)

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

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


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

This reference was written by the Palmer College of Chiropractic West. Do editors seriously think this reference is reliable per MEDRS from Jan 2005. QuackGuru (talk) 06:36, 14 August 2010 (UTC)
 * Yes. Do you have a reliable source which suggests otherwise?  The review is given full in-text attribution so that if users have any doubt they can immediately see who published the article and make their own determinations.  I believe that concept lies at the very core of NPOV.  Ocaasi (talk) 09:09, 14 August 2010 (UTC)
 * WP:MEDRS: "Peer-reviewed medical journals are a natural choice as a source for up-to-date medical information in Wikipedia articles. They contain a mixture of primary and secondary sources, as well as less technical material such as biographies. Although almost all such material will count as a reliable source, not all the material is equally useful.
 * WP:RS#Scholarship: "Material such as an article or research paper that has been vetted by the scholarly community is regarded as reliable. If the material has been published in reputable peer-reviewed sources or by well-regarded academic presses, generally it has been at least preliminarily vetted by one or more other scholars."
 * The source is reliable per MEDRS and RS. We can discuss issues of impartiality and weight but not if you choose to cite policy only to support your preference rather than to apply policy as a whole. Ocaasi (talk) 10:51, 14 August 2010 (UTC)

"Please show which ref in accordance per MEDRS contradicts the risk of death from chiropractic neck manipulation by far outweighs the benefits." The whole point is we don't need to show that because in the article the text that Ocaasi has contributed does not contradict that statement, it merely offers opposing viewpoints. It's like saying "this review stated this, but other sources disagreed" then the reader can make up their mind as to what they believe - it offers a balanced view. Those sources do not need to contradict Ernst because in the article, Ocaasi's text was in no way contradicting Ernst's claims, just offering opposing viewpoints. Javsav (talk) 09:59, 14 August 2010 (UTC)
 * That is correct. This is in addition to the statements by Ernst. Ocaasi (talk) 10:51, 14 August 2010 (UTC)


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


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

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


 * Uptodate has a great overview:

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


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


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

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


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

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


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

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

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


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


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


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


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


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


 * If you find none of this relevant, then we should probably move toward clarifying the questions for an RfC. Not much point in going back and forth if the points aren't being addressed. I recommend we produce two alternate drafts of the Safety and Risk/Benefit sections, a list of implicated policy questions, a list of specific disputed claims, and a list of specific disputed sources. User:Ocaasi 18:43, 19 August 2010 (UTC)
 * Javsav and Silver Seren where not able to address the sourcing issues per MEDRS. We can't use a low-quality source to argue against a systematic review and add editorializing WP:OR. This view conflicted with prior recommendations[editorializing?] is not stated in the source. That is your personal interpretation and original research. I don't see in the WHO report that the risk of death from manipulations to the neck does not outweigh the benefit and the WHO report can't be used in the risk-benefit section because it is not specifically about risk-benefit. Do you have any WP:MEDRS sources that are specifically about risk-benefit and not generally about stated risk that meet MEDRS. QuackGuru (talk) 00:36, 20 August 2010 (UTC)
 * QG, it doesn't appear that you read my comments carefully. I have no problem taking out what you called editorializing or original research: the WHO quote is significant, not the description of the quote which we can change.  Silver Seren did address the sourcing issue per MEDRS, please see that comment.  The WHO's guidlines on chiropractic are neither low-quality nor outside MEDRS.  The WHO report is clearly about the context of research around adverse events.  If you want to leave out the "conflicts with the view" part, that's fine, as long as we include the WHO's interpretation.  All of these sources are about the claims related to VBA stroke, vascular accidents, rates of adverse events, and general safety.  A source which literally says "Ernst's claims are wrong" is not necessary to include other information.  It's a bar that is neither being suggested nor is required by policy.  As repeated before, Ernst is not a problem.  The problem is the lack of sources which provide additional/alternate/competing views which exist in reliable medical sources about these issues.  If none of this makes sense, then I think we should consider something towards an RfC. Ocaasi (talk) 03:33, 20 August 2010 (UTC)
 * You or any other editor did not give a valid reason to ignore MEDRS or expand the safety section. You have no problem taking out what is editorializing or original research but I assume you don't understand what you want to add is against WP:OR or it does not matter to you that adding OR is against Wikipedia's consensus. The WHO report is about adverse events which is already covered in the safety section. You want to add repetitive material to double the size of the safety section that will coverup or drown the existing text.
 * The Neurologist journal recommended further research using prospective cohort study[This is too much attribution in the text.] designs to uncover both the benefits and the risks associated with chiropractic manipulation.[15][Many studies recommend further research. This does not tell the reader anything significant.] The proposal does not add anything significant to the safety section.
 * Here is a question to see if you understand MEDRS. Do you think it is appropriate to use a primary source or low-quality source to argue against a higher-quality source such as a systemetic review. QuackGuru (talk) 04:14, 20 August 2010 (UTC)
 * Part of the proposal is "The risk of a serious adverse event within one week of treatment is low to very low,"[1][Unreliable medical source?] This is vague and repetitive. The 24 to 48 hours is more concise.
 * "Spinal manipulation is associated with frequent, mild and temporary adverse effects,[21][22] including new or worsening pain or stiffness in the affected region.[144] They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours.[145]" This is currently in the article. There is no reason to change it. QuackGuru (talk) 04:36, 20 August 2010 (UTC)
 * Myself, and other editors, have given numerous reasons to improve the sourcing in this article per MEDRS. Your continual characterization of interpreting policy differently as ignoring policy makes this discussion difficult.  Nothing I have suggested in the revised form is OR, provided the words are chosen carefully.  The WHO quote cannot be OR, because, it's a quote.
 * I want to accurately reflect the variety of views held by reliable sources. If that changes the current balance of the section, it does not mean the current form is better.  Attribution is useful where issues are contentious or where reliability is in question.  Increased attribution in the instance of Neurologist, increases the credibility of the sentence rather than undermine it, as in-line attribution can be misused to do.  The Neurologist recommended a specific type of study which reflected the lack of dispositive research on these contentious issues.  Per your MEDRS question, none of the sources are primary, and calling them low-quality if they are not just avoids having to use the sources.  An RfC will help resolve the appropriate weight the sources deserve.
 * The low-to-very-low summary is important, particularly considering that 24-48 hours only covers a specific timeframe. Doc James statistics about 1:400k to 1:2m are directly relevant and reliably sourced.  There is reason to include additional, qualifying, contextualizing, conflicting reports.  If you don't want to try and figure out which sources would best do that from the new ones that have been introduced, then we should have other editors weigh in on matters of sources and policy.  If you are very confident in your interpretation of policy, then an RfC should only help bolster your position.  It might also help address some of the specific claims that have been made. Ocaasi (talk) 04:48, 20 August 2010 (UTC)


 * For the article we can't use the statistics about 1:400k to 1:2m that are from an older systematic review from 2002.
 * This is dated material from 2002. This shows Ocaasi does not have a problem with violating MEDRS. We have better material currently in the article anyhow.
 * "Estimates vary widely for the incidence of these complications, and the actual incidence is unknown, due to high levels of underreporting and to the difficulty of linking manipulation to adverse effects such as stroke, which is a particular concern. " This is more accurate than older statistics.
 * The proposal will drown out the safety section and replace it with vague information and insignificant information. 24-48 hours bit is more precise than the proposal. QuackGuru (talk) 05:07, 20 August 2010 (UTC)

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


 * From WP:MEDRS:
 * Use up-to-date evidence:...Look for reviews published in the last five years or so, preferably in the last two or three years. The range of reviews examined should be wide enough to catch at least one full review cycle, containing newer reviews written and published in the light of older ones and of more-recent primary studies....Prefer recent reviews to older primary sources on the same topic. If recent reviews don't mention an older primary source, the older source is dubious....These are just rules of thumb. There are exceptions:... Cochrane Library reviews are generally of high quality and are routinely maintained even if their initial publication dates fall outside the above window.
 * Doc James' stats are from uptodate.com, a reliable and 'uptodate' tertiary source. Please see this previous discussion on RSN, also here.  More importantly, the source provides global ratios for incidents, which Ernst does not.  26 deaths since 1934 is significant, but out of how many treatments?
 * Also, as MEDRS suggest, Ernst 2010 may even be too soon to be specifically contradicted, since it has not been through a full review cycle. Since no other sources have had time to dispute its specific claims, WPMEDRS on systematic reviews might be reasonably relaxed in this context to allow competing views.  Also, do you think it is curious or problematic that the risk/benefit section contains four references 'all' to Ernst?
 * 24-48 hours is specific but not complete. It only describes the time-frame of moderate effects, not the probability of adverse effects, which published data shows is remarkably low, low enough that it is perhaps safer than many conventional treatments.  There is also evidence that adverse effects (though possibly underreported) are also possibly conflated with underlying conditions. Thus, there is a broader picture which your approach does not sufficiently describe.  You are again accusing me of ignoring policy when I am offering a different application of the policy in this circumstance.  We could continue on the merits, but not if you are only going to repeat mischaracterizations.
 * I think I will try and bring some other editors' views to the page. Would you prefer WP:30, WP:Mediation, WP:RSN/WP:NPOVN, or WP:RFC? Ocaasi (talk) 06:52, 20 August 2010 (UTC)


 * "Spinal manipulation is associated with frequent, mild and temporary adverse effects,[21][22] including new or worsening pain or stiffness in the affected region.[144] They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours.[145]"
 * The estimates are about frequent, mild and temporary adverse effects.
 * "They have been estimated to occur in 33% to 61% of patients, and frequently occur within an hour of treatment and disappear within 24 to 48 hours."
 * You want to delete this material from a systematic review specifically on Safety of chiropractic interventions and replace it with a reference that is not specifically about safety.
 * The reference from 2002 is not an up-to-date reference. This is too dated.
 * The Safety section is made up of text written by Wikipedians. The absurd proposal is made of attribution in the text and quotes. Adding a several quotes does not have an encyclopedic feel. It is very poor writing to add quote after quote.
 * There are similar references like the new systematic review. So there has been given enough time for other researchers to write about risk-benefit of the neck manipulation.
 * Abstract
 * Manipulation of the cervical spine (MCS) is used in the treatment of people with neck pain and muscle-tension headache. The purposes of this article are to review previously reported cases in which injuries were attributed to MCS, to identify cases of injury involving treatment by physical therapists, and to describe the risks and benefits of MCS. One hundred seventy-seven published cases of injury reported in 116 articles were reviewed. The cases were published between 1925 and 1997. The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases. Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists. Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements). The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed.
 * Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65.
 * WPMEDRS on systematic reviews might be reasonably relaxed in this context to allow competing views? You have not given any other view specifically about risk-benefit. Not all the reviews are written soely by one author. There is one of the reviews written by two authors. QuackGuru (talk) 03:00, 21 August 2010 (UTC)
 * "The estimates for serious adverse events varied between 5 strokes in 100,000 manipulations to 1.46 serious adverse events in 10,000,000 manipulations and 2.68 deaths in 10,000,000 manipulations.[145]"
 * I added this material using a recent systematic review specifcally about safety. This is about serious adverse events. QuackGuru (talk) 06:26, 22 August 2010 (UTC)'
 * I added this material using a recent systematic review specifcally about safety. This is about serious adverse events. QuackGuru (talk) 06:26, 22 August 2010 (UTC)'

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

Criticism section
Please see WP:CRITS. I don't think this article needs this section at all. Criticism can (and is already) worked into the appropriate sections of the article. Such as Safety, Effectiveness and Public Safety. Why does there need to be a separate section with mostly duplicate arguments? It is poorly worded, and is inherently skewed. I propose we remove it completely and work in what little material that it doesn't duplicate into the appropriate sections. --Anon 02:23, 22 August 2010 (UTC)


 * There was a previous discussion on this to keep the section per WP:CON. QuackGuru (talk) 05:55, 22 August 2010 (UTC)
 * A tried a compromise. I shortened the section. QuackGuru (talk) 17:47, 22 August 2010 (UTC)
 * I think there is plenty material on the controversy already. If you want to keep the section under the name "Controversy" - I agree it is a slightly better solution, but the section itself is still poorly skewed and presents a one sided argument. Please do not remove NPOV dispute tags until NPOV issues have been addressed.--Anon 07:27, 23 August 2010 (UTC)
 * When you agree it was a slightly better solution and the section was shortened that's what a compromise is. The past discussion did address this section. See Talk:Chiropractic/Archive 30. This was discussed here to have such a section. QuackGuru (talk) 17:34, 3 September 2010 (UTC)

Revert warring
I have looked at the edit history of this page and there seems to be a big dispute going on. Reverting opposing views without a proper discussion is NOT an appropriate way to resolve a dispute. I can only comment on the parts that I myself edited, I do not know the full issues. But could the parties involved please start discussing it here before we get admins involved.--Anon 07:43, 23 August 2010 (UTC)
 * Never mind. Looks like this is an issue that has stalled, I have requested a mediation cabal request to help us move on: Mediation Cabal/Cases/2010-08-23/Chiropractic. Please participate once the case has been accepted by a mediator. --Anon 08:14, 23 August 2010 (UTC)

QuackGuru reverts any edits Ocaasi or I make to the page Javsav (talk) 16:24, 23 August 2010 (UTC)

The last sentence...
I guess you have been to busy discussing cost/benefit and E. Ernst to see that someone, for fun or to have a go, has changed the last sentence to "Chiropractic is effective for any health problem, with the possible exception of lower back pain." I would have added an "in", but couldn't figure out how to edit in English Wikipedia...

Regards, Miraclewoman (talk) 20:52, 26 August 2010 (UTC)


 * You've quoted the sentence out of context. The full sentence is: "Research has not demonstrated that spinal manipulation, the main treatment method employed by all chiropractors, is effective for any medical condition, with the possible exception of treatment for back pain.[14]".--Anon 03:02, 27 August 2010 (UTC)

Neutral talk page headings
This article is controversial enough without adding bias to the discussion headings. It prejudices interactions and can go against forming consensus. Talk page guidelines are pretty clear about this; I'm planning on rephrasing several of the headings on this page, unless there is objection consistent with the following:


 * Talk_page_guidelines
 * Keep headings neutral: A heading should indicate what the topic is, but not communicate a specific view about it.


 * Talk_page_guidelines
 * Section headings: Because threads are shared by multiple editors (regardless how many have posted so far), no one, including the original poster, "owns" a talk page discussion or its heading. It is generally acceptable to change headings when a better header is appropriate, e.g. one more descriptive of the content of the discussion or the issue discussed, less one-sided, more appropriate for accessibility reasons, etc. To avoid disputes it is best to discuss a heading change with the editor who started the thread, if possible, when a change is likely to be controversial.

Thoughts? Ocaasi (talk) 19:10, 9 September 2010 (UTC)


 * I tend to agree, but I expect the general meaning of the section headings to be retained, or your changes should and will be reverted. — Arthur Rubin  (talk) 21:35, 9 September 2010 (UTC)
 * I'm glad you agree with the policy, but you seem unduly skeptical. Is there a reason you seem predisposed to doubt the motivations here or presume the need to act as an enforcer?  If you check the edit history where this was addressed, I think you'll see the efforts were in line with policy.  It is also fairly clear that current titles are not.  Ocaasi (talk) 21:55, 9 September 2010 (UTC)
 * It was very provocative to dilute the meaning of the descriptive talk page headers. QuackGuru (talk) 02:46, 10 September 2010 (UTC)
 * Perhaps I should have ran it by you first, but I didn't see the guidelines until after; I was merely acting on an instinct for NPOV. That's why I used this section to discuss the changes.  It seems policy backs it up, regardless of the motives you ascribe.  I think it is beyond question that your versions of 'description' are reflective of your personal opinions rather than neutral headings.  If you find that "diluting", then that is just part of the change from making a point in the heading to making the headings neutral and making a point in the section itself.


 * This is part of the issue about editing the same article as you, QG. By putting headings up such as "Failed verification" as opposed to "Verification and Ernst 2010" or something similar, it assumes your conclusions, presumptively shifts the burden of proof on others, denies the possibility of alternate good faith points of view or interpretations, and generally creates an atmosphere of contention rather than consensus.  I don't think other editors will find my changes provocative, except to provoke a better editing atmosphere. Ocaasi (talk) 03:20, 10 September 2010 (UTC)
 * I have repeatedly asked for verification and you were not able to provide verification. The descriptive header name is clearly. QuackGuru (talk) 03:25, 10 September 2010 (UTC)
 * Two issues: The first is that you titled it 'Failed verification' before there was any response.  That means that the outcome was determined before the discussion, which is the problem I am describing. The second is that regardless of the current state of our discussion (which hasn't even concluded), the outcome or accuracy of your claim is distinct from the topic itself.  Headings are not verdicts; they are titles.  They describe an area of debate, like 'climate change' as opposed to 'climate change deniers are wrong'.  It is not relevant for the title whether the latter turns out to be true, because that is a matter for the discussion and not the header.
 * This small debate gets at the crux of our impasse. Your opinion is necessary but not sufficient to establish consensus. More importantly, it can be beneficial to explain your points rather than to just assert them.  Like ASF for opinions, it creates a less adversarial environment to attribute opinions, especially where the assertion of them as fact seems to preempt or prejudice discussion.  All that is easier accomplished under a neutral banner.  I think that the same applies to more substantive disagreements, for adversarial dynamics can cloud or devolve broader debate as well.  You seem to think that those aspects of civility are just attempts to 'muddy the water'.  I think they're attempts to turn off the bullhorns. Ocaasi 04:02, 10 September 2010 (UTC)
 * I fully support more neutral talk page headings. QuackGuru, please consider this. We need to move forward.--Anon 05:43, 10 September 2010 (UTC)
 * Because policy appears unambiguous about this, and contentious editing has been a continual problem, I'm planning to change the headings and to assume that future sections will follow a similar convention. If QG would prefer to change his headings himself, go for it.  If not, I'll put in neutral titles.   Ocaasi (talk) 08:04, 10 September 2010 (UTC)
 * In regard "Failed verification":
 * There is no policy being violated; NPOV does not apply to talk pages.
 * The guideline suggests that the title should be changed; however, since the initial comment makes little sense with the proposed title, so this violates policy (and QG's moral rights, if not legal rights) by changing the meaning of others' comments by changing the context.
 * — Arthur Rubin (talk) 12:38, 10 September 2010 (UTC)
 * I've created a discussion on WP:AN with regards to this.--Anon 08:57, 11 September 2010 (UTC)
 * I think we should just change it, regardless of Arthur's comments. The "guideline" is on our side, while the "moral and legal rights" business has little to do with anything.--Anon 00:03, 12 September 2010 (UTC)
 * Actually, the guideline would only be in favor of you if you changed the section heading, and then reinserted the text (was "Section heading you consider objectionable") in the text just below the header. In that case, I would have no objection, even though QG may still have a valid objection to the change.  — Arthur Rubin  (talk) 02:31, 12 September 2010 (UTC)
 * I don't support censorship as a way to form consensus, but there are certain ways of conducting discussions which keep the focus on issues rather than argumentativeness. Having a discussion under a section titled "You're wrong" is not ideal.  I don't support the characterization that QG's rights are violated in any way, since the text of his argument remains 100% intact.  All that changes is the title of the heading.  For example, if I disagreed with you ardently and titled a section, "Why Editor x is completely, totally wrong", it would not really be civil, or conducive to discussion.  That's akin to what is happening here, except the title says, "Why edit x is completely, totally wrong".  The effect is the same, because it leads to a defense of an assertion rather than a discussion of a situation.
 * It seems that the policy is overwhelmingly clear that headings are not owned by individual editors. What QG is actually doing it titling his comment.  That's fine.  If he wants to put put in bold Failed Verification:, like we do at an straw poll, that makes sense.  But the title itself of the poll would never take a stance.  Imagine the discussion about pending changes being titled "Pending changes is a waste of time".  It would be preposterous.  The heading would be "Pending changes", period, or "Is pending changes effective?", or "The future of pending changes".  We discuss issues in a space defined by a title.  The title is not supposed to take a side.  I'm curious what Admin Noticeboard says.  It might set an interesting precedent for controversial articles.  Maybe we should throw out an RfC to clarify the policy.Ocaasi (talk) 02:44, 12 September 2010 (UTC)
 * It is very obvious that it is a fact that the text "did not identify substantial benefits" is not in the source given per WP:V. So the words did indeed fail verification. QuackGuru (talk) 18:27, 12 September 2010 (UTC)


