Talk:Spinal manipulation/Archive 1

Redirect for lack of a proper article
The redirect takes one to the chiropractic concept of Spinal adjustment, which is not exactly the same as spinal manipulation. The intent is very different. A separate article for scientifically justified Spinal manipulation is needed. MDs and PTs do not manipulate for the purpose of removing non-existent chiropractic vertebral subluxations, which is the chiropractic justification for using "adjustments." -- Fyslee 05:27, 23 August 2006 (UTC)

From Manipulation article
In the context of joints, manipulation is the skilled passive movement of a joint that is applied at varying speeds and amplitudes, including a small-amplitude/high velocity therapeutic movement or thrust. It can also refer to the process of bringing fragments of fractured bone or  displaced joints into normal  anatomical alignment (otherwise known as 'setting' the bone).

Manipulation does not imply specificity or the correction of the chiropractic subluxation, and therefore is not entirely synonymous with the chiropractic adjustment. -- Fyslee 20:31, 3 September 2006 (UTC)

POV issues
There are big issues in this article, most notably the recent dominant inclusions from Edzard Ernst who is not a specialist or expert in manipulation/chiropractic and the overall bad tone of the safety section, POV issues with attribution to chiropractic "strokes" when DCs were not involved as well as the underreporting which is challenged in physical med journals. Furthermore, there are major omissions in recent papers which have studied the stroke issue in depth by experts in SMT and stroke. CorticoSpinal (talk) 23:13, 25 April 2008 (UTC)
 * We disagree as to what the POV problems are. That's OK.  What's not OK is your unsourced assertion that 90% of spinal manipulations are performed by chiropractors, even if you restrict yourself to manipulations in which the practitioner is trained.  &mdash; Arthur Rubin  (talk) 04:01, 26 April 2008 (UTC)
 * Before we begin, I just want to confirm that you're really the Arthur Rubin, mathematician extraordinaire, right? Good, now we've noted that, I would like to remind of you of a little something, I urge you to look at the scope of the article.  Do you see that medical stub there?  Well, that falls under my domain, my expetise.  My expertise is chiropractic medicine and spinal manipulation is the characteristic treatment. Admin Baegis had some very good advice which he opined "If you struggled with passing calculus, don't go mucking about with the taylor series article.".  That's some good advice, methinks.


 * So, here is the source you wanted, (there are more) and it is considered the authoritative source whose chapter on SMT alone would be extremely beneficial to include with the plethora of research into the neurophysiologal responses and proposed theories too. After all, chiropractors are the expert providers of spinal adjustment, manipulation and manual therapy.   There are also tons more to add to the article from a scientific, cultural and historical POV whilst also addressing some severely biased POV issues.  Here's another: Can you please explain to me rationally why this section here on further reading consists of texts from 2 MDs, 5 PTs, and 0 DCs.  Because that seems rather odd when you factor than 90% of spinal manipulations are performed by DCs.  Looking forward to working with you.  CorticoSpinal (talk) 07:15, 26 April 2008 (UTC)


 * In the absence of evidence to the contrary, that seems a valid source for the statement, but please include the source. However, only (some) chiropractors understand the difference (if any) between spinal manipulation and chiropractic adjustment, so that it is still not the case that the chiropractic POV should dominate this article.  Please do not add unsourced statements, but you probably should add more reading material.  As an aside, you seem to be suggesting that this article is a POV fork of chiropractic adjustment, and should be merged into that article.  I'm not sure I agree with that suggestion, but it seems to be what you are suggesting.  &mdash; Arthur Rubin  (talk) 15:00, 26 April 2008 (UTC)
 * I think you may be confused, or misinformed, Mr. Rubin. The chiropractic scientists who are publishing the texts are quite clear that SMT is interchangeable with adjustment and this is the position of the majority of the profession. I think you may be referring to the minority position amongst "ultra-straights" who may still carry some metaphysical interpretations; but this is the fringe position within the profession.  I also never suggested that chiropractic POV should dominate the article; but they are the experts in manipulation.  The article will be scientific; it's a medical procedure (it falls under the wikiproject medicine scope) and I shall bring it up to snuff so that it can become, in time, a FA.  CorticoSpinal (talk) 18:17, 26 April 2008 (UTC)
 * Your editing style looks familiar. Have I worked with you before under another name?
 * In any case, as you assert that chiropractic adjustment and spinal manipulation are the same topic, you should be supporting merging the articles, before doing serious work updating one or the other.
 * You haven't said that the chiropractic point of view should dominate the article, but you've said that the scientific point of view should dominate (oddly enough, I disagree — most of the medical discussion of spinal manipulation is not scientific), and that the relevant scientists are chiropractors.
 * &mdash; Arthur Rubin (talk) 18:44, 26 April 2008 (UTC)
 * To be clear; you disagree the spinal manipulation is a medical procedure that does not have much scientific evidence? What exactly are you disputing here so we can iron out issues before I begin to bring the article up to wikipedia's project medicine standards?  Thanks in advance. CorticoSpinal (talk) 19:50, 29 April 2008 (UTC)
 * Is that a double negative or a triple negative? In any case, I believe that it is not the case that spinal manipulation is a medical procedure which has scientific evidence.  Because of disputes originated by chiropractors, it's not clear whether spinal manipulation is the same as chiropractic adjustment, and whether anyone can reliably distinguish between the two without knowing the intent of the practitioner. &mdash; Arthur Rubin  (talk) 22:31, 29 April 2008 (UTC)

Hi Guys, if I may. It is widely regarded that chiropractors perform approx 90% of manipulations in the US, but not in the world. In fact, in the UK, the majority of manipulations are performed by osteopaths, who outnumber chiropractors by approx 2:1. As WP is a global source of information, I think it would be wise to note the limitations of the 90% statement (specifically that it relates only to the US). By the same token, spinal manipulation is the generic term for the intervention applied by chiropractors, osteopaths, and physiotherapists/physical therapists, etc. If the chiropractic profession insist on claiming that the term 'adjustment' includes other non-manipulation interventions *as they often appear to), then I would be very much against an article merge.Davwillev (talk) 15:29, 30 April 2008 (UTC) BTW, if we are being strict with sources here, we need a better source than a textbook for the 90% claim. This is secondary referencing unless the original piece of research is cited.Davwillev (talk) 15:58, 30 April 2008 (UTC)
 * I have no problem with changing to North America. The same situation applies in Canada where DCs do 90% of the manips.  As for secondary sources, according to a strict interpretation of WP:MEDRS these are preferred; but if you want an actual paper, it's easy enough to fetch.  I support the merger of spinal adjustment and manipulation; adjustment (as interpreted by the STRAIGHT DCs) is a subset of spinal manipulation, whereas the MIXERS view it essentially as synonymous with SMT.  Waaaaaaaaay too much is being made behind of the 1910's philo of adjustment which is tenuously being guarded by the extreme fringe within the chiropractic profession. It's time to reflect the contemporary POV of manips (by the mainstream of DCs) It seems like people's beliefs system around here could use an adjustment! —Preceding unsigned comment added by CorticoSpinal  (talk • contribs) 19:24, May 4, 2008
 * I've got a problem with that. It still seems improbable to me, and it's not sourced.  As for an adjustment of your attitude, as you have been sanctioned for POV edits under another name, the mainstream scientific or medical point of view is what should be used, not the "mainstream" chiropractic point of view.  As far as I can tell, the mainstream medical point of view on spinal manipulation is that it is frequently called chiropractic adjustment, but that no one, not even practicing chiropractors, can define the difference.  &mdash; Arthur Rubin  (talk) 17:42, 4 May 2008 (UTC)

Establishing context in the lead
People will be confused, as I was, if they read the lead of this article and there is no reference to chiropracty. There's a lengthy debate above over whether this should be merged into chiropractic adjustment. Clearly we should note chiropractic adjustment in the lead. II | (t - c) 22:45, 23 July 2008 (UTC)

Firstly, there are more professional groups than just chiropractic (please note proper term) that perform spinal manipulation, and have contributed to the research base on the subject. These include osteopaths, osteopathic physicians, and physical therapists. There is adequate provision to describe this usage in the section called 'Current Providers'. Furthermore, the 'Chiropractic' article clearly refers to this one. If we start referring to individual professional groups in the lead, then we would need to refer to the others - this would not be useful. I am therefore re-deleting your (ImperfectlyInformed) edits, and hope you don't persist with them.Davwillev (talk) 18:51, 24 July 2008 (UTC)

== WP:WEIGHT Safety, proposal to merge Spinal adjustment with Spinal manipulation ==

There is an eggregious amount of text dedicated to the safety of SMT with a lot of puffery, quotes and outdated studies. It can be more concise. Also, Spinal adjustment can be incorporated into this article with a a sub-section dedicates to the differences between 'adjustment' and 'manipulation' if any. As per WP:MEDRS, high quality research is required, not merely conjecture! Soyuz113 (talk) 19:08, 6 September 2008 (UTC) (Edits of indef blocked user stricken.)