 * Editing others comments is frowned upon and should not happen IMO. Yes the headings should probably be toned down but that is something you request the person who created them do themselves not something one should take upon themselves per "To avoid disputes it is best to discuss a heading change with the editor who started the thread". Doc James  (talk · contribs · email) 06:16, 15 September 2010 (UTC)

I'm trying to catch up on discussions here since I haven't been watching for awhile. I have to state that I too agree that no editor has the right to change someone else's writing like being discussed above, unless it's not a discussion to improve the article. If you don't like the title ask the editor to change it. Right now you are discussing changes to heading that already have editors discussing things, so no you don't go changing what is said by anyone else. I would also suggest losing the us against them kind of comments that I see going on too. That also doesn't allow for nice conversations when editors decide who is with them or against them. Just talk about the disagreements going on, which from the looks of it are quite a few. No other comments as of yet since I am still 'catching up'. I left here because of circular conversations and bad attitudes so I'm looking to see if there is actually conversations to discuss the changes made to the article. Any help is welcomed to show me what the disagreements are that I maybe able help with. Thanks, -- Crohnie Gal Talk  09:43, 18 September 2010 (UTC)
 * Crohnie Gal, please read the text quoted at the top of this section. Editing other users' comments is a no-no, but expecting fair and productive discussions to happen under talk page headers which serve double-duty as preemptive verdicts is not a good way to run a talk-page.  And the guidelines pretty clearly support phrasing them neutrally. Ocaasi 07:24, 19 September 2010 (UTC)


 * Then you politely ask the editor who made the headers to change them to be more neutral. You don't wait until there is a lot of discussions going on under the headers and then say well these are wrong so I'm going to change them now.  As is said above, it's frowned upon changing others editing here.  I think if you ask QG, he may change them for you, have you even asked him?  HTH, -- Crohnie Gal  Talk  12:28, 19 September 2010 (UTC)


 * The headings explain what the issues are because they are descriptive. Ocaasi prefers vague headings which do not explain the issues. I'm afraid Ocaasi has not yet provided verification for the controversial text Ocaasi added to the article. QuackGuru (talk) 16:17, 19 September 2010 (UTC)

Recent edits about Ernst
I have attempted to make changes to the description of Ernst 2010 "systematic review" of case reports describing "death from chiropractic", but it has been reverted each time. This "systematic review" has been used to conclude the section on safety of chiropractic, thus getting the final word in the section, and yet can not be given much weight at all in the overall debate. Critics of chiropractic (Ernst himself) have adamently refuted the use of case studies to support chiropractic efficacy for the treatment of any condition, and I am in 100% agreement with this. Case studies reflect anecdotal tales that are not able to be used to prove (or even suggest) causation. Thus, the description of Ernst 2010 review:

"A 2010 systematic review of published literature since 1934 found reports of 26 deaths that resulted from chiropractic manipulations... The dissection of a vertebral artery, typically caused by neck manipulation, was a likely cause"

is highly flawed. First, as mentioned, case reports cannot prove that the deaths resulted from chiropractic. These are anecdotal reports, and only support the need to do real research, they dont constitute research themselves. Further, A list of case reports (as represented by this review) are no more evidence than a single case report....simply a list of anecdotes. Finally, the last sentence is unsubstantiated, as vertebral artery dissections have not yet been proven in the literature to "typically result from neck manipulations".

Sincerely, 173.206.208.87 (talk) 11:05, 18 September 2010 (UTC)
 * 173.206.208.87, please visit the Mediation Cabal/Cases/2010-08-23/Chiropractic. This has been a problem for quite some time and QuackGuru will revert any edit without discussion. He is a bully . ---Javsav (talk) 13:13, 18 September 2010 (UTC)
 * IP 173, you may be right, and I also find flaws with the methodology, but we need to find published sources which say so, and the more reliable the better. We're currently debating whether Rosner's 2010 critique qualifies.  There is also a published critique from 2006.  I'm not sure if we can report on general issues with case studies that don't explicitly mention chiropractic, but it's worth figuring out.
 * Javsav, please strike your 'bully' comment. As I've said before, there are situations where it is worse to say it than to deal with it other ways.
 * Generally, while the mediation is going, we should try to use that as the forum to gain consensus, rather than letting edit-warring distract from it. These are complicated issues about research, bias, and policy, etc. that could use clarification on before changing.Ocaasi 04:51, 19 September 2010 (UTC)


 * Good comments above Ocaasi, nice to see. :) Is there a mediation page going on somewhere that I've missed? Thanks in advance, -- Crohnie Gal  Talk  12:31, 19 September 2010 (UTC)


 * Sorry, internet problems this morning. I missed the above comment about the mediation, my apologies for that.  If I can stay online long enough I'll continue reading it.  Thanks, -- Crohnie Gal  Talk  13:13, 19 September 2010 (UTC)


 * The mediation is going to officially start sooner or later when there is a mediator. The mediation is at Mediation Cabal/Cases/2010-08-23/Chiropractic. QuackGuru (talk) 16:11, 19 September 2010 (UTC)

Violation of ASF when there is no serious dispute
This controversial change by Javsav added attribution in the text where there is no serious dispute and added "in a small scale Australian questionnaire" which is also a violation of ASF which implies there is a dispute when there is none. There was previous discussion about ASF violations. See Talk:Chiropractic. QuackGuru (talk) 20:42, 18 September 2010 (UTC)
 * Mentioning the "small scale..." is undermining. But using attribution for the systematic review is okay.  The recent and evolving state of research means that these issues are not "plain facts" per ASF.  Editorial discretion allows us to use attribution if it will improve the article, especially in borderline cases.  I think that trying to verifiably characterize the weight of findings, or mentioning the size/scope/date of studies helps readers to ascertain the state of research.  That is an encyclopedic bonus, even if it prevents asserting all recent findings as definitive.  Even a "Recent research suggests/has found..." is a way to contextualize these ongoing developments.  As for findings like Ernst's risk/benefit balance, attribution can be useful, particularly if there is not corroboration through other sources; describing statements as "Current scientific consensus" is also a way to bridge the gap between relatively recent findings and the unequivocal status of textbook medicine which matures through decades of confirmation. Ocaasi 07:12, 19 September 2010 (UTC)
 * I'm afraid that MEDRS makes it clear that the contents of an undisputed secondary source are "plain facts" per ASF. Our encyclopedia reflects the current mainstream state of knowledge and is not news. It would be helpful to carefully review the advice contained in WP:MEDRS, particularly the second and last paragraphs. It is acceptable to cite a primary study that illustrates a novel point, but it must be attributed. What is not acceptable is to use such primary sources to rebut conclusions already covered in a reliable secondary source, nor is it acceptable to present the findings of a reliable secondary source in the manner that implies they have the status of a primary. In other words: no, it is not ok to attribute reliable secondary sources, unless other reliable secondary sources offer different findings. It is not our job to "contextualise" secondary sources as a way of hinting that we personally disagree with their findings. We offer the references to the reader so that they can form their own judgements, but we don't allow our own judgements to colour the way we present the article text. --RexxS (talk) 08:07, 19 September 2010 (UTC)
 * Rexxs, I read the section closely and found no explicit support for treating systematic reviews (SRs) as plain facts. SRs are clearly supposed to predominate, to not be held on the same level as recent primary studies, and to be presented as scientific consensus if undisputed.  But nowhere did I see anything about not mentioning where conclusions came from, in other words, attributing consensus to a systematic review, particularly when the review is the only one which draws a certain conclusion.  In the case of Ernst's 2010 review, it was the first time anyone asserted unequivocally that the risk outweighs the benefits.  That's fine.  I disagree with aspects of his reasoning, but I have no problem presenting that view as described.  I just want to attribute the conclusion to his systematic review, since that is where it came from, since the review was particularly recent, since the risk-benefit analysis was secondary to his study on deaths, and since he explained in his own words how he came to the risk-benefit conclusion, which we can paraphrase or quote for the reader's understanding.  All of that traces back to Ernst.  Why shouldn't we mention him and the prominence of his studies in shaping this scientific consensus? Ocaasi 09:23, 20 September 2010 (UTC)
 * From Identifying reliable sources (medicine):
 * "Literature reviews, systematic review articles and specialist textbooks are examples of secondary sources, as are position statements and literature reviews by major health organizations." (my emphasis)
 * From Neutral point of view:
 * "Assert facts, including facts about opinions—but do not assert the opinions themselves. A fact is a statement about which there is no serious dispute among reliable sources."
 * "An "opinion" on the other hand, is a statement which expresses a value judgment, or a statement construed as factual that does not reflect the consensus in other reliable sources."
 * "Values or opinions must not be written as if they were in Wikipedia's voice. Factually attribute the opinion in the text to a person, organization, group of persons, or percentage of persons, and state as fact that they have this opinion, citing a reliable source."
 * It is abundantly clear from the above that a statement in a reliably published systematic review is a "fact" by our definition, not a mere "opinion", unless it is disputed by other reliable sources. When you decide to attribute a statement to a reliable secondary source, you are mimicking our convention to attribute opinions, which unjustifiably casts an aspersion on the authority of the fact. Your decision therefore introduces your unsupported POV, which indirectly disputes the statement. That is why such suggestions will be strongly rejected. If you have sourced information about the prominence of Ernst's studies in shaping scientific consensus in this field, then the article Edzard Ernst is the proper place for it. If you feel readers of this article would like to know more about Ernst's work, then a simple wikilink to his article will suffice. I'll add that now. --RexxS (talk) 10:43, 20 September 2010 (UTC)
 * Ocaasi, It is not that we should necessarily treat every systematic review as plain fact, it is that we need to concentrate on describing chiropractic without getting diverted by irrelevancies. In articles where the topic has only a few scientific papers, it can be appropriate to devote a detailed section to describing the nuances of each. In this case, though, that would severely overburden the article, distracting focus from presentation of the topic itself; this is doubly true in the lead section, which should be kept to no more than a few hundred words at most. - 2/0 (cont.) 12:34, 20 September 2010 (UTC)

If QuackGuru had alerted me to this discussion on the talk page I would have not continued edit warring.

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

You will realise that the estimate of 5 strokes in 100,000 manipulations is from a small scale australian study using a questionnaire. All the review does is compare different studies rather than averaging incidence. The first estimate is from one small australian study. As such, I have changed it to:

"A systematic review found that estimates for serious adverse events varied between 5 strokes in 100,000 manipulations (from a small scale Australian study using questionnaires) to 1.46 serious adverse events in 10,000,000 manipulations and 2.68 deaths in 10,000,000 manipulations"

QuackGuru consistently reverts this without alerting me to the discussion for no reason. Please respond with your reasoning QuackGuru. The way that this study is represented in the text now is blatantly misleading. The fact that the estimate of 5 strokes in 100,000 was an Australian study using a questionnaire is very relevant. --Javsav (talk) 04:15, 21 September 2010 (UTC)


 * Please don't edit-war. The only result of edit warring is that the page gets protected and that delays making improvements to the article. I was the one who changed the text to assert the findings of the review as fact (rather than attributing them). Your last edit to re-insert attribution was reverted by 2/0, and when multiple editors are reverting you (not just QG), you should be heading for the talk pages sooner.
 * Would you have another look at my second response to Ocaasi above (dated 10:43, 20 September 2010 (UTC))? It saves me having to repeat the same arguments to you. I do understand that you are unhappy with the findings of Gouveia 2009, but you need to have other reliable secondary sources publish the analysis you are making for it to carry any weight. While a reliable secondary source has its findings uncontested by another reliable source, those findings remain "facts" as far as Wikipedia is concerned. I hope you can see the point I'm making above: that if you treat an undisputed reliable source as if it were an opinion (by attribution), you are effectively expressing your personal disagreement with the source's findings to the readers, albeit subtly. On your final point, you are missing the fact that when a secondary source reproduces findings taken from a primary source, those findings then carry the authority of the secondary source, which has considered a broad range of the available sources and analysed them. We are not citing a small Australian primary study; we are citing a reliable, undisputed, secondary review, with all the weight that it carries according to WP:MEDRS. --RexxS (talk) 05:19, 21 September 2010 (UTC)

Actually, you seem to be missing my point. I am not unhappy with the findings, I just think there needs to be a clarification of what those findings were. The way that it is portrayed in the text in the article at the moment is ambiguous. especially because there is a huge disparity between 5 strokes in 100,000 manipulations to the other figures. Do you really think that is a realistic figure - there would be a lot more dead patients around if it were? A systematic review is meant to analyse multiple studies and average incidences, but the way that this review has been used in the text is that the author (QG) has simply stated the findings of a few studies. He may aswell have cited those studies rather than the systematic review. That was not a finding of the review, that was the finding of a small study. If you read the mediation cabal page I actually TOLD quack guru that I was going to reword it and he did not say anything to stop me. --Javsav (talk) 06:06, 21 September 2010 (UTC)


 * Javsav, I think you are confusing systematic review with meta-analysis.
 * Citing the systematic review is very different from merely citing the cited studies. The review gives both relevance to the numbers chosen and some assurance that a comprehensive search was undertaken. In this case, the finding being cited is that the true incidence is unknown and estimates vary widely, with the numbers being provided to inform the reader of both the range bracketed and the degree of variability. When someone comes out with a good estimate of the incidence of complications (preferably a large prospective trial of some sort), we can add that or even replace the current numbers. For now, though, we have to use the best sourcing available without editorializing. - 2/0 (cont.) 13:54, 21 September 2010 (UTC)

Violation of MEDRS when citing the 2010 systematic review
[Note: Comment by Javsav was cut and pasted from the mediation page.] Well, it is unlucky for you that it was not a Cochrane review, because that means that the Ernst review is not allowed on the page as per MEDRS: "The range of reviews examined should be wide enough to catch at least one full review cycle, containing newer reviews written and published in the light of older ones and of more-recent primary studies." As such having only the Ernst review is violating MEDRS. -Javsav (talk) 20:58, 18 September 2010 (UTC)
 * According to the above comment in mediation it is a violation of MEDRS to use the 2010 systemativ review. I disagree. It would be a violation of MEDRS to not cite the 2010 review. Other reviews are being cited and no serious disagreement with the 2010 systematic review has been presented. QuackGuru (talk) 21:25, 18 September 2010 (UTC)

Third-party perspective here: This article is largely dominated by references to just one researcher: E ERNST. I've counted about 35 references to the one person. Be that as it is, I would say that this article suffers from a limited perspective.66.75.82.49 (talk) 04:52, 19 September 2010 (UTC)
 * Yes Ernst is a prolific reviewer and one of the most published authors on the subject. The Cochran collaboration has also been referenced 4 or 5 times.  Increasing it us would be a good idea. Doc James  (talk · contribs · email) 06:08, 19 September 2010 (UTC)
 * I am just pointing out that from my perspective, this article seems heavily one-sided. I would very much appreciate more and diverse sources. I don't know the rules of article writing too well but I would think that limiting the scope so narrowly does not make for good writing.66.75.82.49 (talk) 06:29, 19 September 2010 (UTC)
 * The way we write articles is by finding and reading the best reliable sources, and then reflecting what they say. When there is a content dispute between editors, the normal step is for them to bring to the talk page as many reliable sources as they can find, and then reach a consensus on the talk page what to include by using our policies of WP:RS, WP:NPOV, WP:UNDUE, and in this case WP:MEDRS. QG has offered half a dozen in a collapse box in the section Unreliable references against MEDRS above. Everyone else is able to make their suggestions. It is not productive to bemoan the limited number of sources already used, because that does nothing to move us forward. It is productive to discuss the sources already on the table, and add to them if you are able. That way lies consensus. --RexxS (talk) 07:34, 19 September 2010 (UTC)

[http://www.jmptonline.org/article/PIIS0161475405003027/fulltext#section1 A systematic review is the most efficient way to access high-quality information. No study, regardless of its type, should be interpreted in isolation. Thus, a systematic review is generally considered one of the best forms of evidence. Systematic reviews synthesize multiple studies, enabling increased and efficient access to evidence.] QuackGuru (talk) 20:00, 19 September 2010 (UTC)

Ernst is completely antichiropractic and has admitted that his views are "hotly disputed". As such, this page suffers from bias --Javsav (talk) 06:03, 21 September 2010 (UTC)


 * Ernst is the leading researcher on chiropractic and his views are disputed in the chiropractic community but not in scholarly journals. QuackGuru (talk) 06:12, 21 September 2010 (UTC)

(comment removed) -Javsav (talk) 06:16, 21 September 2010 (UTC)
 * I've removed the previous comment by for clear violation of WP:BLP, which applies to all pages on this project. --RexxS (talk) 06:40, 21 September 2010 (UTC)

Let me rephrase what I was saying, it is MY opinion that Ernst is clearly biased against chiropractors, his studies speak for themselves -Javsav (talk) 07:37, 21 September 2010 (UTC)


 * Your opinion is not WP:RS and is obviously WP:OR. QuackGuru (talk) 03:24, 23 September 2010 (UTC)

Way to point out the obvious QuackGuru, wow, my OPINION is OR? I'm flabbergasted that an OPINION is OR. How amazingly surprising. Well, pigs can fly after all. Ernst's studies are being given undue weight (WP:UNDUE) -Javsav (talk) 04:46, 23 September 2010 (UTC)


 * Yes, your opinion is OR if it was included in the article. Ernst studies have been carefully weighted. QuackGuru (talk) 04:53, 23 September 2010 (UTC)

That was my point, but you seemed to have missed the sarcasm. An opinion is always original research. Opinions are allowed on talk pages because they help to reach consensus. You telling me that my opinion is OR is redundant. -Javsav (talk) 05:13, 23 September 2010 (UTC)


 * Your interpretation of the source is OR and I doubt it will reach consensus to include your personal analysis of the source. QuackGuru (talk) 05:18, 23 September 2010 (UTC)


 * Can we move this back to a discussion of sources? What sources of similar quality could be used to replace the reviews under question? - 2/0 (cont.) 08:48, 23 September 2010 (UTC)

QuackGuru, you again misinterpreted me, but I'm used to that by now. Herzog, Austin, and the WHO statement are sources that are reliable and countering to these safety statistics --58.96.105.189 (talk) 09:16, 23 September 2010 (UTC)
 * Ernst 2010 contains a number of findings. I don't think any editor here doubts that WHO is a reliable source, but some (myself included) have pointed out that nothing in there actually contradicts Ernst; although I can see that others believe that the WHO statements about adverse effects could be read to imply a disagreement with Ernst's unequivocal statement that "risks outweigh benefits", for example. As for Herzog, I would consider him possibly RS on the topic of mechanism, although I doubt that the paper meets MEDRS as a whole, since others have cast doubt on whether it can be considered secondary by MEDRS standards. I'm not sure there's anybody left who thinks Austin is worthy of inclusion. Please feel free to correct my impression of Austin if I am wrong. In these sort of cases, I'd recommend you make use of the Reliable Sources Noticeboard, where you can often get neutral third-party opinions on the reliability of sources in a particular context. You'll need to carefully read the instructions if you want to get useful responses. --RexxS (talk) 16:25, 23 September 2010 (UTC)


 * I don't see how the unreliable source Herzog, the unreliable source Austin, or the WHO statement are sources that counter safety statistics. First, where does it mention in any of those sources anything specifically about statistics. Second, the statistics currently in safety is from a highly reliable source per MEDRS. You can't dig down into less reliable or unreliable sources to argue against a recent review. QuackGuru (talk) 18:02, 23 September 2010 (UTC)
 * QG, Your criticism of the Herzog review and WHO are odd, as the Ernst "review", which appears in multiple sections of the wikipedia article, also does not offer any real statistics on the topic of safety. As has been mentioned before, this review is purely a list of case-studies. Never does the number of individual cases of death get compared to total C manipulations that occured over the same time period, nor does it critically review any studies examining clinical outcomes of C manipulation. It simply lists 26 case reports of death. Further, it does not critically "review" any of those cases, some of which ocured weeks after any C manipulation. Despite this, the "conclusion" that "the risks by far outweigh the benefits" (repeated at least twice in the Wikipedia article) is given the final say in multiple sections (eg: last sentence of opening section, last sentence of respective paragraph in safety section, last sentence in the risk/benefit section). After you have used this very weak review so many times in the wikipedia article to support that very claim, it seems hypocritical that you continually criticize the Herzog review as inadequate, not even "allowing" it a single mention with regard to the debate on the safety of C manipulation. The Herzog review clearly and completely analyzes the evidence with regard to the biomechanical and anatomical characteristics of spinal manipulation and its effect on the vertebral artery. As such, it deserves mention in the safety section of the wikipedia article. The fact that it is clearly labelled a review in the journal that published it should be sufficient to support our use of it as a secondary source.173.206.208.56 (talk) 01:12, 24 September 2010 (UTC)173.206.208.56 (talk) 01:20, 24 September 2010 (UTC)


 * Who is criticizing the 2005 WHO guidelines? We cite them seven times explicitly, with a few more in hidden comments to make sure that future editors understand the sourcing chain. - 2/0 (cont.) 01:49, 24 September 2010 (UTC)
 * 2over0, Please Note QG's criticism of WHO statement lacking statistics in support of his POV immediately above my post.173.206.208.56 (talk) 01:57, 24 September 2010 (UTC)
 * Yes. To my reading that is a statement of the limitations of the source - it takes us so far, then later sources pick up the story. - 2/0 (cont.) 02:03, 24 September 2010 (UTC)

Controversial change to 2010 systematic review
[Rewrite added weasel words and original research] A 2010 systematic review of published literature since 1934 found 26 anecdotal[editorializing?] case reports that associate[neutrality is disputed] death with chiropractic manipulations, with suspected substantial underreporting. The dissection of a vertebral artery was suggested[editorializing] to be the cause.

[previous version] A 2010 systematic review of published literature since 1934 found reports of 26 deaths that resulted from chiropractic manipulations, with suspected substantial underreporting. The dissection of a vertebral artery, typically caused by neck manipulation, was a likely cause.

This controversial change moved and changed the wording of the text. I think the text should be restored and moved back. QuackGuru (talk) 17:22, 19 September 2010 (UTC)


 * With regard to the descriptor "anecdotal", I am in agreement...."anecdotal" was a biased adjective...I have removed it.
 * With regard to the movement of the text, this is appropriate, as the description of the Ernst article is now located with the section that already described case reports of death following manipulation. The Ernst article is a review of all those case reports, thus it is best placed following the first sentence that states that there are case reports describing death after manipulation.
 * With regard to the criticism of the text that was altered to say "association" of death with neck manipulation, The original interpretation was biased and incorrect. The Erst review article presents cases where "deaths that resulted after chiropractic manipulations" (a statement of association), this is not the same as the original version of the wikipedia text, which altered the true wording to state "deaths that resulted from chiropractic manipulations" (a statement of causation).
 * Similarly, with regard to the criticism of the text changes "suggested to be caused by manipulation", I also disagree. The original text is unsubstantiated editorializing, the new wording is an accurate representation of the current state of the literature. I am unable to find any literature that has shown vertebral artery dissections are "commonly caused by neck manipulation". The Ernst review states "extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism". Thus, this mechanism is a suggested cause.173.206.208.87 (talk) 21:13, 19 September 2010 (UTC)


 * The case reports in the beginning of the paragraph are about stroke not death. So the text should be moved back. It was more than merely an association. Death resulted directly after chiropractic manipulation. The review states "extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism". But the review went on to say more along the lines of a "likely cause". So the cause was plausible and after manipulations. QuackGuru (talk) 21:31, 19 September 2010 (UTC)


 * "the likely cause" and "the cause" are in no way the same thing. Further, the review describes the "alleged pathology", an admission that causation was not verified in any of the cases. Also, the "alleged pathology" was almost always due to stroke, thus it belongs with the first sentence describing cases of stroke after manipulation, that is, Ernst picked out those cases where the stroke ultimately resulted in death. 173.206.208.87 (talk) 21:52, 19 September 2010 (UTC)
 * Stroke and death are two different things. This is confusing to move the text about death to the beginning about stroke. You seem to know the source says "the likely cause" but you changed the text to weaken its original meaning. QuackGuru (talk) 22:03, 19 September 2010 (UTC)


 * I still fail to see how the statement "a likely cause" is anything more than an association? Perhaps I am missing something, but a "likely cause" is not "the cause" until it has been proven through original research (or I guess in a court of law). This review presents 26 case studies where each case "alleges" (taken straight from the review itself) that manipulation was the cause. Causation was not shown in any of the cases. You seem to know this, but have changed the text to strengthen its original meaning and sensationalize the outcome. 173.206.208.87 (talk) 22:24, 19 September 2010 (UTC)


 * The statement "the likely cause" following chiropractic manipulation is from the source per WP:V. To claim it was just associated with manipulation weakened the claim. The study was about death not stroke. Do you have a copy of the Ernst review? Other studies do claim causation. CONCLUSIONS: Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. QuackGuru (talk) 02:15, 20 September 2010 (UTC)


 * I have the article, it doesnt change the facts. If the weak to moderate evidence that supports causation is your bottom line, then use it in the sentence, ie., "26 published case reports of death following cervical manipulation were found; weak to moderate evidence supports the suggestion that neck manipulation resulting in vertebral artery dissection was the cause."
 * I honestly think this review is already given far to much weight in the debate anyways, as it is simply a collection of anecdotes. It is solely the fact that it was somehow allowed to be labelled a review that it is getting this much attention in the wikipedia article. Another contributer, 2over0 has a great quote on his profile: "The plural of anecdote is confirmation bias." 209.183.26.162 (talk) 14:28, 20 September 2010 (UTC)

Here is a quote from Ersnt himself. "Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely (e.g. 30,31)." QuackGuru (talk) 15:42, 20 September 2010 (UTC)

"The published literature contains reports of at least 26 deaths since 1934 following chiropractic manipulations. The dissection of a vertebral artery, typically caused by neck manipulation, is a causality that is at least likely.[23]"

I rewrote the text to more accurately reflect the source presented. QuackGuru (talk) 18:35, 20 September 2010 (UTC)

There is no way that it can be proven that that was the cause as vertebral dissection is often spontaneous. I am in agreement with 209.183.26.163--Javsav (talk) 06:21, 21 September 2010 (UTC)


 * Wikipedia is not about proving things. I provided verificationn and wrote the text in accordance with V. QuackGuru (talk) 06:23, 21 September 2010 (UTC)

Wikipedia is not about proving things? I never said wikipedia was about proving things. All I am saying is that on the part about risk benefit it should say that it was only assumed that chiropractic was the cause -Javsav (talk) 07:39, 21 September 2010 (UTC)


 * The part about risk benefit should not say that it was "only assumed that chiropractic was the cause" because this would be reviewing the reference ourselves and conducting our very own original research. QuackGuru (talk) 19:31, 21 September 2010 (UTC)

It is not OR, it says in the review that "The dissection of a vertebral artery, typically caused by neck manipulation, is a causality that is at least likely" As such, it is assumed that chiropractic was the cause - he says so himself in the review. There was no way of proving this, he said that it is a causality that is at least likely - but not proven. CONCLUSIONS: Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. weak to moderate evidence --Javsav (talk) 01:54, 23 September 2010 (UTC)


 * As such, it is assumed that chiropractic was the cause? We don't conduct our own review of the source presented. That would be OR. QuackGuru (talk) 03:24, 23 September 2010 (UTC)

It is not OR. The dissection of the vertebral artery WAS suggested to be the cause as per Ernst's review. You don't have to quote the study word for word, in fact that would be plagiarism. Ernst did suggest that VA dissection was the cause -Javsav (talk) 04:49, 23 September 2010 (UTC)


 * The dissection of the vertebral artery was suggested to be the cause. is OR. That is not what the source said. The source did not say we suggest it was a cause. QuackGuru (talk) 05:02, 23 September 2010 (UTC)

The source did suggest it was the cause "The dissection of a vertebral artery, caused by neck manipulation, is a causality that was at least likely" That is a suggestion, not a proof. Have you ever heard of paraphrasing? The words do not have to be exactly the same as the source -Javsav (talk) 05:19, 23 September 2010 (UTC)


 * Where in the source did it say it was a suggestion, not a proof. QuackGuru (talk) 05:27, 23 September 2010 (UTC)

Template
I moved CONSISELEAD to Verbose, which makes it more general and less shouty. Rich Farmbrough, 05:20, 20 September 2010 (UTC).
 * Thanks, but you also changed " Davenport, Iowa " to " Davenport, Iowa ", which I find a wholly unnecessary change. I'm more concerned by your changes of "specialty" to "speciality", "skillfully" to "skilfully" and "disproven" to "dis-proven", which appears to be a clear breach of WP:ENGVAR (unnecessarily changing from en-us to en-gb). These are not minor changes (in the Wikipedia sense of indisputable) and should not have been marked as such, especially when you fail to provide an edit summary. --RexxS (talk) 09:55, 20 September 2010 (UTC)


 * Those wording changes were unnecessary. I think a shortcut for would also work. QuackGuru (talk) 15:42, 20 September 2010 (UTC)

"Content" tag on Effectiveness section
There is currently a tag Content in Chiropractic questioning the relevance of some of the material in that section. I removed the bit about deaths, as it is covered more appropriately at #Safety. Is this tag still necessary, or can we get by with discussion and more specific tags? - 2/0 (cont.) 16:08, 20 September 2010 (UTC)


 * The tag can be removed now. This is the edit that deleted relevant content and added irrelevant content to Effectivenss. QuackGuru (talk) 16:46, 20 September 2010 (UTC)

SYN tag
Quackery is more prevalent in chiropractic than in other health care professions which is a violation of the social contract between patients and physicians.[syn]

Chiropractic authors stated that fraud, abuse and quackery is more prevalent in chiropractic than in other health care professions.

I rewrote the sentence while removing the SYN tag. QuackGuru (talk) 18:20, 20 September 2010 (UTC)

POV tag
We don't have a dispute over the entire article. A lot of the problems were a few editors did not understand that they were adding unreliable references or violating ASF. There was OR added to the article and text that failed verification. I don't see a good reason to continue having a tag that is for a content dispute over the entire article when we don't have multiple sections under dispute. QuackGuru (talk) 18:27, 20 September 2010 (UTC)


 * Give it 24 hours, but unless anyone else objects I think we can remove the tag and work on individual sections. - 2/0 (cont.) 21:50, 20 September 2010 (UTC)

No we can not remove the tag. I was away when this discussion was started. The tag must remain until the mediation has finished. That was the agreement --Javsav (talk) 05:24, 23 September 2010 (UTC)


 * There is no requirement for a tag becuase of mediation and you have not shown there are multiple sections under dispute. QuackGuru (talk) 05:26, 23 September 2010 (UTC)

I definitely think that the tag should remain. If you read this talk page there are plenty of sections under dispute by several different editors. --Axxaer (talk) 05:29, 23 September 2010 (UTC)


 * I don't see multiple sections in the article under dispute. QuackGuru (talk) 05:30, 23 September 2010 (UTC)

Talk:Chiropractic/Systematic review about safety, Attribution of secondary sources, Herzog 2010, Controversial change to safety, Controversial change to 2010 systematic review, Violation of MEDRS when citing the 2010 systematic review, Violation of ASF when there is no serious dispute, Conducting your own original research, Recent edits about Ernst, Failed verification, Unreliable references against MEDRS, Unreliable chirorpractic literature failed RS, The word critics failed verification, ASF violation when there is no serious dispute. Then the whole of this archive: Talk:Chiropractic/Archive_31 --Axxaer (talk) 05:42, 23 September 2010 (UTC)


 * We have a few discussions running, yes, but ideally none of our articles would be tagged; the tag is intended to spur discussion, not to substitute for it or to hold the article hostage in the face of consensus. Could someone who supports the tag please outline in a new subsection *specifically* what changes you would like to see? Then, we can bring the weight of sources to bear on each issue. - 2/0 (cont.) 09:08, 23 September 2010 (UTC)

Changes
==>58.96.105.189 (talk) 09:20, 23 September 2010 (UTC)
 * Adding of new reliable sources such as the WHO, Austin and Herzog to safety
 * Fixing for the blatant statement in the lead re "risks outweighing benefits" - vertebral artery is only suggested to be the cause, not proven
 * Removal of unnecessary controversy section and accusing chiropractors of "Quackery"


 * The WHO source is in the article. Both the Austin and Herzog sources are unreliable.
 * The text in the lead regarding "risks outweighing benefits" is attributed to the source using attribution in the text as a compromise. The comment "vertebral artery is only suggested to be the cause, not proven" is original research. Where does it say it was suggested to be the cause in the source? We don't analyse the source ourselves.
 * There was a previous discussion per WP:SUMMARY to have a Controversy section. See Talk:Chiropractic/Archive 31. This is about social conduct regarding the term quackery not medical related information. In this case, the MEDRS inline tag does not apply. The term 'quackery' is sourced (and has attribution in the text) in accordance with V. QuackGuru (talk) 17:12, 23 September 2010 (UTC)


 * WHO is a good source; what findings would you like to see reported in Safety and can you suggest a proposed text?
 * I think there's a consensus not to include Austin. Have a read through this page and see if you disagree.
 * Opinion seems to be split on Herzog. You may need to make a case for its inclusion or seek an outside opinion at WP:RSN.
 * The "risks outweighing benefits" statement is sourced to a reliable secondary source. Are you suggesting removal of the text or amendment to something different? If so, what?
 * The Controversy section summarises the daughter article Chiropractic controversy and criticism, which is reliably sourced, so it would be utterly inappropriate to suggest deleting it.
 * "Quackery" is sourced to Murphy 2008: "The chiropractic profession has an obligation to actively divorce itself from metaphysical explanations of health and disease as well as to actively regulate itself in refusing to tolerate fraud, abuse and quackery, which are more rampant in our profession than in other healthcare professions." Are you claiming Murphy is not MEDRS in this context? --RexxS (talk) 17:24, 23 September 2010 (UTC)

Sentence blanking
An IP deleted a sentence and also deleted two references from a sentence without explanation so I reverted it. I forgot to put in an edit summary for my edit. QuackGuru (talk) 19:21, 20 September 2010 (UTC)

"A systematic review determined that the risk of death from manipulations to the neck by far outweighs the benefits.[23]"

"In conclusion, numerous deaths have been associated with chiropractic neck manipulations. There are reasons to suspect that under-reporting is substantial and reliable incidence figures do not exist. The risks of chiropractic neck manipulations by far outweigh their benefits. Healthcare professionals should advise the public accordingly." This is a copy from the full text PDF file which verified the claim per V policy. QuackGuru (talk) 06:02, 21 September 2010 (UTC)

Systematic review about safety
QuackGuru consistently is reverting my edits (4 times now without discussion) to the section about safety regarding a systematic review. The text as it was currently standing was "Estimates for serious adverse events varied between 5 strokes in 100,000 manipulations to 1.46 serious adverse events in 10,000,000 manipulations and 2.68 deaths in 10,000,000 manipulations"

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

You will realise that the estimate of 5 strokes in 100,000 manipulations is from a small scale australian study using a questionnaire. All the review does is compare different studies rather than averaging incidence. The first estimate is from one small australian study. As such, I have changed it to:

"A systematic review found that estimates for serious adverse events varied between 5 strokes in 100,000 manipulations (from a small scale Australian study using questionnaires) to 1.46 serious adverse events in 10,000,000 manipulations and 2.68 deaths in 10,000,000 manipulations"

QuackGuru consistently reverts this without discussion for no reason. Please respond with your reasoning QuackGuru. To revert without discussion of this completely reasonable edit is against wikiepdia's guidelines. -Javsav (talk) 03:33, 21 September 2010 (UTC)


 * I believe that this is being discussed at . - 2/0 (cont.) 04:12, 21 September 2010 (UTC)


 * Me thinks there is also a discussion at . Javsav, please don't accuse me of reverting your edit when another editor deleted the WP:ASSERT violations. I tagged the text. QuackGuru (talk) 05:09, 21 September 2010 (UTC)

Request citation
Two U.S. states (Washington and Arkansas) prohibit physical therapists from performing SM,[citation needed] I request a reference for the non-controversial text. See under Chiropractic. QuackGuru (talk) 20:13, 21 September 2010 (UTC)

This Seattle Times blog article cites both states but indirectly. I'm looking for the actual legislation, but the citations are a bit tricky to pin down. In Washington, it's the WA PT Act of 1988. It's all over the news, since they're lobbying to change it, but I can't find links to the statutes themselves. Ocaasi (talk) 06:25, 22 September 2010 (UTC)


 * I added the ref to verify the claim. QuackGuru (talk) 17:12, 23 September 2010 (UTC)

Request images
I request images of chiropractor spinal manipulations for the Treatment techniques section and historical chiropractic images for the History section. QuackGuru (talk) 20:20, 21 September 2010 (UTC)

"Brings Ridicule"
Keating writes of subluxation: "Acceptable as hypothesis, the widespread assertion of the clinical meaningfulness of this notion brings ridicule from the scientific and health care communities and confusion within the chiropractic profession." The last sentence of the first paragraph in our article paraphrases this describing subluxation: "a vitalistic notion that brings ridicule from mainstream science and medicine".