 * Soyuz113 has "been blocked indefinitely from editing in accordance with Wikipedia's blocking policy for sockpuppetry, edit warring, disruption and block evasion." I have stricken his remarks, as striking or removal is customary in such situations. -- Fyslee / talk 06:16, 8 September 2008 (UTC)

Assendelft et al Cochrane Review
I have added a reference at Spinal manipulative therapy with a Cochrane Review by Assendelft et al "Spinal manipulative therapy for low-back pain". Could it contribute to this article too? If so, perhaps an active editor here could find the right place to add it.--papageno (talk) 19:48, 19 March 2009 (UTC)

NCCAM on SM
[http://nccam.nih.gov/health/providers/digest/backpain-science?nav=cd Spinal Manipulation for Low-Back Pain: What the Science Says. May 2012]

Brangifer (talk) 15:21, 15 May 2012 (UTC)

Is Spinal Manipulation for Neck Pain Safe?
Here's something for the safety section. While some of this isn't MEDRS compliant for medical facts, it does refer to such sources, as well as documenting the controversy and public debate:


 * Sides Square Off on Manipulation for Neck Pain. MedPage Today, By Michael Smith, June 07, 2012


 * Is Spinal Manipulation for Neck Pain Safe? ABC News, by Lara Salahi, June 8, 2012


 * Pros and cons of spinal manipulation. The Washington Post, by Jennifer Huget, 06/07/2012

The UK National Health Service considers the debate notable enough to weigh in on the discussion with an analysis of the debate and some advice for the public:


 * Debate over risk from spinal manipulation. NHS Choices, June 8 2012

They provided these links for further information:


 * Links to the headlines


 * Warning over 'quack' osteopaths. The Independent, June 8 2012


 * Letting a chiropractor 'crack' your neck to ease pain could trigger stroke. Daily Mail, June 8 2012


 * Why having your neck clicked could do more harm than good. The Daily Telegraph, June 8 2012


 * Spine manipulation for neck pain 'inadvisable'. BBC News, June 8 2012


 * Links to the science


 * Cassidy JD, Bronfort G, Hartvigsen J. Should we abandon cervical spine manipulation for mechanical neck pain? No. BMJ. Published online June 8 2012


 * Wand BM, Heine PJ, O’Connell NE. Should we abandon cervical spine manipulation for mechanical neck pain? Yes. BMJ. Published online June 8 2012

Brangifer (talk) 14:18, 9 June 2012 (UTC)

Orphaned references in Spinal manipulation
I check pages listed in Category:Pages with incorrect ref formatting to try to fix reference errors. One of the things I do is look for content for orphaned references in wikilinked articles. I have found content for some of Spinal manipulation's orphans, the problem is that I found more than one version. I can't determine which (if any) is correct for this article, so I am asking for a sentient editor to look it over and copy the correct ref content into this article.

Reference named "NBCE_techniques": From Chiropractic:  From Activator technique:  

Reference named "WHO-guidelines": From Chiropractic controversy and criticism: WHO guidelines on basic training and safety in chiropractic - 2005 From Chiropractic:  

I apologize if any of the above are effectively identical; I am just a simple computer program, so I can't determine whether minor differences are significant or not. AnomieBOT ⚡ 19:37, 3 February 2013 (UTC)

Something is missing...
Over the past year, glowing descriptions of the history of spinal manipulation have been added, but the definition has been lost. In addition, it has transformed from a general description of spinal manipulation to one about spinal manipulation in the context of chiropractic. The present article probably should be redirected to chiropractic, or comments about spinal manipulation as not seen in the context of chiropractic are restored. — Arthur Rubin (talk) 17:27, 17 February 2013 (UTC)
 * We can't do a re-direct because osteopaths and physical therapists also perform SM. This is the 'generic' page for SM so that it is inclusive all of type, techniques of spinal manipulation.  It's also extremely hard to omit chiropractic from the SM entirely since they are the dominant provider of SM services.  I can add the specific biomechanical characteristics (i.e. HVLA thrust).  DVMt (talk) 17:40, 17 February 2013 (UTC)
 * I have done a few edits to address your concerns, specifically in the lead and generalizing chiro stuff to simply 'manual and manipulative therapy'. DVMt (talk) 17:51, 17 February 2013 (UTC)