I don't think it sounds very encyclopedic. It maybe technically true, but the encyclopedic point is that subluxation has no support in mainstream science and has been an obstacle to the reputation of chiropractic as a legitimate modality. Something like that. But the way it is now focuses on the ridicule rather than scientific consensus or the historical significance which is that Vitalism has not been good for advancing the profession. Also, 'brings' in the present tense seems to be the wrong tense, and as a grammatical point, 'science and medicine' can't ridicule, since they are academic disciplines not speaking agents. Thoughts? Ocaasi (talk) 05:36, 22 September 2010 (UTC)


 * It maybe technically true? We are not dealing with truth here. We are repeating what is written in the source per WP:V. Do you think your rewrite suggestion that "subluxation has no support in mainstream science and has been an obstacle to the reputation of chiropractic as a legitimate modality." is verifiable. When proposing a rewrite it would help if you can show the text you want to include is sourced. The present tense for 'brings' is the way it is written in the Keating article. Changing the tense would say it is no longer ridiculed by maintream health care. It is 'mainstream science and medicine' not 'science and medicine'. The word 'mainstream' is another way of writing 'community' for brevity. It is best to keep the lead concise. QuackGuru (talk) 17:45, 22 September 2010 (UTC)

The text does not have to be directly from the source, it can be paraphrased. To quote text directly from the source is plagiarism -Axxaer (talk) 05:32, 23 September 2010 (UTC)


 * You must show the text is sourced or the text failed V. QuackGuru (talk) 05:35, 23 September 2010 (UTC)


 * Quoting text from a named source involves attribution of the source, which means that the editor is not claiming that they created the quoted text. This is not plagiarism, since that involves claiming another's work as your own. However, too large a direct quote may constitute a copyright violation, so quotations should be brief. Unless the exact words used by the author are essential to making an issue clear, it is generally considered poor encyclopedic style not to summarise the source text. --RexxS (talk) 18:52, 23 September 2010 (UTC)


 * Additionally, any paraphrase must honestly convey the gist of the source. We are not permitted merely to cherry pick the parts we like or to rephrase around the authors' intent to make clear conclusions more palatable to our own biases. There is a nice short essay on this topic linked on my userpage. - 2/0 (cont.) 00:38, 24 September 2010 (UTC)

Neutrality tag
Why was the neutrality tag at the top of the page removed? Was there a discussion about this? The tag was not meant to be removed until the mediation had taken place --Javsav (talk) 01:13, 23 September 2010 (UTC)


 * We don't have multiple sections under dispute. See Talk:Chiropractic. QuackGuru (talk) 03:24, 23 September 2010 (UTC)

Controversial changes to safety
More recent research has contradicted the suggestion that neck manipulation can result in vertebral artery dissection,[editorializing?] as the stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during simple passive neck range of motion. [152][Unreliable medical source?]

Further,[editorializing?] animal models of the human vertebral artery have suggested that repetitive stresses of several magnitudes greater than that which result from spinal manipulation are required to produce any microtrauma in the arterial tissues.[153][Unreliable medical source?]

This controversial change and this controversial change added original research and an unreliable reference that is not a systematic review of safety information. QuackGuru (talk) 21:57, 19 September 2010 (UTC)

''"There is no concept of "level of evidence" on Wikipedia." and "We substitute expert judgement here with a reliance on the outside world to make the judgements for us." and "No editor on Wikipedia is qualified to substitute their individual opinion on a reliable secondary source for the process involved in publishing that source." and "If it is weak or flawed, then scholarly literature will make those points."''
 * As was stated in the arbitration forum:
 * In this case, the article presented is peer reviewed and published, it is not our place to judge the evidence to be strong or weak at this point. If you dispute the evidence presented then you need to find equivalent or better research that disputes the outcome of this study. —Preceding unsigned comment added by 173.206.208.87 (talk) 22:02, 19 September 2010 (UTC)


 * It is our place to judge the reliability of the sources used. There is the concept of WP:MEDRS. QuackGuru (talk) 22:06, 19 September 2010 (UTC)


 * If it is our place to judge the reliability of evidence which has already been accepted by the scientific community through peer review, then the crticism of my comments regarding Ernst review (a list of case reports, and the lowest possible level of evidence) still holds. As I was told that "No editor on Wikipedia is qualified to substitute their individual opinion on a reliable secondary source for the process involved in publishing that source" I hold to my claim that you cannot personally argue with a paper that has been peer reviewed and published in a legitimate journal. You are required to present research that refutes the findings of the Herzog paper, your opinion of its quality or level of evidence is irrelevant.173.206.208.87 (talk) 22:14, 19 September 2010 (UTC)


 * You have not shown how theses sources meet MEDRS. QuackGuru (talk) 22:15, 19 September 2010 (UTC)

Ok, I see what you are referring to (MEDRS), I will look into it before I further refute your opinion of the article I have presented. Thanks 173.206.208.87 (talk) 22:27, 19 September 2010 (UTC) Thus, it is a valid reference to support the point I made in the text of the wikipedia article, that "More recent research has contradicted the suggestion that neck manipulation can result in vertebral artery dissection". 173.206.208.87 (talk) 22:44, 19 September 2010 (UTC) I will compromise though, and remove the text that references the primary source, which describes an animal model. 173.206.208.87 (talk) 22:55, 19 September 2010 (UTC)
 * Many thanks for pointing me to MEDRS, as it was very helpful in supporting my use of the Herzog article. MEDRS states that "Controversies or areas of uncertainty in medicine should be illustrated with reliable secondary sources describing the varying viewpoints." The article presented by Herzog "The biomechanics of spinal manipulation" is a secondary source (a review, invited by the editors of the Journal of Bodywork and Movement Therapies), thus is an acceptable source to refute earlier works. Further, in regards to the way I used the review by Herzog to make the claim of safety of spinal manipulation, this is also valid as the review "itself directly makes such a claim" (quoted from MEDRS) that: "Combined, the results of this study suggest that spinal manipulative treatments produce stretches of the vertebral artery that are much smaller than those that are produced during normal everyday movements, and thus they appear harmless."
 * It seems your removal of the Austin 2010 study was reverted, and I will not revert a reversion, so I've gone ahead and attributed it as well as adding its caveat and Haynes' criticism of it. I leave to others to decide if there is now undue weight on the animal model topic, although it's the only study that seems to examine possible mechanisms of arterial dissection.
 * On the point you make above, I am by no means convinced that Herzog 2010 is actually a secondary source. However I can only see the abstract, but it seems to be written as describing a study, rather than a review of other studies. If someone who has access to the full text can clarify that it actually is a secondary source, I'd be grateful if they would amend my text to reflect that. --RexxS (talk) 00:46, 20 September 2010 (UTC)

I have no problem with any of the changes you have made...I feel that they very accurately reflect the current state of the literature and the controversial issue. As far as the Herzog paper goes, I do believe that it constitutes a secondary source. It is listed as an "Invited Review" on the journals table of contents, further the introduction of the article ends with: "Here, I will attempt to briefly review what is known about the external forces applied by chiropractors during HVLA manipulative treatments on patients, discuss selected effects of these forces, and then focus specifically on an increasingly important topic of internal force transmission: the stresses and strains experienced by the vertebral artery during HVLA neck manipulations." Thanks and best regards 173.206.208.87 (talk) 01:13, 20 September 2010 (UTC)
 * "Controversies or areas of uncertainty in medicine should be illustrated with reliable secondary sources describing the varying viewpoints." is irrelevant to this situation. There is no controversy or disagreement over the systematic reviews covering safety, thus is an unacceptable source to refute earlier works.
 * "The biomechanics of spinal manipulation" is not even a review according to the PubMed listing. Using this article to argue against systematic reviews is not appropriate per MEDRS. QuackGuru (talk) 02:30, 20 September 2010 (UTC)
 * QG, would you be willing to consider the point I mentioned above? I do not view the Herzog paper as a direct contradiction of Ernst, in that Ernst's review produces a convincing case for causality of arterial dissection by cervical spinal manipulation, but does not suggest the mechanism; while the Herzog and Austin papers explore possible mechanisms, without being able to reach an explanation (although Haynes' clarification does go some way to suggest a possibility). I also read allusions to the possibility that SM may exacerbate pre-existing conditions – which in no way invalidates Ernst's conclusions – and may explain the inability of Herzog and Austin to find a mechanism. I'd be content to see all of this removed from the article text on the grounds of undue weight, but I think you may be mistaken in suggesting the text be excluded on the grounds of non-compliance with MEDRS. --RexxS (talk) 09:35, 20 September 2010 (UTC)
 * QG it seems you are interpreting MEDRS to exclude other reliable sources. While systematic reviews are given prominence, their presence does not mean that any other reliable secondary (or recent primary) studies can't be included, proportionately, and accurately.  This is not debunking Ernst; it is mentioning all relevant reliable research.  MEDRS requires giving weight depending on source quality.  It appears that you are trying to give Ernst 100% weight by excluding all other studies.  Where does MEDRS support that?  There is a way we can include these studies to accurately describe the state of research.  Ocaasi 10:00, 20 September 2010 (UTC)
 * QG it seems you are interpreting MEDRS to exclude other reliable sources. While systematic reviews are given prominence, their presence does not mean that any other reliable secondary (or recent primary) studies can't be included, proportionately, and accurately.  This is not debunking Ernst; it is mentioning all relevant reliable research.  MEDRS requires giving weight depending on source quality.  It appears that you are trying to give Ernst 100% weight by excluding all other studies.  Where does MEDRS support that?  There is a way we can include these studies to accurately describe the state of research.  Ocaasi 10:00, 20 September 2010 (UTC)


 * It seems QG is correctly interpreting MEDRS to leave out unreliable references before the section becomes bloated with irrelevant text. I am shocked there is a ref about rabbits in safety. If editors still feel strongly about the Herzog paper it can be moved to one of the spinal manipulation articles. QuackGuru (talk) 15:42, 20 September 2010 (UTC)


 * It seems that QG is incorrectly interpretting MEDRS to mean leave out any reference that does not support his view. The Herzog paper is a secondary source that deals with the biomechanical and anatomical considerations of vertebral artery dissection with regard to manipulation of the neck. This article most certainly belongs in the safety section of the article. I am in agreement with QG criticism of the inclusion of the animal studies, although it has been stated by a third aprty above that it may represent the only paper that deals with mechanism for VA dissection, thus its inclusion here may hold some value.209.183.26.162 (talk) 16:15, 20 September 2010 (UTC)

QuackGuru, you have a misinterpretation of MEDRS. You are allowed to add other reliable sources that aren't systematic reviews to include additional information. This paper should definitely be included in the safety section. You are biased against anything that has opposing views to yours and this is unhelpful to the development of a page with a NPOV -Javsav (talk) 02:04, 23 September 2010 (UTC)


 * You have stated it is merely a paper. A paper is an opinion piece and not worth mentioning. QuackGuru (talk) 03:24, 23 September 2010 (UTC)

Stooping to semantics now QuackGuru, how mature of you. It is a review. When you print out a review, it is a paper. You just don't want it included because it goes against your opinion. Stop commandeering this page -Javsav (talk) 04:51, 23 September 2010 (UTC)


 * Javsav, finding and summarizing additional sources is great, but we need to be careful to avoid misrepresenting the sources. Specifically, a systematic review provides a professional weighting of the relevant literature, and we need to be careful to respect the quality of our several sources. Could we continue this discussion in the more focused subsection immediately following? - 2/0 (cont.) 09:00, 23 September 2010 (UTC)

Herzog 2010
This reference from Journal of Bodywork and Movement Therapies is being used in #Safety to support the text: A 2010 study by Herzog concluded that "stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during simple passive neck range of motion." This is fine as far as it goes, but the relevance remains to be established. This is far from a top-tier journal, and the article does not directly address the question of safety. If this source is to be used, it should not be in such a way as to invite synthesis in contradiction to a more recent and more reliable source. - 2/0 (cont.) 15:12, 20 September 2010 (UTC)
 * So your presumption is that a review of the relevant literature dealing with the biomechanical and anatomical plausibility of vertebral artery dissection from manipulation (Herzog review) is less meaningful to the issue of safety then a review of case studies where death likely resulted from manipulation? I disagree whole-heartedly!! The Herzog review is valid and relevant to the issue of safety! 209.183.26.162 (talk) 15:49, 20 September 2010 (UTC)
 * Moreover, Your more recent and reliable source is a list of case-studies. I refer you to your own profile where you state: "The plural of anecdote is confirmation bias"  As such, you are attempting to use confirmation bias to outweight a relevant review of biomechanical and anatomical considerations of the issue at hand. Please see "Controversial changes to safety" above where this has already been discussed and some consensus has already been achieved. The Herzog article is a review of the literature and thus constitutes a secondary source as per MEDRS. 209.183.26.162 (talk) 16:00, 20 September 2010 (UTC)
 * The Herzog paper is listed as an "Invited Review" on the journals table of contents, further the introduction of the article ends with:

"Here, I will attempt to briefly review what is known about the external forces applied by chiropractors during HVLA manipulative treatments on patients, discuss selected effects of these forces, and then focus specifically on an increasingly important topic of internal force transmission: the stresses and strains experienced by the vertebral artery during HVLA neck manipulations."209.183.26.162 (talk) 16:38, 20 September 2010 (UTC)


 * It fails WP:MEDRS, and I'm not entirely sure about regular WP:RS. It seems to be an inappropriate journal to discuss the results, and it may be a Chiropractic journal, making it inappropriate as a reliable source for "facts" in an article about Chiropractic.  — Arthur Rubin  (talk) 16:52, 20 September 2010 (UTC)
 * First, The Journal of Bodywork and Movement Therapies is not a chiropractic journal. Second, if it were, how would that compromise its relevence? Should we go to the entry on the usefullness of aspirin in the prevention of heart disease and see how many of the articles are not in medical journals? or to the satellite entry and see how many articles are not published in physics journals? 209.183.26.162 (talk) 18:53, 20 September 2010 (UTC)
 * It possibly meets RS. "Journal of Bodywork and Movement Therapies is the official journal of the Association of Neuromuscular Physical Therapists, Australian Pilates Method Association, and the National Association of Myofascial Trigger Point Therapists" is not exactly encouraging, and I can't see the editorial policy. However, it's published online by Elsevier, and gets around 1490 hits on Google Scholar, although a mere 136 on PubMed. I wouldn't agree that being an "X" journal necessarily makes a journal inappropriate as a reliable source for the "X" article (Nat. Rev. Cancer in Cancer? – it would just need to be treated with caution). It's the reputation of a journal in the scholarly literature that is the acid test, and examining its editorial and peer-review policies, along with how often its papers are externally cited that lets us make that determination. I'm undecided in this case, so perhaps someone more familiar with this field than I, can put this journal into context. --RexxS (talk) 18:59, 20 September 2010 (UTC)

"and it may be a Chiropractic journal" Firstly, it isn't. Secondly, do you realise the ludicrousness of your statement? All of the ERNST papers are completely antichiropractic - they are the antithesis of chiropractic, so by your logic they should also not be included in the article due to bias -Javsav (talk) 02:13, 23 September 2010 (UTC)


 * 2over0, you claim above that: "Specifically, a systematic review provides a professional weighting of the relevant literature". Further, your profile correctly states: "the plural of anecdote is confirmation bias". I wonder, have you actually read the Ernst review? A list of 26 case reports of death (table 1) where C manipulation was alleged to be the cause (C manipulation ocurred 52 days earlier in one of the cases). Never does the "review" critically analyze the case reports presented, nor does it compare the incidences of death to the total number of C manipulations that occured over that time period. NOTE:I understand that it is not our place to question the review as it has been accepted in the peer-reviewed literature, and our opinions of the reviews quality are irrelevant, BUT, the fact that the biased conclusion from the very weak Ernst article is found three times in the wikipedia article (last sentence of opening section, last sentence of relevant paragraph in safety section, last setence of risk/benefit section), and yet we are having a great struggle to have the Herzog review mentioned even once in this supposed NPOV article is stunning!! 173.206.208.56 (talk) 01:52, 24 September 2010 (UTC)


 * Without a source to review the literature for us, we would at most be able to state that reports exist. If a Wikipedia editor were to attempt to review the relevant literature and come to such an accounting, that would fall afoul of original research, and the result could not be treated as comprehensive. - 2/0 (cont.) 01:57, 24 September 2010 (UTC)
 * Why exactly is a source required to review a review? Herzog has written a review of previous sources already. Further, it is an invited review, implying that the journal recognizes Herzog as an expert in the field. As such, I dont understand your statement. I have previously linked to the table of contents of the Journal of BodyWork and Movement Therapies where Herzogs review is labelled as an invited review, also, I have previously quoted the last sentence of his introduction where he describes what his review will focus on (ie., what is known about the biomechanics of manual therapies and specifically the forces on the vertebral artery). Your refusal of its inclusion in the wikipedia article has made the article very one-sided in favour of a single biased review done by a known critic of chiropractic and all other complementary therapies (ie., Ernst).209.183.26.162 (talk) 13:20, 24 September 2010 (UTC)

Austin 2010
This reference from Journal of Manipulative and Physiological Therapies is being used in #Safety to support the text: A 2010 study by Austin et al on the rabbit vertebral artery suggested that repetitive stresses of several magnitudes greater than that which result from spinal manipulation are required to produce any microtrauma in the arterial tissues, although the authors cautioned that "the results should not be translated to the human VA (vertebral artery) without due consideration." The quote from the authors and the Haynes 2010 following pretty much make the point here, but it is worth elaborating. While animal studies are a necessary part of medical advancement, there is a distinct issue of undue weight here. This is very early stage recent preliminary research, and care should be taken in this article that we do not present it as definitive or conclusive. It is interesting that people are doing this research, but the caveats strictly limit its usefulness to this article. Given the availability of higher quality and more directly relevant research, this paper should not be used at this time. If the relevant academic community takes note of the paper and begins discussing it in the proper context, then we should re-examine the issue. - 2/0 (cont.) 15:12, 20 September 2010 (UTC)
 * I am content with the suggestions of 2over0 with regard to the animal studies by Austin. I would be satisfied with its removal.209.183.26.162 (talk) 16:20, 20 September 2010 (UTC)


 * I don't see why the animal studies should not be included in the article. specifically because they caution that the results should not be translated to the human VA without due consideration. Axxaer (talk) 05:50, 23 September 2010 (UTC)
 * The inability to make a simple extrapolation from the rabbit to a human (see Haynes' response) is probably a reason why some may think it is not very relevant. --RexxS (talk) 16:53, 23 September 2010 (UTC)

Duplication and OR
This controversial change added duplcation to the lead using a ref that is not in the body. Using a ref that is not in the body usually means the text from the reference did not summarise the body.

"However, this report was based on a review of case studies and so does not provide strong evidence regarding the actual prevalence of adverse effects." is OR and editorialising. "On the other hand, a recent study published in the journal Spine concluded that there was "no evidence of excess risk of VBA stroke" associated with chiropractic care compared to primary [medical] care.[24]" is duplication from earleir in the lead. The lead already says "Chiropractic care is generally safe when employed skillfully and appropriately.[20] However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or fatal complications in rare cases.[21][22]" The part "On the other hand," is also editorialising and OR. QuackGuru (talk) 18:19, 24 September 2010 (UTC)

This edit and this edit did not balance the lead using a ref that is not in the body. We are using the WHO statmement and the recent review to balance the lead regarding safety. There was past discussion that the lead was not balanced using only the WHO statement for safety in the lead when the safety of chiropractic spinal manipulation is at the very least under question. See Talk:Chiropractic/Archive 30. QuackGuru (talk) 05:48, 25 September 2010 (UTC)

Conducting our own original research
Javsav, you suggested you want to average out the numbers. But you stated "Basically all they are doing is looking at each study and stating the numbers, they didn't even average it out." Averaging out the studies is conducting your own original research and a clear violation of WP:OR. When they didn't even average it out and you want to average it out yourself, you trying to put words in the cited source's mouth. QuackGuru (talk) 20:33, 18 September 2010 (UTC)
 * I think Javasv was suggesting we report on the study's methodology, not average the numbers ourselves.
 * As repeated before, accusing editors of violating policy assumes a whole host of not good faith things, namely that: a) you accurately understand what they want to change; b) that your interpretation of policy is correct; c) that the proposed change in fact violates policy; d) that there are not other reasonable interpretations of policy; e) that another textual change might not be suggested which improves the article nonetheless without violating policy; and f) in a word, that you're right and they're wrong. Starting discussions with these assumptions is why editing with you is more painful than necessary and less productive than it could be.  If you're right, when all is said and none other editors will agree with you, even if you don't try to prosecute the outcome from the beginning of a discussion.  Ocaasi 04:59, 19 September 2010 (UTC)
 * What source are you going to use to report on the review's methodology? Wikipedia editors have no remit to analyse and comment upon reliable sources, because that is original research. The place for such analysis is in scholarly journals, not in an encyclopedia. We reflect, in as neutral a manner as possible, what the reliable sources say. In Wikipedia terms, an expert is not someone who can tell you what the facts are; an expert is someone who can tell you where to find the best sources describing the facts. --RexxS (talk) 07:46, 19 September 2010 (UTC)
 * We don't need a tertiary source; we have the study itself. Why can't we describe its methodology?  In specific, relevant places, details about how a study reached its results will inform readers about the current state of research and how studies have arrived at their conclusions.  This allows readers to understand how research is progressing.  We shouldn't make particular judgments, but we shouldn't be prohibited from detailing aspects of a study if they add explain the research findings using the study itself as a source.  Ocaasi 09:04, 20 September 2010 (UTC)
 * It's not a study; it's a review. What you are suggesting is not a description, but an amateur analysis of how you think a secondary source reached its conclusions. You are not qualified to do that. Nobody's suggesting using a tertiary source. If a later review includes an earlier review (secondary source) in its considerations, it does not make the later one a tertiary source. A secondary source performs analysis on earlier sources, and reaches its own conclusions; a tertiary source (such as an encyclopedia) merely aggregates other sources without performing its own analysis. We have no remit to provide our own unsourced interpretations of reliable sources, and attempting to explain what we think about such sources is prohibited. I hope that is clearer now. --RexxS (talk) 10:12, 20 September 2010 (UTC)

QuackGuru, I never said I was going to and never intended on averaging the values, however correct me if I am wrong, but is manipulation of data in that sense actually original research? RexxS, stating a study's methodology is not an analysis. It is a statement. --Javsav (talk) 08:37, 21 September 2010 (UTC)
 * If you say, for example, "The methodology was to review 200 studies and look for common trends", then you are describing the methodology – but that's an unnecessary detail in an article, particularly when the reader can click on the reference and see that if they are interested. If you were to say "He made a mistake by not averaging out" or "He was wrong to mention that study in his conclusions", then you are analysing the source, even though "it is a statement". You need to stop imposing your own value judgements on reliable sources. The place for that is in the scholarly literature. Get your analysis published in a quality journal, and then we can discuss it here. --RexxS (talk) 17:14, 21 September 2010 (UTC)

Actually, although you may be correct about the methodology of the study, the text cited in the page is from the abstract, which does not accurately reflect the study - and i never would plan on saying "he made a mistkae by not averaging it out" - what do you take me for? Please stop putting words into my mouth - this is harassment. Re the methodology - if we are talking about the methodology of the text from the abstract cited in the page the statement would read more along the lines of "The methodology was to review 200 studies and identify that with the lowest incidence and that with the highest incidence." - BUT that would only be if the text remains as it is in the page as it is currently because the way that it is written currently is not properly reporting upon the DATA of the review, that sentence is simply from the abstract. The true methodology of the review is different to this and I will compose a better sentence (not on the methodology, but on the data from the review from the discussion section directly from the review). And please stop continually patronising me by suggesting me that my analysis should be published in a Journal - I am am a medical student and do not have the resources or time for this, and as such you are implicitly harassing me by repeating this over and over again and I request that you would please cease this immediately --Javsav (talk) 00:47, 23 September 2010 (UTC)
 * Read WP:HARASS and collect your evidence as difs, then take your accusation to WP:ANI as described. Be aware that falsely accusing another editor of harassment is treated very seriously, per WP:HA. --RexxS (talk) 01:54, 23 September 2010 (UTC)

Can you tell me in any way how your repeated suggestions that I conduct my own systematic reviews or medical analyses published in journals can in any way be a civil or polite request? I'd be pleased to hear your explanation. I have no need to report it, all I ask is that you stop doing it. -Javsav (talk) 05:10, 23 September 2010 (UTC)
 * Once you understand that no wiki editor is qualified to make their own analyses of reliable sources, then I'll be perfectly happy to no longer have to explain to you that the only way your analysis can carry weight here is if you get published as a reliable source. I'd be quite relieved not to have to repeatedly refer you to policies that you should already have been aware of. Now, are you ready to get back to discussing reliable sources that comply with MEDRS? --RexxS (talk) 16:07, 23 September 2010 (UTC)

I have never attempted to make my own analysis of the page. I have discussed errors with methodology of reviews on the TALK page. You have neglected to comment on how your suggestion could be considered polite or civil, because it is obvious that it was not, and there is no way in which it could be. As such, I once again say, it is harassment and patronising, and I ask you to stop doing it, a request which you have once again denied as above. Please stop this, and stop it NOW -Javsav (talk) 01:12, 27 September 2010 (UTC)

Attribution of secondary sources
I've reverted this edit because it attributes a reliable secondary source that, at present, is not subject to serious dispute among reliable sources. WP:ASSERT is quite clear about this: This includes the "5 strokes in 100,000 manipulations" fact, because it is sourced to, and relies for its authority upon, the same reliable secondary source, not simply the original Australian study. "Drilling down" within a secondary source to examine the primaries which it evaluates is discouraged, because it misses the point that the secondary source exercises an overview of multiple studies, which elevates the status of the finding.
 * "Assert facts, including facts about opinions—but do not assert the opinions themselves. A fact is a statement about which there is no serious dispute among reliable sources."

The convention of attribution of secondary sources is reserved on Wikipedia for when multiple secondary sources differ in their findings, since it then becomes helpful to the reader to be able to identify which source stated what. Attribution is also appropriate for primary sources whose results are not examined by secondaries, since it then becomes clearer that the text is reporting an as-yet uncorroborated statement. Of course, attribution is expected when the text of any source is quoted directly.

I understand that Javsav feels that the findings of Ernst 2010 are disputed, but no reliable secondary source has been brought forward yet to support that. It is perfectly possible that such a source may exist (or may emerge in the future), but until such a source is found, we should not be diminishing the authority of a secondary source on the grounds that we find it misleading. Hope that helps. --RexxS (talk) 08:43, 20 September 2010 (UTC)


 * Javsav wrote this needs clarification as it is misleading without this, please stop reverting this quackguru without discussion. I did not remove the attribution in the text. RexxS removed it. It is misleading to imply there is serious dispute with Simon-says style attribution. I don't see Javsav disputing the results of Ernst 2010 with another reliable source per MEDRS. There is no serious disagreement. Attribution in the text is reserved for a serious disagreement. Here is some advise: When you're drilling down into a hole of primary sources, stop digging. QuackGuru (talk) 15:42, 20 September 2010 (UTC)

There is plenty of disagreement among reliable sources, read: Talk:Chiropractic/Archive_31 Javsav (talk) 06:25, 21 September 2010 (UTC)


 * Exactly which reference disputes the varied estimates. QuackGuru (talk) 06:30, 21 September 2010 (UTC)

Converting a plain fact into a disputed opinion is a breach of ASSERT
The recently added phrase "studies from" is unnecessary attribution in the text. QuackGuru (talk) 06:43, 21 September 2010 (UTC)


 * I agree that between studies is suboptimal - the numbers cited are given relevance by the review article (I changed the text to Estimates ... vary instead of varied, but am leaving the between studies text for now - there is entirely too much edit warring at this article already). This sentence immediately follows one cited to the same review stating that the actual incidence is currently unknown. The fact that the estimates given come only from actual studies rather than just being numbers someone made up should be assumed. Am I missing the issue here? - 2/0 (cont.) 13:19, 21 September 2010 (UTC)


 * The part vary between accurately explains the context of the text but adding the words studies from is a breach of WP:ASSERT when no evidence of a dispute has been presented. The Estimates ... are a plain fact but unintentionally converting a "fact" into an "opinion" is needlessly attributing uncontroversial statements, and so creating the appearance of doubt or disagreement where there is none. QuackGuru (talk) 19:18, 21 September 2010 (UTC)

In a different, unrelated thread Javsav wrote in part: I have no problem removing the attribution in the text, in fact if I did it would strengthen the text. According to this comment I assume the editor understands removing attribution in the text will strengthen the text when there is no serious disagreement.

I agree with this edit that removed the attribution in the text that was weakening the strength of the estimates. Javsav, please show a serious dispute for the estimates or otherwise it is not appropriate to create doubt by attributing the text. QuackGuru (talk) 05:48, 25 September 2010 (UTC)

I was removing ambiguity in the text, not trying to undermine the review. What I was in no way dong was attribution, it was clarification of the estimates. And QuackGuru,your quote is taken out of context, I was referring to attribution of articles that are not systematic reviews, in fact attributing systematic reviews should theoretically strenghthen their position - this is irrelevant to what I was saying because I was not attributing the systematic review I was removign ambiguity from the text. This is true of what the review is stating - it is saying that estimates varied between conrolled studies (and in the case of a questionnaire, thsi removal of ambiguity is highly generous). When I first read it I was confused by the fact that 1 stroke in 20,000 manipulations, which would invariably lead to death, is then followed by 2.6 deaths in some invariably huge number, it confused me at first as you can see on the mediation cabal page -Javsav (talk) 00:21, 27 September 2010 (UTC)
 * It may be helpful to observe that the majority of strokes are not fatal. There are some fatality rates in this Lancet article, but obviously they can't be extrapolated to a particular setting, such as events following SM. It's probably best not to try to draw our own conclusions about reported stroke rate vs mortality rate in this case, particularly as there's no convincing evidence of the mechanism. --RexxS (talk) 01:21, 27 September 2010 (UTC)


 * It was adding attribution in the text according to WP:ASSERT, even when you are not trying to undermine the estimates. QuackGuru (talk) 03:35, 27 September 2010 (UTC)

7 dead links
Houston we have a problem. QuackGuru (talk) 04:05, 30 September 2010 (UTC)

I looks like it was a false alarm by QG (what problem?). The links have been updated. QuackGuru (talk) 05:54, 1 October 2010 (UTC)


 * There are still three more. I should have a chance to look for them tomorrow if nobody else gets to it first. - 2/0 (cont.) 08:14, 1 October 2010 (UTC)


 * Finished. - 2/0 (cont.) 16:06, 2 October 2010 (UTC)

Utilization material
In the U.S., chiropractors perform over 90% of all manipulative treatments.

I think this information can be moved to Utilization with the readable article. QuackGuru (talk) 06:09, 1 October 2010 (UTC)


 * Works for me. The flow of that section probably still needs some work, but I agree with not discarding information. - 2/0 (cont.) 08:11, 1 October 2010 (UTC)

Tips for keeping article length down

 * Rather than wikilinking directly to an article just wikilink the word unless you need to wikilink to a specific section. For example, the phrase vertebrobasilar artery stroke redirects to vertebral artery dissection but it helps keep the article length down without adding additional words like this: vertebrobasilar artery stroke.


 * For the references, wikilink the first instance of the publisher but do not wikilink the publisher twice for the reference section. Once is enough.


 * Add ref names only when needed to verify another sentence.


 * Keep ref names short and it is unnecessary to put ref names in quotes ( unnecessary quotation marks) ( keeps article length down without quotes) QuackGuru (talk) 18:45, 2 October 2010 (UTC)


 * For editors without the page size script, here are the document statistics as of 2 October 2010:

* File size: 373 kB   * Prose size (including all HTML code): 69 kB    * References (including all HTML code): 244 kB    * Wiki text: 106 kB    * Prose size (text only): 41 kB (5978 words) "readable prose size" * References (text only): 38 kB
 * WP:Article size suggests around 30 kB to 50kB of readable prose as an upper limit, so I suspect that at some point, the article will have to convert more sections to summary style. Perhaps some discussion would be appropriate on whether that is possible, and if so, which other sections could be split off? --RexxS (talk) 20:50, 2 October 2010 (UTC)


 * I believe that reference names and piped links do not matter when considering article length, as they do not render except when editing. It is also good style to always include the quote marks in ref names to ensure that the parameter is well-formed, even though they are only strictly necessary if the name has a space (which latter should be avoided, obviously). On the other hand, if we are down to worrying about reference style, I think this article might be in pretty good shape.
 * Is that Dr pda's script, RexxS? It is a good one. I am actually surprised that we are within the readable prose recommendation with this article. A bit more summary style might be good regardless. #Vertebral subluxation, for instance, is maybe half as long as the main article (less the lengthy block quotes). #Scope of practice would seem a natural spin out target, especially if we can focus on the global aspects here and expand on matters of only national relevance in sections of the new article. #Effectiveness I think we could cut by about a third by reducing the study X concluded Y style, but I think we would need a new section discussing this before enacting. The last two sections look about right to me for a top-level article with a constellation of subarticles. - 2/0 (cont.) 21:42, 2 October 2010 (UTC)
 * It is Dr pda's script and it was remiss of me, not to credit the author. For anyone interested, the script is at User:Dr pda/prosesize.js, documentation at User:Dr pda/prosesize and discussion is at User talk:Dr pda/prosesize.js.
 * I would also prefer editors to enclose ref names in quotes, not just because element parameters should always have quoted values. Our referencing system is not intuitive to a newcomer and many learn by copying and adapting. Providing quotes makes good examples, which avoids learners becoming confused when their adapted copies don't give the results they expect. On the other hand, with about 200 'ref' tags, we'd save 400 bytes.
 * I know this article is in a contentious area, and in fairness to all contributors, I'd also want to see ample discussion reaching a consensus before any major revamp. Cheers --RexxS (talk) 22:45, 2 October 2010 (UTC)

ASF violation when there is no serious dispute
Two reviews of published studies on chiropractic practices found a lack of good methodology in the studies that were examined.

This is attribution in the text and a violation of WP:ASF. This is also editorializing which is a common problem on Wikipedia. QuackGuru (talk) 06:43, 22 August 2010 (UTC)


 * Only one of the studies concludes what you attribute to two studies. And "low quality" is far too vague to be a useful statement.--Anon 07:25, 23 August 2010 (UTC)


 * "Two reviews of published studies on chiropractic practices" is still a violation of ASF whern there is no serious dispute. Which reference said there are two reviews. QuackGuru (talk) 17:04, 2 September 2010 (UTC)


 * Do we have recent reviews that say the evidence base is good / excellent? If there is no disagreement of equal quality than I agree WP:ASF. Doc James  (talk · contribs · email) 05:53, 15 September 2010 (UTC)

What we mean is that when it is a fact (a piece of information about which there is no serious dispute) it can be asserted without prefixing it with "(Source) says that ...", and when it is an opinion (a matter which is subject to dispute) it can be attributed using this sort of inline-text attribution.

Most facts, except the most obvious ones - like “Mars is a planet” and “Plato was a philosopher” - must be verified through a reliable source regardless of whether it is a truthful statement. However, for WP:ASF, it is how we present the verified text from reliable sources.

Wikipedia is devoted to stating facts and only facts, in this sense. Where we might want to state opinions, we convert that opinion into a fact by attributing the opinion to someone. When asserting a fact about an opinion, it is important also to assert facts about competing opinions, and to do so without implying that any one of the opinions is correct. It's also generally important to give the facts about the reasons behind the views, and to make it clear who holds them.

Requiring an inline qualifier for widespread consensus of reliable sources on the grounds that it is "opinion" would allow a contrarian reader to insist on an inline qualifier for material about which there is no serious dispute, using the argument that the material is an "opinion". This would mean, in the end, that all material in Wikipedia would require an inline qualifier, even if only one Wikipedia editor insisted on it, which is not the goal of ASF. Presenting a "fact" as an "opinion" is needlessly attributing uncontroversial statements, and so creating the appearance of doubt or disagreement where there is none. QuackGuru (talk) 19:39, 15 September 2010 (UTC)

I don't see any valid reason why we should not comply with ASF. I think the original version without the ASF violation should be restored. QuackGuru (talk) 20:00, 16 September 2010 (UTC)

There are serious disputes, attribution should be given. "Mars is a planet" is a completely different kind of statement to "the risks outweigh the benefits" for example, especially considering the methodology of that particular study (I know we are referring to different reviews here but the principle remains the same) -Javsav (talk) 00:55, 23 September 2010 (UTC)


 * You have not shown there is a serious dispute among reliable sources. QuackGuru (talk) 03:24, 23 September 2010 (UTC)

The word Critics failed verification
There was another controversial edit. For example, the word "Critics" is WP:OR.


 * Critics is not necessarily OR. It depends on usage.  If it is accurate, the word can help to accurately describe a debate, essential to NPOV.

The conclusion of the reference says "The results of the study suggest that the continuing education course was effective in enhancing knowledge in the evidence-based approach and that the presentation was well accepted." The word "can" was added. That word is unsourced and also WP:OR. QuackGuru (talk) 03:36, 23 August 2010 (UTC)


 * The word 'can' only helps distinguish between a finding and a plain fact. It is not "OR" since it doesn't change the meaning significantly.  "The results of the study suggest that the continuing education course was effective" and "Continuing education can be effective" are basically identical. Ocaasi (talk) 09:37, 23 August 2010 (UTC)

Agreed. To call "can" OR is slightly ludicrous Javsav (talk) 16:29, 23 August 2010 (UTC)


 * Critics is OR and no editor provided verification. Which sentence from the reference verified the word "Critics". QuackGuru (talk) 17:04, 2 September 2010 (UTC)
 * Per OR: Wikipedia does not publish original research. The term "original research" refers to material&mdash;such as facts, allegations, ideas, and stories&mdash;not already published by reliable sources. It also refers to any analysis or synthesis by Wikipedians of published material, where the analysis or synthesis advances a position not advanced by the sources.
 * Per V: The threshold for inclusion in Wikipedia is verifiability, not truth&mdash;whether readers can check that material in Wikipedia has already been published by a reliable source, not whether editors think it is true.
 * Again, which sentence from the reference verified the word "Critics"? QuackGuru (talk) 19:59, 15 September 2010 (UTC)

I requested verification but none was provided for the word "Critics". It is "OR" since the word is not written in any of the sources given. QuackGuru (talk) 20:00, 16 September 2010 (UTC)

I requested verification from the editor who originally added the "Critics" OR but the editor refuses to provide V. Ocaasi, do you agree the OR should be removed? QuackGuru (talk) 15:42, 20 September 2010 (UTC)

"Critics" is not OR, it is referenced at the end of the sentence, those people who did that study are the critics. I don't see why you have a problem with this rewording, it is making the page read more smoothly -Javsav (talk) 02:56, 23 September 2010 (UTC)


 * The word "Critics" is OR. The claim "those people who did that study are the critics." is also OR. Where in the source does it say they are "Critics". QuackGuru (talk) 03:24, 23 September 2010 (UTC)

It doesn't have to say it in the source, I have read the source and you can make the inference that they are critics of vitalism from the context. --Axxaer (talk) 04:57, 23 September 2010 (UTC)


 * You know it is not in the source and if you make up stuff that is not in the source then it is OR. QuackGuru (talk) 05:00, 23 September 2010 (UTC)


 * The Manual of Style suggests that we should avoid using such words as "critics". We need to be especially careful on contentious articles to avoid applying our own biases to the wording of the article. - 2/0 (cont.) 08:46, 23 September 2010 (UTC)

Unreliable chiropractic literature failed RS
A 2010 review by Edzard Ernst focusing on deaths after chiropractic care stated that the risks of spinal manipulation "far outweigh its benefit".[23] The study was refuted by Anthony L. Rosner, who labelled the study as "blatantly misleading", citing lack of risk-benefit analysis and inclusion of deaths that were found to be not related to chiropractic care.[114][Unreliable medical source?]

Adding the name of the author is not the way we write text for this article. This text is not about effectiveness and an unreliable source was added to the article that was written by Anthony L. Rosner. QuackGuru (talk) 06:43, 22 August 2010 (UTC)


 * My version of the text quotes the Ernst study directly. I can hardly see how someone else's interpretation is better than a direct quote. Anthony L. Rosner published a detailed argument against the study, I don't see why it should not be included. We need to present both sides of the argument.---Anon 07:25, 23 August 2010 (UTC)


 * Trying to "balance" Ernst's study like this is not good editing: "The study received criticism in chiropractic literature, with one review calling it "blatantly misleading", citing a lack of risk-benefit analysis and the inclusion of deaths that were not related to chiropractic care." You shouldn't juxtapose peer reviewed literature with the opinions of chiropracters. Of course chiropracters won't like a study that says that their practice can be dangerous. What was the reception of the review outside chiropracty? Fences  &amp;  Windows  10:55, 27 August 2010 (UTC)
 * Give us a link then.--Anon 06:37, 28 August 2010 (UTC)
 * WP:SPAM and WP:RS. The reference is unreliable that has banner ads on the website. The reference is not even peer-reviewed or from a journal. QuackGuru (talk) 17:04, 2 September 2010 (UTC)


 * A 2010 systematic review found there is no good evidence to assume that chiropractic neck manipulation is effective for any medical condition.
 * Without explanation for the second time an editor removed the above sentence, added duplicate material about risk-benefit that is in another section, and added an unreliable source from ChiroACCESS. This unreliable reference is WP:SPAM. QuackGuru (talk) 17:09, 2 September 2010 (UTC)
 * Once you're done accusing me of being a spammer, I will discuss the links with you. Until you do, go have a long read of the pages that you link to and WP:NPA.--Anon 11:54, 4 September 2010 (UTC)


 * I was making note that the website does have banner promotional links. This is a fact. See it for yourself. Does any other editor see the banner links on the website. Anyhow, the website is unreliable per RS. This is not a response from a peer-reviewed journal. QuackGuru (talk) 02:03, 5 September 2010 (UTC)


 * Chiroaccess appears to be an unreliable reference for unscientific literature in the chiropractic community. This alone disqualifies it especially when it is not a peer-reviewed article. QuackGuru (talk) 06:19, 5 September 2010 (UTC)


 * It was obvious that Anon included the source for the purpose of its content and not the ads on the page. Ads are not a great sign of scientific rigor, but neither do they disqualify a source. The website, Chiroaccess appears to be the primary reference for scientific literature in the Chiropractic community. That it has ads promoting products which the profession uses shouldn't disqualify it. Ever looked at the stationary in a doctor's office? You can't assume the conclusion that ChiroAccess is unreliable--that is the claim being addressed.  If you want to make that argument, you have to have reasons.  What reasons or sources make Chiroaccess unreliable or unscientific?


 * The 2010 review of Ernst's study was written by Anthony Rosner, who is not some random practitioner. Here's his bio:


 * Anthony Rosner became Research Director of the International College of Applied Kinesiology in September 2009. From 1992-2007, he had been a Director of Research and Education at the Foundation for Chiropractic Education and Research and Director of Research Initiatives at the Parker College of Chiropractic from 2007-2009. After obtaining his Ph.D. in Medical Sciences at Harvard in 1972 and conducting postdoctoral research at the NIH in Bethesda and at the CNRS in Gif-sur-Yvette, France, in 1973 and 1974, he directed research and clinical chemistry laboratories at Boston's Beth Israel Hospital and at an affiliate of the Mayo Clinic, then taught chemistry and served as Department Administrator in Chemistry at Brandeis University and managed research operations in neonatology at Children's Hospital in Boston until he joined FCER in 1992. He chaired one of six charter committees at the inception of the National Center for Complementary and Alternative Medicine in 1992 and has served on the editorial board of three peer-reviewed journals, authoring papers reviewing manual medicine, critiquing recent publications of questionable research design, and exploring the role of homocysteine in provoking spontaneous vertebral artery dissection.


 * A nice bio doesn't make it a systematic review, but it means it's not spam and not 'unscientific' on its face. Editing in good faith means avoiding the absolute worst insinuations possible and focusing on the ones that are both more likely and more relevant.


 * On the merits, the source is a direct criticism of the primary evidence against spinal manipulation--Ernst's 2010 review. It does not 'equal' or 'refute' Ernst, but it raises serious points, cites relevant literature, and deserves some mention in the Chiropractic article, if for no other reason than to accurately describe the current debate amongst actual members of Chiropractic and the research community. RS is presenting the whole story. This is part of the story. We don't have to present it as an equal counterweight, but the reality that the chiropractic profession finds Ernst to be incorrect or biased, and that this article speaks for them, means it should be included. If you want to place it outside of the EBM section, because MEDRS standards strictly apply to scientific studies, then that is an option, but it should then be included in a "response" or "criticism" or "ongoing debate" section, in which Chiropractic literature can speak to the claims. Ocaasi (talk) 06:04, 5 September 2010 (UTC)


 * We should take it to WP:NPOVN and WP:RSN, the 2010 review of Ernst as well as the 2006 review of Ernst and get some feedback on if, where, and how, to include them: 2006 critique  2010 critique   If you're so sure that these sources have no place in this article then others should feel the same way. Ocaasi (talk) 06:54, 5 September 2010 (UTC)


 * Do you think the website is a peer-reviewed journal? I don't see how it meets RS let alone MEDRS. What part of RS shows that non-peer reviewed chiropractic literature is reliable. References like this were removed a long time ago from this article. They were replaced with peer-reviewed literature per WP:MEDASSESS. QuackGuru (talk) 07:10, 5 September 2010 (UTC)


 * The Chiroaccess link I posted here was intended as an example of criticism. It is NOT and was never intended to be an "assertion of fact" or a medical result. It is a criticism and was presented as such. I don't think it's that common to publish criticism of fringe studies in peer-reviewed journals (and I do believe Ernst there is a classic example of a WP:FRINGE point of view).--Anon 07:28, 9 September 2010 (UTC)


 * Chiroaccess cannot possibly be considered a reliable source, except for the opinions of the authors of the article, if they meet WP:SPS. — Arthur Rubin  (talk) 21:29, 9 September 2010 (UTC)


 * Agree Chiroaccess is not a reliable source and cannot per WP:MEDRS be used to refute a review article. Now if Anthony L. Rosner published his own review and it came to different conclusions than yes we could add him. Doc James  (talk · contribs · email) 05:29, 15 September 2010 (UTC)
 * The article in Chiroaccess is an opinion piece, with no evidence of peer-review or quality of editorial oversight for the publication process. It fails WP:RS. The only possible way Rosner's opinion could be considered to meet RS is to demonstrate here that he is an acknowledged, published expert in this field. Even then, it will fail WP:MEDRS, since it is a primary WP:SPS and cannot be used to rebut a secondary source such as Ernst's review. Many reviews will have critics, but there are no grounds for including every (or any) piece of criticism of a secondary source unless that criticism enjoys wide-spread support as evidenced by other reviews expressing that view. That does not appear to be the case here. --RexxS (talk) 08:47, 15 September 2010 (UTC)

I see WP:CON to remove the unreliable Chiroaccess article from the chiropractic page. QuackGuru (talk) 20:00, 16 September 2010 (UTC)

The guy is not a chiropractor.. he has a PhD in MEDICAL SCIENCES and works at a research institute. It doesn't matter what JOURNAL it was published in.. it was only published in chiroaccess because that is where people would read it. This criticism needs to be included and it raises VERY valid points -Javsav (talk) 21:45, 18 September 2010 (UTC)

If you are going with consensus, it is anon, ocaasi and myself against you and doc.. so the consensus is to include it --Javsav (talk) 21:47, 18 September 2010 (UTC)


 * Consensus is not a voting system, and you seem to have ignored 2/0 and myself. It is abundantly clear that there is undue weight being given to fringe opinion, which per WP:PSTS must not be used to rebut the results of reliable secondary sources. --RexxS (talk) 22:20, 18 September 2010 (UTC)

Have you read the critique? It makes very valid points. QuackGuru was the one citing WP:CON. A systematic review can not conclude that the risks outweigh the benefits. Only a reviewer (Ernst) can. The review possibly can if it employs some risk benefit analysis formulae, which his does not. Whether or not the risks outweigh the benefits is completely subjective. If someone was suicidal, then the benefits would definitely outweigh the risks (If Ernst opinion was correct). While this is an extreme example, it is an example used to prove the point that this type of sentence is completely subective ("the risks outweigh the benefits"). Even Ernst has admitted that his views regarding chiropractic are "hotly disputed." Ernst's review claims that there is no good evidence to assume that manipulation is an effective treatment for any condition, however another review says it is effective for back pain. From WP:MEDRS "The range of reviews examined should be wide enough to catch at least one full review cycle, containing newer reviews written and published in the light of older ones and of more-recent primary studies" As such, Ernst's review can not stand alone, as it is not published in the light of old reviews; there has not been one review cycle. In Ernst's review he admits proudly that this is "the first review of its kind published in the literature". Sure there were 26 deaths since 1937 (>22 of them before 2000 when chiropractic developed much stricter regulations regarding cervical manipulations) but per how many treatments. In fact, if you consider that, the incidence is ridiculously low. Maybe we should calculate the incidence based on this data - this would not be OR, this would be manipulation of data within the review, which is allowed on wikipedia. I don't know how you could call someone with a PhD in medical sciences from harvard who runs a research facility a fringe opinion, in fact I'd much sooner call Ernst a fringe opinion, considering he has admitted that his views are hotly disputed. Can you comprehend the number of years of training in MEDICAL science and the effort and length of time it takes to write a thesis in MEDICAL science. This guy can not be biased in the least. I find it amusing that you say consensus is not a voting system when it clearly is... when an article is nominated for deletion it is basically the more responders that it should stay or the more that say it should delete, determines whether or not it stays or is deleted. And when you say that I am forgetting 2/0 and yourself, you had not commented under this subheading at all until now. -Javsav (talk) 08:16, 19 September 2010 (UTC)
 * Yes I've read the critique, and I've also researched where it is published. Valid points are those made by reliable sources, which neither you nor the critique are. If you personally dispute Ernst's conclusion "The risks of this treatment by far outweigh its benefit", then get your view published in a scholarly journal, and your argument will be taken seriously here. It's not our place to produce our own analysis of reliable secondary sources, we trust the processes in the publishing journal and subsequent reliably-sourced commentary to do that. You need to find a MEDRS-compliant source that makes your arguments.
 * I agree that Ernst's review need not stand alone, but all reliable secondary sources since the last Cochrane review need to be considered (including Ernst). QG has offered half a dozen of them. It would be helpful if you would bring forward the reliable secondary source within the current review cycle that supports your assertions.
 * The mainstream view is that reflected in the majority of reliable secondary sources; fringe views are those which have little or no currency within such sources. While my own experience of producing a doctoral thesis is of no consequence here, I have seen sufficient fringe theories put forward to know that academic credentials are no guarantee of a reliable source. Thankfully, the consensus on Wikipedia agrees with me. You need to understand that I have no view on Rosner's credentials, experience, commitment, or possible bias, since they are not relevant. I do hold a strong view that Chiroaccess is not a reliable source. If Rosner gets his views published in a high-quality journal such as IJCP, then we can discuss how they might be used.
 * I'm sorry you found humour in the fact that WP:CON is a not a vote. It is a process of discussion, based upon our policies, to arrive at a solution which a neutral outsider would judge as a fair representation of the reasonable views expressed. I'd strongly recommend you study that policy and consider how you can help build consensus. AfD is rather off-topic, but the instructions to the closer require them to evaluate consensus by the strength of the arguments presented, and their compliance with policy. I would not be surprised if any of the regular AfD-closers were offended your belittling of their efforts.
 * Finally, I'll draw your attention to my contribution to the consensus – clearly visible above, dated 15 September – and expect you to revise your last sentence. --RexxS (talk) 10:13, 19 September 2010 (UTC)


 * I've just read this whole section and as an outside opinion who is not involved in this article I have to say I agree with the editors above who say this is not a reliable source. If this is the only way to get to this opinion piece than it needs to be removed per the arguments made above esp. from RexxS and QuackGuru.  -- Crohnie Gal  Talk  12:21, 19 September 2010 (UTC)

I'll concede that this is not a reliable source, in fact I always knew in the back of my mind that it was not a reliable source per se, but if he published it in a journal it would be, and it does raise valid points. All involved please read this discussion re: adding of more reliable sources to balance POV and QG's responses. Quack guru refuses to consider anything other than a systematic review a reliable source, not even a review. By the way, I am a Medical Student, I am not biased, and I can prove this is if you request it from me by showing the relevant documentation. I apologise for the comment Rexx, I was in the wrong and I in no way meant to offend you, but I have been here for a lot longer than you putting up with QG's stubborn ways as this archived discussion will show, and it is taking its toll on me, because studying medicine is an exhausting thing to do while having to concurrently argue with QG. Archived discussion on edits to safety section of article. It is a long but necessary read to understand the scope of the problem here. Crohnie Gal, the piece doesn't need to be removed, it was never in there for more than a second until QuackGuru reverted it. Thats just what he does. -Javsav (talk) 07:44, 20 September 2010 (UTC)

And I think you guys need to keep an open mind when it comes to chiropractic. I found this story by Quentin Wilson, a presenter on "Top Gear" extremely inspiring, and I think I may even include it under a subheading in the article as it is from the telegraph, a reliable source. Give it a read and see what you think (not about including it, just what you think about the story. If it was included it would be included under something like "notable cases", though I don't see QG allowing me to do that any time in the future, but pigs may fly. Many of the doctors I know and work with visit a chiropractor.) http://www.telegraph.co.uk/health/alternativemedicine/3318749/He-was-lucky-to-be-walking.html --Javsav (talk) 08:24, 20 September 2010 (UTC)


 * Javsav, I appreciate your enthusiasm for this topic, and I accept that all your contributions are made in good faith. While you have been contributing to this article since 4 August (longer than I), you might want to consider whether you have become too close to a single topic, and spend more of your time on other medical articles (as you did in 2006). Personally, I'm quite happy to keep an open mind about this topic, but none of us should be letting our own views get in the way of producing the best quality encyclopedic content. That means we have to ignore our own knowledge when writing text, and scrupulously rely on reliable sources for the content of the encyclopedia. Our policies on sourcing, although frustrating at times, need to be observed because this is a collaborative project, and without using those policies we will not make progress in moving forwards to improve the article. I still think that drawing up a list of MEDRS-compliant sources and discussing them dispassionately with QG to reach consensus, then writing an agreed text, will produce a better result in the long run. --RexxS (talk) 09:12, 20 September 2010 (UTC)
 * Thanks Rexx, but as you could see, none of those sources violated MEDRS and they did not contradict Ernst's study, rather offered opposing viewpoints but he would have none of it. Even the WHO statement which is considered equivalent to systematic reviews on the reliable soruces page was disallowed. The article as it is is too one sided and can completely malign a whole profession - people with jobs whose income relies on the fact that their employess do not go on wikiepdia and read a blanket statement such as "the risks outweigh the benefits" which would completely deter them from visiting their chiropractor again. I like to edit pages with an unbalanced POV because I do not think it is fair to screw over alll those chiropractors like this. Originally the statment in the lead simply read "and the risks outweigh the benefits" and it took a lot to get QuackGuru to even budge from that. This kind of conduct is bullying. Ocaasi has always discussed these sources dispassionately with QG to no avail. Re your suggestion - if you rea the archived link, that is exactly what Ocaasi did and to no avail -Javsav (talk) 10:52, 20 September 2010 (UTC)

Furthermore, I find it patronising and offensive that you are telling me to edit medical articles. I have the right to edit whichever article I see fit to edit, and I am in no need of your suggestions of which article to edit. -Javsav (talk) 08:40, 21 September 2010 (UTC)
 * I have read the archive and I still don't see any reliable secondary sources that contradict "the risks outweigh the benefits". The WHO source talks solely about adverse affects, and does not make the risk–benefit analysis that Ernst 2010 does. There really isn't anything in there that would suggest there is "a serious dispute with other reliable sources".
 * I'm sorry you're unable to take my advice in the spirit in which it was intended. I was suggesting that you might consider other articles, not to dispute your right to choose where you edit, but because experience of a broader range of wikipedia (especially in the less contentious areas) might be good for you. I won't raise the issue again. --RexxS (talk) 18:09, 21 September 2010 (UTC)

It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects. adverse effects and beneficial results is about risk benefit. "gives beneficial results" you see when you put few adverse effects/beneficial results you get a risk/benefit formula. The Journal of Manipulative Physiological Therapeutics similarly found, "the direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures." This is from a reliable source. A crossover study found that increased risks of VBA stroke associated with chiropractic and general practitioner visits was likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke.[10] A literature synthesis found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care.[11] further quotes from RELIABLE sources as per MDERS. I think you are biased here RexxS and you refuse to concede per MEDRS that these are reliable sources. There was a spirit in which your suggestion was intended, and I believe it was a negative one - it equated to "edit other pages because you are not welcome here" --Javsav (talk) 01:06, 23 September 2010 (UTC)
 * You can't compare adverse effects and beneficial results until you evaluate the amount of beneficial effect and the seriousness/incidence of adverse effects. If the beneficial effect is relief of low back pain and the adverse effect is mortality, then it needs some incidence figures to arrive at a conclusion. WHO did not say "the benefits outweigh the risks". Ernst did say "the risks outweigh the benefits". The Journal of Manipulative Physiological Therapeutics has all of 38 hits on PubMed. Which one were you quoting? Your allegations of bias and refusal to AGF of a fellow editor is a violation of WP:CIVIL. Cut it out and start producing some real sources that we can discuss. --RexxS (talk) 01:33, 23 September 2010 (UTC)

I'm just joining in now, but I've read the archive discussion and those are reliable sources per MEDRS. The WHO bases their statements on research: when they say that it gives beneficial results with few adverse effects, they are not talking out of their rear ends, they are basing these opinions on research - they are a very reliable source. I've also read the Ernst paper and have noted that by your logic RexxS, Ernst paper can not conclude that the "risks outweigh the benefits" because he has no risk benefit formula. The WHO is a reliable source, and I believe javsav is being more than civil, and he is being blunt rather than beating around the bush. Your suggestion for him to edit other pages, while masquerading as polite, did seem to me to be rather patronising. Another reliable source is the Herzog review mentioned below on the page: "More recent research has contradicted the suggestion that neck manipulation can result in vertebral artery dissection, as the stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during simple passive neck range of motion. " --Axxaer (talk) 05:08, 23 September 2010 (UTC)
 * Well, Javsav did say he'd bring some meatpuppets along, but welcome anyway. We all agree WHO is a reliable source; You'll have to make the case for the Journal of Manipulative Physiological Therapeutics. I'll assume that you're not trying to claim ChiroAccess is a reliable source as well, are you? Your understanding of my logic seems to flawed, since Ernst 2010 quite clearly did conclude that "The risks of this treatment by far outweigh its benefit" (direct quote), despite your assertion that he cannot say that. Have you found a reliable source that says "the benefits outweigh the risks" yet? Herzog has been disputed by other editors (not me) as a reliable source, so that remains unsettled. He states "Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures", which is a null result for determining the mechanism of adverse effects of spinal manipulation. The source didn't say "this contradicts the findings that serious adverse effects can follow neck manipulation". So the source text does not translate into your phraseology, where you are drawing conclusions unsupported by the source. That sort of editorialising imposes your POV on the source's conclusions, and should be avoided. If it's any help, I'm open-minded about possible causative mechanisms: Ernst 2010 is a review of published cases of "Deaths after chiropractic", and there's no discussion of putative mechanisms there. Is it possible that in the vary rare cases when death follows chiropractic, the individuals already had pre-existing conditions that made them susceptible to complications? Sure – after all aneurism or a similar weakness could be a significant possibility. But (and it's a big BUT), all of this is hypothetical, and we simply don't know. There's no reliable source that I've found, which tells us what is actually happening in the cases that Ernst reviewed, and until we have such a source, our article has to remain silent on the matter. --RexxS (talk) 18:34, 23 September 2010 (UTC)

Comments on sources

 * All of those sources meet WP:MEDRS and I think they would be great additions to the safety section in order to give it a NPOV. Well done. -Axxaer (talk) 10:43, 23 September 2010 (UTC)


 * The "Risk of vertebrobasilar stroke and chiropractic care: results of a population-based case-control and case-crossover study." reference number 1 is from a lower quality ref that is duplicate information from safety.
 * The duplication from ref 1 says "A crossover study found that increased risks of VBA stroke associated with chiropractic and general practitioner visits was likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke.[1]"
 * The article says: "Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[126][149]"
 * Reference number 2 is not a systematic review but claims it is a systematic review using attribution in the text.
 * The part "More recent research has contradicted the suggestion that neck manipulation can result in vertebral artery dissection," is completely OR from ref 3. "The biomechanics of spinal manipulation." ref number 3 is not specifically about safety.
 * The "Microstructural damage in arterial tissue exposed to repeated tensile strains." ref number 4 is about rabbits not humans.
 * All those sources do not meet MEDRS and I think they would make a bad addition to the safety section because the addition would flood the safety information per WP:WEIGHT. Furthermore, adding a bunch of attribution in the text is poor writing when there is no serious disagreement per WP:ASSERT. For example, stating "A crossover study" is attribution in the text. Why use lower quality studies and repetitive text to argue against more reliable studies? QuackGuru (talk) 17:12, 23 September 2010 (UTC)

No original research may be worth a read here. - 2/0 (cont.) 01:37, 24 September 2010 (UTC)

I've read the OR page; I know what original research is. From ref 2 " A total list of 99 relevant articles was generated. Additional references were collected from citations incorporated within the included articles." sounds like a systematic review to me. I'm not sure what you're saying about duplicate information from a study. Regarding ref 1, the line can be changed to "vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[126][149]". It is not a low quality source, it meeds MEDRS. How can you call ref 3 Original research? the direct quote from the study is " Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures.". This is directly relevant to safety. I have no problem removing the attribution in the text, in fact if I did it would strengthen the text. Please do not call other editors meatpuppets, it is offensive and an incorrect usage of the term -58.96.105.189 (talk) 11:14, 24 September 2010 (UTC)

Regarding animal studies, animal studies are frequently used to extrapolate to human physiology. Thousands of articles on wikipedia use animal studies, particularly drug articles. are you suggesting that we delete them all? This quote can also be included "the results should not be translated to the human VA (vertebral artery) without due consideration." to warn that this is not necessarily able to extrapolate to human physiology --Axxaer (talk) —Preceding undated comment added 11:33, 24 September 2010 (UTC).


 * As for ref 1, the line doesn't need to be changed to the text I put on the talk page. It is already in the article. I posted it here to show that part of your proposal is duplcation.
 * Reference 2 does not claim to be a systematic review. Sounds and claims are two different things.
 * The part of the proposal "More recent research has contradicted the suggestion that neck manipulation can result in vertebral artery dissection," is completely OR when using ref 3 as a citation. The biomechanics of spinal manipulation from ref 3 is a low quality study and does not add anything to chiropractic safety. I don't see the point to compare "passive range of motion testing and diagnostic procedures" to chiropractic spinal manipulation.
 * The ref 4 animal study is not even relevant to this article. Again, we have better sources currently used for this article. QuackGuru (talk) 17:50, 24 September 2010 (UTC)


 * So how would you define meatpuppets then?
 * "I may do similar to you and bring in some of my medical student friends with more of an open mind.. --Javsav (talk) 01:09, 23 September 2010 (UTC)"
 * "If you could help us out with the multitude of discussions on talk:chiropractic, specifically this one, it would be greatly appreciated Talk:Chiropractic#Controversial_changes_to_safety --Axxaer (talk) 05:45, 23 September 2010 (UTC)"
 * Your first edit here was when? See WP:DUCK. You're all most welcome to contribute here constructively, but I'd be grateful if you didn't insult my intelligence. --RexxS (talk) 01:45, 25 September 2010 (UTC)

MeatPuppets refers to new editors. "the recruitment of new editors for this purpose is a violation of this policy. A new user who engages in the same behavior as another user in the same context". Axxaer has been an editor since 2006. I don't know why you are referring to the comment he put on Be Critical's page, we do not know Be Critical. QuackGuru, you still have failed to explain how ref 1 is duplication, and how ref 3 is original research. The quotes are directly from the study, as such, how could it be original research? If ref 2 is not a systematic review, then please tell me what it is. " A total list of 99 relevant articles was generated. Additional references were collected from citations incorporated within the included articles." what else could this be other than a systematic review? I am eager to hear your explanations. Furthermore, these are not low quality sources, they meet MEDRS, please show me how they do not meet MEDRS -Javsav (talk) 09:12, 25 September 2010 (UTC)


 * Can we take the discussion of meatpuppetry elsewhere? Once awareness of the potential issue has been established, it is incumbent on any editor continuing to cast aspersions to substantiate and escalate up the dispute resolution chain. For instance, requesting review at sockpuppet investigations or the administrators' noticeboard might be appropriate, while continuing to discuss it here is really not.

More relevantly, I just reverted the addition by someone in ON of Cassidy 2008 to the lead. I fubared the edit summary, but hopefully it is abundantly clear to everyone here that we should not use a 2008 study to cast doubt on the conclusions of a 2010 review. - 2/0 (cont.) 13:18, 25 September 2010 (UTC)


 * Thank you for your well-intended advice, 2/0, but as there seems to be no dispute about the facts, there's nothing to resolve through escalating that issue into DR. Additional perspectives are welcome here, and it's good to see return after his 32-month Wikibreak. --RexxS (talk) 13:50, 25 September 2010 (UTC)


 * Ref 1 is duplicate of this text that is in Safety "Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[126][149]"
 * Ref 2 is not a systematic review, it seems to be a primary study. Ref 2 never claimed to be a systematic review but the text of the proposal claims it is a systematic review.
 * If ref 3 is an exact quote form the study without it being in quotes then it could be plagiarism.
 * How part of the proposal from ref 3 is original research? The part "More recent research has contradicted the suggestion that neck manipulation can result in vertebral artery dissection," is OR when is is unsourced. We should not use primary studies or low quality studies to refute higher quality studies like recent systematic reviews. Javsav, I did explain most of this in my previous comments on the sources. QuackGuru (talk) 18:38, 25 September 2010 (UTC)


 * Well obviously if ref 1 is already in the safety section, it obviously meets MEDRS and further quotes can be used from it. It is often in wikipedia that more than one piece of information is taken from an article to add to the page. Ref 3 isn't OR, it is directly from the source, which you would realise if you read the article, and if you would like we can use the quote from the source, in quotations, to avoid plagiarism. e.g. Chiropractic manipulation of the cervical vertebrae has been fond unlikely to cause vertebral artery dissection, as "Stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much smaller than those produced during passive range of motion testing and diagnostic procedures." Ernst's systematic review was about deaths likely attributed to chiropractic, with no proof.


 * This study is about the mechanisms by which this makes Ernst's study unlikely, however it is in a completely different line of research to Ernst's sytematic review, which was only about deaths possibly attributed to chiropractic, whereas this refers to biomechanical mechanisms of manipulation and offers an opposing, but not a contradictory review. Because Ernst's systematic review did not include any of such articles, but rather case reports of death, the two are unrelated and as such can be used in tandem to provide a balanced POV.


 * QuackGuru, you claimed you explained the duplication and OR in your previous posts, however you simply stated "ref 1 is duplication" "ref 3 is OR" without alluding to why. In the future, please try and explain further what you mean, and it will prevent a lot of this back and forth between us. Maybe its just me but I had a hard time understanding what meant/were getting at.


 * RexxS, regarding your comment discussing Axxaer's 32 month leave of absence, [comment removed for privacy] -Javsav (talk) 03:29, 27 September 2010 (UTC) I'd appreciate that you didn't search the history for this comment out of a mattery of courtesy toward Axxaer. Thanks for you cooperation --Javsav (talk) 23:27, 28 September 2010 (UTC)

--Javsav (talk) —Preceding undated comment added 02:14, 27 September 2010 (UTC).


 * I'm really sorry to hear about Axxaer's unfortunate experiences, but I'd rather you removed your description of them from a public page, please. Your point is well-made and I perfectly willing to take your word. It is never my intention to cause distress to another editor, and I'm sorry if my reference to his break caused offence. Both he and you are capable of making good contributions, and I don't mean to be patronising. I'm sincere in my acceptance that other editors will disagree over many issues.
 * I think that we're nearer common ground now, because I don't see Herzog as contradictory to Ernst either. However, I read Herzog to be saying that he has examined possible mechanisms of arterial dissection (AD) consequent to properly performed spinal manipulation (SM), and in the cases he examined found the stresses and strains to be within the range produced by other interventions. It seems to me that he does not rule out possibilities such as inexpert or over-forceful SM, or pre-existing conditions. I understand him to be saying that he doesn't deny adverse effects such as AD following SM, but cannot find a mechanism. Nevertheless I accept that you may read the sources differently to me. --RexxS (talk) 03:16, 27 September 2010 (UTC)


 * Thanks for your understanding. I'll give the herzog a whole read and the lack of ruling out inexpert chiropractic manipulation can be integrated into the article if it is within the source. Cheers --Javsav (talk) 03:28, 27 September 2010 (UTC)


 * Ref 1 is not used in the safety section. I have repeately explained there is similar information already existing in the safety section.
 * The text of the proposal is similar to current text from 126 and 149 refs but is not from ref 1 is "Vertebrobasilar artery stroke is statistically associated with chiropractic services in persons under 45 years of age, but it is similarly associated with general practitioner services, suggesting that these associations are likely explained by preexisting conditions.[126][149]"
 * The part of the the text "A systematic review" is OR. The unreliable ref does not claim to be a systematic review. Can you provide V for the claim "A systematic review". Another part from ref 2 "concluding "the direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures." is similar to "Chiropractic care in general is safe when employed skillfully and appropriately." that is in Safety using the WHO ref.
 * What part of ref 3 supports "More recent research has contradicted the suggestion that neck manipulation can result in vertebral artery dissection," per Wikipedia's WP:V or otherwise it is WP:OR.
 * For the future, putting text in quotes does not have an ecyclopedic feel. It would be better to rewrite text in our own words that would still be verifiable. But for this source I think the ref is not really reliable.
 * The word "Further," seems to be OR. The source does not make the claim "Further".
 * The biomechanics of spinal manipulation ref and the Microstructural damage in arterial tissue exposed to repeated tensile strains ref are primary studies that do not meet MEDRS. We have systematic reviews on spinal manipulation safety that should not be undermined with weak sources or duplicate text. QuackGuru (talk) 03:58, 27 September 2010 (UTC)
 * It is interesting to note that the table of contents of the Journal of BodyWork and Movement Therapies has Herzogs review labelled as an invited review, both supporting our consideration of it as a review, and also implying that the journal recognizes Herzog as an expert in the field. Upon further investigation it is even more interesting that the International Journal of Clinical Practice has Ernsts 2010 "review" labelled as a short communication in their table of contents . Perhaps we should remove Ernst 2010 paper altogether from the wikipedia article. 209.183.26.162 (talk) 17:11, 27 September 2010 (UTC)
 * Herzog 2010 does not claim to be a review of the literature according to the PubMed abstract. and it is not from a quality journal. QuackGuru (talk) 18:47, 27 September 2010 (UTC)
 * Research related to biomechanics of SM belong in the treatment techniques section using top-tier journals like The Spine Journal. QuackGuru (talk) 19:39, 27 September 2010 (UTC)

Javsav, I would prefer if you did not comment on my personal life without asking me beforehand, but I will forgive you in this instance. QuackGuru, RexxS has agreed that the Herzog can be used, and I think you should be more forgiving when allowing sources that apply to MEDRS. You seem to have a skewed misinterpretation of MEDRS - it does say that systematic reviews are the highest source, but it does not say that other articles which comply with MEDRS can not be used to give further information in the interest of giving the page a NPOV --Axxaer (talk) 22:46, 28 September 2010 (UTC)

Sorry, Axxaer, I will talk to you privately regarding this matter. It doesn't have to say "More recent research has contradicted the suggestion that neck manipulation can result in vertebral artery dissection, as the stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much lesser than those produced during simple passive neck range of motion", it could possibly say "More recent research has offered opposing views to the suggestion that neck manipulation can result in vertebral artery dissection, as the stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much lesser than those produced during simple passive neck range of motion". However, you seem to be confused regarding OR. It is clear that this reference does contradict that suggestion. It doesn't need to say it in the source, because the evidence from this source does contradict that suggestion. That is not Original Research, it is inference from the source. However,I would be happy to change it to the latter ("More recent research has offered opposing views to the suggestion that neck manipulation can result in vertebral artery dissection, as the stresses and strains on the vertebral artery during chiropractic spinal manipulation of the neck were always much lesser than those produced during simple passive neck range of motion") if you fail to understand my position -Javsav (talk) 23:23, 28 September 2010 (UTC)
 * @Axxaer - my position on Herzog is rather more nuanced. The publishing journal (J Bodyw Mov Ther) has much less currency than IJCP and Neurologist, and PubMed throws doubt on whether Herzog's findings should be regarded as a primary or secondary source, despite the "invited review" nomenclature used by JBMT. I understand you do not agree with QG on this point. If Herzog is primary, then per MEDRS, it cannot be used to rebut the findings of Ernst 2010 and Miley 2008, which state the causality relating SM and AD. Our text currently reads:
 * "Weak to moderately strong evidence supports causation (as opposed to statistical association) between cervical manipulative therapy (whether chiropractic or not) and vertebrobasilar artery stroke.[Miley 2008] The published literature contains reports of at least 26 deaths since 1934 following chiropractic manipulations. The dissection of a vertebral artery, typically caused by neck manipulation, is a causality that is at least likely.[Ernst 2010]"
 * I accept that you feel that these findings are disputable, but even if Herzog were secondary, the choice of publication leaves it in a weak position to refute two unequivocally recent reliable secondary sources. I would be very uncomfortable in accepting that there is a "serious dispute" among reliable sources, based only on Herzog.
 * That is particularly true since I read Herzog to be addressing the question of possible mechanism of AD following SM. To be as clear as I can: I maintain that an inability to find a mechanism does not not rule out causality. If you were looking to discuss possible mechanisms of AD in the article, then without other sources (neither Ernst nor Miley address mechanism), a case could be made for using Herzog, and others. Perhaps something along the lines of "No mechanism by which SM could cause AD has been established, as the stresses and strains on the VA during SM are observed to be much less than during passive range of motion testing and diagnostic procedures" might be capable of achieving consensus? --RexxS (talk) 00:10, 29 September 2010 (UTC)
 * I don't think "passive range of motion testing and diagnostic procedures" is a treatment option for neck pain and I fail to see how this is relevant to safety. How could we use a weak source for "the stresses and strains on the VA during SM are observed to be much less than during passive range of motion testing and diagnostic procedures" when there is more relevant information in safety that reads: "adverse reactions appear to be more common following manipulation than mobilization.[148 The Spine Journal]" QuackGuru (talk) 03:38, 29 September 2010 (UTC)


 * Herzog2010 not relevant to safety

This is not even close to a top quality journal, and the primary study does not directly address the issue of safety. This unreliable source is proposed to be used in such a way as to invite synthesis to contradict more recent, reliable reviews. QuackGuru (talk) 03:49, 29 September 2010 (UTC)

In a similar study the preliminary report cautioned that general conclusions should not be drawn from these preliminary results. This is concrete evidence that this is primary research from Herzog W. QuackGuru (talk) 06:13, 29 September 2010 (UTC)
 * Note that the "similar study" you refer to was not a similar study at all...it was a primary study in itself. The recent paper which is under debate is a review, which includes data from the said primary study as part of that review, along with data from a plethora of other primary sources. This is concrete evidence that Herzog's review is secondary evidence.209.183.26.162 (talk) 18:49, 4 October 2010 (UTC)
 * The claim "which includes data from the said primary study as part of that review, along with data from a plethora of other primary sources." is irrelevant. You have not shown that this new kind of research meets MEDRS using a weak journal. QuackGuru (talk) 18:57, 4 October 2010 (UTC)

Unreliable references against MEDRS
This edit added more unreliable references. The references are very old. See WP:MEDRS. QuackGuru (talk) 17:04, 2 September 2010 (UTC)

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

References from 1978 do not pass Identifying reliable sources (medicine). QuackGuru (talk) 02:30, 5 September 2010 (UTC)

Per MEDRS: See the Reliable sources noticeboard for queries about the reliability of particular sources or ask at relevant Wikiprojects such as WikiProject Medicine or WikiProject Pharmacology.

If editors cannot agree we can take the recently added sources to one of the noticeboards. References from 1978 are not reliable because we have newer sources currently used in the article. QuackGuru (talk) 03:41, 6 September 2010 (UTC)

After requesting for the editor who added the 1978 studies against MEDRS to explain the edit the editor just reverted the comment. No explanation was made to use old studies to argue against newer ones. QuackGuru (talk) 03:14, 9 September 2010 (UTC)

I made this change to tag the unreliable references from 1978. QuackGuru (talk) 03:35, 9 September 2010 (UTC)


 * First of all it's a guideline not a rule. Second of all, you're quoting it out of context, the context is: "These guidelines are appropriate for actively researched areas with many primary sources and several reviews, and may need to be relaxed in areas where little progress is being made and few reviews are being published". Thirdly, I listed the studies in chronological order, with newer studies coming after, this shows that there have been conflicting results over the decades. Finally, if you have a newer study that compares joint mobilization to chiropractic manipulations please feel free to point it out.--Anon 07:21, 9 September 2010 (UTC)


 * I did not quote MEDRS out of context. I quoted the most relevant part. We don't need to relax the reference selection because there are currently plenty of sources on the topic of hand.
 * "A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache.[131] A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[132] A 2004 review found that SM may be effective for migraine and tension headache, and SM and neck exercises may be effective for cervicogenic headache.[133] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SM.[108]"
 * I don't see how there is little progress when we do have newer sources available. MEDRR is a guideline that is very easy to follow for this page especially when there are newer sources available. According to MEDRS we "Look for reviews published in the last five years or so, preferably in the last two or three years." So in this case we shouldn't use sources over the decedes. QuackGuru (talk) 02:46, 10 September 2010 (UTC)
 * I disagree and I think the studies have their place. Per my reasons above.--Anon 05:44, 10 September 2010 (UTC)
 * Actually, the dated studies don't have a place in this article per the progress made on this topic and extensive recent reviews. QuackGuru (talk) 18:27, 12 September 2010 (UTC)

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

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

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

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

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

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

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

The text "A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache." ias supported by

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

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

Harvard Medical School, Boston, MA, USA.

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

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

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

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

The text "A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine." is supported by

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

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

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

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

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

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

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

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

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

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

The text "A 2004 review found that SM may be effective for migraine and tension headache, and SM and neck exercises may be effective for cervicogenic headache." is supported by

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

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

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

Comment in:

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

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

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

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

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

The text "Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SM." is supported by

There has not been little progress and there has not been a few reviews being published. In fact, there has been a lot of progress and clearly there has been more than a few reviews on the topic. MEDRS is not a policy but for alternative medicine articles like chiropractic editors have followed MEDRS. Using old unreliable references to argue against newer high quality references like the Cochrane Database Syst Rev is against MEDRS. QuackGuru (talk) 18:27, 12 September 2010 (UTC)
 * I still don't agree. But, how about we just write: "A 1978 study found . However, more recent studies "?--Anon 10:17, 13 September 2010 (UTC)
 * Articles from 1978 are not usually usable except maybe in a section on history or about conditions that no longer exist. Please use something from the last 10 years (3 to 5 years) is best.  1978 is \before the term evidence based medicine even existed. Doc James  (talk · contribs · email) 05:40, 15 September 2010 (UTC)
 * Sir Anon, I disagree with your proposal. "A 1978 study found" is from a dated reference against MEDRS. "However, more recent studies" is editorialising which is against V and OR. At this point I think it is best to seek outside comments to help resolve the dispute over the references. See Wikipedia talk:WikiProject Medicine. QuackGuru (talk) 05:49, 15 September 2010 (UTC)
 * Since there are multiple recent reviews from the Cochrane 2004 review onwards, the text of the Effectiveness/Headache section should be written to reflect the views expressed in those secondary sources. It is wholly inappropriate to introduce text based on a 30 year old source, particularly when it conflicts with current mainstream medical opinion as shown in the recent secondary sources. --RexxS (talk) 09:05, 15 September 2010 (UTC)


 * Let's stay away from sources older than 5 years old. They're too dated. If a subject hasn't been reviewed in the past 5 years, then it's probably not worth summarizing here.
 * Again, there is no intent to ignore old data. If old data is still important, it should appear in a recent review. If it doesn't appear, that's good evidence that it wasn't that important after all, at least according to published expert reviewers.
 * Wikipedia is not the place to conduct research reviews on our own, overriding reviews already published by experts in the field. Multiple reviews are cited in Chiropractic; they are from many different authors. Other reliable review sources are welcome, as per the usual WP:MEDRS guidelines. Reaching down into primary studies is dubious.
 * No argument has been put forth that the reviews in question are incongruent with the topic at hand. On the contrary, the reviews are quite congruent with the topic of effectiveness. There is no good reason to disregard reliable reviews and to substitute our own opinion about the the reviewed studies. QuackGuru (talk) 19:39, 15 September 2010 (UTC)
 * It may be considered a little arbitrary to simply pick a figure of 5 years old, as not all niche fields will have necessarily completed a review cycle in that period of time. A Cochrane review is often the most significant review in a cycle and may be expected to comprehensively summarise all significant previous studies. In this case, I'd humbly suggest that 6 years (the time since the 2004 Cochrane review) would be a justifiable cut-off point. I would therefore suggest that the 2004 Cochrane review should be the starting point for the text, built upon by taking into account the views expressed in later reliable secondary sources, where they introduce developments or aspects not already covered. It should go without saying that WP:ASF expects that we should assert these views as facts, without the distraction of attribution (after all, anyone can see the reference used for the text). Obviously the only exception to this is where two recent reliable secondary sources differ in their views, where it may be necessary to contrast the views and attribute each (although from what I've been able to read in the sources, it appears unlikely that it will be necessary in this case). --RexxS (talk) 20:38, 15 September 2010 (UTC)
 * Per Identifying reliable sources (medicine):
 * "These are just rules of thumb. There are exceptions:
 * Cochrane Library reviews are generally of high quality and are routinely maintained even if their initial publication dates fall outside the above window."
 * I suggest we stick with about five years. When there is an older Cochrane review we will cite it until a newer Cochrane review is available. QuackGuru (talk) 20:52, 15 September 2010 (UTC)
 * I think we're pretty much in agreement then. When I considered the sources that you kindly provided in the collapse box above, I didn't want to lose Bondi (Jun 2005) because an arbitrary sharp 5 year cut-off would disqualify it (by a few months), and I didn't think that was the spirit of WP:MEDRS. It ought to be justifiable to consider such structured reviews, since they postdate the Cochrane review. Would you then agree that the sources in the collapse box could comprise the short list for sourcing the text in this section, or are there others that ought to be considered? --RexxS (talk) 21:56, 15 September 2010 (UTC)


 * Every section must have a certain amount of information to thoroughly cover each specific topic. I think we are going to keep the reference until a newer, similar reference would replace Bondi 2005. We can strive for 5 but don't disqualify a ref because it is six or seven years old. QuackGuru (talk) 20:00, 16 September 2010 (UTC)

I see WP:CON to remove the dated 1978 articles from the chiropractic page. Editors should try to stick within five years using recent reviews. If the section is very short then we can relax MEDRS a bit to include an additional ref or two. QuackGuru (talk) 20:00, 16 September 2010 (UTC)


 * Done. - 2/0 (cont.) 15:59, 20 September 2010 (UTC)

Failed verification
This change was made without explanation and does not seem to be written from a neutral point of view. The claim did not identify substantial benefits failed verification and seems to be the personal interpretation of an editor. We report what the source say not review the references ourselves. We don't put words in the cited source's mouth. See WP:V and WP:OR. QuackGuru (talk) 01:06, 8 September 2010 (UTC)
 * It might help to address editors directly. Also it's not great practice to make your points in discussion headings.


 * The edits were mine, as explained in the edit summary. Compared to the prior version, they improved upon both the unnecessary mention of Ernst's country of residence as well as clarified the logic which led him to his conclusion.   It is not a personal opinion that Ernst does did not identify substantial benefits to spinal manipulation.  That was my paraphrasing of his results.  Can you suggest a different wording?


 * Referencing guidelines over and over does not help consensus, and implies editors are intentionally misusing or completely ignorant of policy. It also assumes your conclusion.  It might be better to just offer alternatives or explain how something could be improved.  That way it seems less like you're shooting down good faith edits and more like you're helping to educate and reach consensus.  Ocaasi 03:15, 8 September 2010 (UTC)


 * It is a personal opinion that the review did not identify substantial benefits to spinal manipulation when it is not in the citation given and not in the results. The text failed verification because it is not in the source. The version of the sentence in the lead before the controversial changes were made was fine and sourced in accordance with V. If you still think it is sourced then what sentence in the article verified the text. QuackGuru (talk) 16:08, 8 September 2010 (UTC)
 * They might have been fine with you. I found them sub-optimal and think the more explanatory version is better to inform readers.  It is not a personal opinion that Ernst did not identify substantial benefits.  It is consistent with results.  Could you rephrase that phrase so that it is more accurate?  That would be better than constantly challenging under the pretense that other editors are trying to slip something past.  I have a hunch that it is the word 'substantial' that is causing you a problem.  Would you have a different word or phrase to consider? Ocaasi 17:02, 8 September 2010 (UTC)


 * You claim "It is consistent with results." But you did not provide verification which sentence supported your personal opinion. The previous consensus version before the controversial changes was made was well written and completely sourced. QuackGuru (talk) 17:13, 8 September 2010 (UTC)


 * This edit by Sir Anon did not provide verification for the part of the text that failed verification. The part "did not identify substantial benefits" is still original research. QuackGuru (talk) 03:10, 9 September 2010 (UTC)
 * Your comments towards others makes people reluctant to work with you. So it is all to easy to look at the article and try to fix it up without reading the pages and pages of comments you write here about what terrible policy-vioalting spammers the rest of us are.--Anon 07:24, 9 September 2010 (UTC)


 * I tried to discuss the matter with Sir Anon but the editor just reverted my comment without explanation. Sir Anon, please try to discuss here. QuackGuru (talk) 05:53, 9 September 2010 (UTC)


 * This statement is untrue and has nothing to do with the article, take it somewhere else.--Anon 19:35, 9 September 2010 (UTC)


 * It's not untrue, but it has little to do with the article. However, Anon's "correction" of Ernst's findings is not apparent from Ernst's paper itself; the fv tag is appropriate, regardless of whether QG's attempts to engage you on your talk page were appropriate.  — Arthur Rubin  (talk) 21:25, 9 September 2010 (UTC)


 * I've never corrected that sentence - you're mistaking me for another editor. With regards to the tag removal (which is my only change to that sentence), like I've already told QuackGuru above, I've misinterpreted the tag and at the time and I believed I was providing the requested verification in my edit summary. Apparently the dispute is about something else in that sentence, but I'm not part of that sub-dispute.--Anon 21:52, 9 September 2010 (UTC)


 * Sir Anon, you were told which part of the text failed verification but you did not restore the tag or provide verification. QuackGuru (talk) 02:46, 10 September 2010 (UTC)
 * I'm not paid to edit Wikipedia and I will only make edits I want to make myself. I believe that is my right.--Anon 05:46, 10 September 2010 (UTC)
 * @Anon, I made it very clear that the edits were mine at the beginning of this section. The diff shows as much.  Either QG knows this already or isn't reading the posts.  I offered to discuss the issue but QG seems to prefer his original version to finding a suitable phrasing for "did not identify substantial benefits".
 * @QG, if you want to find a different way of phrasing this, that would be better than just prodding editors to fix a problem that they either don't necessarily agree exists or have expressed an interest in your alternatives. The quotes from Ernst 2010 and the intertextual citation to Ernst's ''Critical Evaluation" paper are, respectively, as follows:
 * "There is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition."
 * "With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition."
 * It is true that Ernst did not identify substantial benefits to spinal manipulation. Is that the most accurate way to phrase his results? Perhaps not.  I'm still open to your alternatives.  We could just write that, the 2010 review, "concluded that since there is no evidence neck manipulation is an effective therapy for any medical condition..."  Which was more or less the intention of my paraphasing. Do you have any thoughts about that? Ocaasi (talk) 08:21, 10 September 2010 (UTC)

Per WP:V: The threshold for inclusion in Wikipedia is verifiability, not truth&mdash;whether readers can check that material in Wikipedia has already been published by a reliable source, not whether editors think it is true.

All material in Wikipedia articles must be attributable to a reliable published source to show that it is not original research, but in practice not everything need actually be attributed. This policy requires that anything challenged or likely to be challenged, including all quotations, be attributed to a reliable source in the form of an inline citation, and that the source directly supports the material in question.

The source did not support the claim "did not identify substantial benefits"[failed verification] to spinal manipulation. It is true that the systematic review did not identify or say that were substantial benefits to chiropractic neck spinal manipulation. When the reference did not verify or support the claim that the source "did not identify substantial benefits" to spinal manipulation it is absolutely WP:OR. Per WP:V, the threshold for inclusion in chiropractic is verifiability, not truth. QuackGuru (talk) 18:27, 12 September 2010 (UTC)


 * Here is a copy-paste quote from the Ernst paper: "Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition (32) Thus, the risk-beneﬁt balance for chiropractic neck manipulation fails to be positive." [32 points to another "study" by... you guessed it, Ernst]. I don't quite understand your and Arthur's objection to Ocaasi's summary of this. Do you have an alternative way of phrasing this in a few words?--Anon 10:23, 13 September 2010 (UTC)


 * Conclusions of a review article are not an "authors viewpoint" but a conclusion based on the evidence. We do not present review article conclusions like this. Doc James  (talk · contribs · email) 05:49, 15 September 2010 (UTC)


 * The direct quote did not verify the claim "did not identify substantial benefits" per WP:OR or WP:V. But the direct quote did verify the claim "A 2010 systematic review found there is no good evidence to assume that chiropractic neck manipulation is effective for any medical condition. " that Sir Anon deleted without a specific explanation. Hmm. QuackGuru (talk) 06:07, 15 September 2010 (UTC)

This change did not remove the text that failed verification or fix the the sentence that is not a concise summary. The part "while identifying no substantial benefits" is still OR. QuackGuru (talk) 15:42, 20 September 2010 (UTC)

I hope it was alright I removed the OR from the lead. QuackGuru (talk) 18:41, 20 September 2010 (UTC)

It is not OR - you have a very biased view of OR. Furthermore, you have been deleting my edits without discussion, and now only realising that this may have landed you in trouble you are now waiting for discussion to delete edits, and you have brought along with you two more biased editors. I may do similar to you and bring in some of my medical student friends with more of an open mind. --Javsav (talk) 01:09, 23 September 2010 (UTC)
 * QG is not in any sort of trouble, as he has not violated any policies. It is not acceptable to accuse another editor of "bias". QG did not bring along "two biased editors" and you need to retract that accusation. You have now threatened to violate our policies on meatpuppetry. I strongly suggest you stop attacking other editors and start discussing reliable sources. --RexxS (talk) 01:42, 23 September 2010 (UTC)


 * Javsav, it is OR and you have not even attempted to provide verification from the source being used. Moreover, you have previously overlooked the discussion and I hope you will at least try to keep an open mind on how other editors are editing in good faith. QuackGuru (talk) 03:24, 23 September 2010 (UTC)

I never said QuackGuru was in trouble. All I was saying that he was previously reverting edits without discussion, until after the mediation was started, at which point he miraculously started "discussion" which involved recruiting two editors using other wikipedia pages about violation of MEDRS, and then shutting down any possible edits. It is not meatpuppetry, the friends I will be inviting are longstanding wikipedia editors and I am not forcing them to say anthing, it is up to them to make their own decisions regarding this topic. -Javsav (talk) 11:14, 23 September 2010 (UTC)


 * I don't mind you invite your friends to this article but admins may have a different perspective. For now, it is time you provide verification or I suggest you move on. QuackGuru (talk) 17:12, 23 September 2010 (UTC)

Concise sentence
The first edit referred to in this thread was replacing the text "A systematic review determined that the risk of death from manipulations to the neck by far outweighs the benefits" by "A systematic review in England reported 26 deaths following manipulations, in the author's viewpoint far outweighing the potential benefits". WP:ASF is clear on this: I see no serious dispute among reliable sources about the conclusion from the secondary source, so the attribution applied in that edit was a breach of the WP:NPOV policy. The original text needs to be restored. --RexxS (talk) 09:27, 15 September 2010 (UTC)
 * "Assert facts, including facts about opinions—but do not assert the opinions themselves. A fact is a statement about which there is no serious dispute among reliable sources."

On further consideration, this is the lead of the article, and must be concise. The text of that sentence should read "The risk of death from manipulations to the neck far outweighs the benefits." --RexxS (talk) 09:39, 15 September 2010 (UTC)


 * "A systematic review determined that the risk of death from manipulations to the neck by far outweighs the benefits." (possible violation of ASF)
 * "The risk of death from manipulations to the neck far outweighs the benefits." (no serious dispute per ASF)
 * I agree the sentence should be concise. I'm fine with both versions but I prefer to assert the text because there is no serious dispute. QuackGuru (talk) 19:39, 15 September 2010 (UTC)


 * Unless other systematic reviews disagree it should be stated as fact. Doc James  (talk · contribs · email) 22:29, 15 September 2010 (UTC)


 * There is a discussion here to restore the more concise version of the sentence but even more detail was reverted into the sentence. This is way too much detail for one sentence. We don't summarise the entire sentence in the lead. Another edit removed the word fatal from a previous sentence which was about fatal complications in rare cases. This balanced the next sentence which is about risk-benefit by far outweights the risk. Next, by far was removed which is sourced and the word neck was wikilinked which seems unnecessary. To state the year of the review in the lead is inappropriate and not a concise summary of the source. The date 2010 is not significant to chiropractic and is too much detail for the lead. Per WP:LEAD: The lead should be able to stand alone as a concise overview of the article. QuackGuru (talk) 16:38, 18 September 2010 (UTC)

A lot of problems were introduced into the article recently against MEDRS, ASF, V, and OR. There was also a lot of rephrasing that diluted the meaning of numerous sentences. At this point, I think the version that is closest to NPOV is this version. The difference between both versions can be reviewed here. QuackGuru (talk) 20:00, 16 September 2010 (UTC)

Relevant content was replaced with irrelevant content
The direct quote did verify the claim "A 2010 systematic review found there is no good evidence to assume that chiropractic neck manipulation is effective for any medical condition. " that an editor deleted without a specific explanation. I think the relevant content should be restored and the irrelevant content along with the unreliable chiropractic article deleted. The section is about effectiveness not safety. QuackGuru (talk) 16:56, 19 September 2010 (UTC)


 * "A 2010 systematic review found there is no good evidence to assume that chiropractic neck manipulation is effective for any medical condition." I restored the sentence to Effectiveness since there was no explanation why it was removed in the first place. QuackGuru (talk) 18:37, 20 September 2010 (UTC)

Replacing sourced content with unsourced original research
Per V: The threshold for inclusion in Wikipedia is verifiability, not truth&mdash;whether readers can check that material in Wikipedia has already been published by a reliable source, not whether editors think it is true.

Per OR: Wikipedia does not publish original research. The term "original research" refers to material&mdash;such as facts, allegations, ideas, and stories&mdash;not already published by reliable sources. It also refers to any analysis or synthesis by Wikipedians of published material, where the analysis or synthesis advances a position not advanced by the sources.

This comment stated "It doesn't have to say it in the source, I have read the source and you can make the inference that they are critics of vitalism from the context." It is not acceptable to replace sourced content with original research editorialising. I cannot stress enough that all editors must adhere to V and OR policies. Please, Wikipedia is not the place to conduct our own review or analysis of the sources. QuackGuru (talk) 17:12, 23 September 2010 (UTC)