Changes
These changes are more or less the ones made to the article on Chiropractic  which have been rejected. As there are attempts to put the exact same content in both places we need to look at the issue of one page being a bit of a co tract of the other. Also seems like a lot of the discussion around safety disappeared in these edits. Doc James (talk · contribs · email) (if I write on your page reply on mine) 02:25, 23 February 2013 (UTC)


 * Safety clearly appears in the article. Per WP:BRD, please discuss what specific issues you prior to deleting secondary sources. DVMt (talk) 15:02, 23 February 2013 (UTC)
 * Edit update: As seen here safety is clearly covered.  Also, please note that SMT≠Chiropractic.  DVMt (talk) 15:06, 23 February 2013 (UTC)
 * Per WP:BRD I shall revert again. There is no consensus for your overly optimistic version. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 19:45, 23 February 2013 (UTC)


 * That's BRRD Doc. Overly optimistic?  You have white-washed the whole article and deleted 24 additional references.  This brings the total of deleted references of manual and manipulative therapy to over 100.  Yes, you read that correctly.  These reckless edits without any discussion when I asked you to list your grievances and you say "overly optimistic".  This is suppression of evidence Doc James.  It's not going to go unchallenged.  There is no consensus for "your" preferred version.  In fact you are edit warring (as an admin no less) but I shall be the bigger person and talk it through. DVMt (talk) 21:08, 23 February 2013 (UTC)
 * I look forwards to seeing the RfC you put together. Continuing to insulting others and the recent review articles that disagree with your personal position is not going to change much.  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 21:22, 23 February 2013 (UTC)


 * Again, not addressing my primary concern which is the deletion of 100 research papers including dozens of systematic reviews, all written from 2005-2013) have disappeared in your editing at chiropractic, vertebral subluxation and spinal manipulative therapy.  We can say you've made your point quite clear.  Suppression of evidence regarding manual and manipulative therapies.  My position is one of science and not relying on fringe, outlier papers on manipulative therapy that directly disagree with the Cochrane reviews.  This is another point you have failed to address.   Please address these concerns in your next post.  DVMt (talk) 21:39, 23 February 2013 (UTC)
 * Look in the nicest terms possible there appears to be a lot of misinterpretation and selective usage of the literature in the edits I reverted. We seem to be using a different number system and talking a different language per Talk:Chiropractic. Create a RfC and get consensus. If you can convince the community that your edits are an improvement they will stick otherwise they will not. Continuing to call all the systematic reviews which disagree with you fringe will get you no were. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 21:47, 23 February 2013 (UTC)


 * I'm not opposed to the inclusion of specifically Ernst and Pozakski papers despite the fact that the Cochrane reviews completely disagrees with them. We agreed on this 2 weeks ago.  The point is, you requested 5 specific papers be included (which is in the draft proposal) but you deleted 100 sources to do so. That's not right.  DVMt (talk) 22:06, 23 February 2013 (UTC)
 * "we agreed" did we? can you provide a link. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 23:01, 23 February 2013 (UTC)
 * Yep. See chiropractic talk.  This is minor however.  I will ask you again why you deleted 100 sources to get 5 in? DVMt (talk) 23:46, 23 February 2013 (UTC)
 * So no link than. Not really anything more to say. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 00:02, 24 February 2013 (UTC)
 * You can comb through the links. Again, for the 4th time, and this is getting quite tendentious, why did you delete over 100 sources regarding basic sciences of spinal manipulation and joint dysfunction?  You also deleted papers that relate to research pertaining specifically to spinal manipulation, chiropractic and joint dysfunction.  DVMt (talk) 00:25, 24 February 2013 (UTC)


 * There is a misleading edit summary here which states the removal of 'promotional' material which is 23 additional citations on the generic topic of SMT that were WP:MEDRS compliant.  Then there was this massive import here  from Chiropractic inserts chiropractic specific material into the general spinal manipulation category.  Why is Doc James trying to white-wash the spinal manipulation article with clear violations of point with respect to safety leading to problems with WP:UNDUE, WP:NPOV etc.
 * Restored NPOV version. Please discuss your mass reversal and itemize your concerns.  DVMt (talk) 21:55, 24 February 2013 (UTC)

RfC Effectiveness of SMT for LBP
Proposed wording:

"Scientific consensus suggests manual and manipulative therapies are equivalent to interventions such as standard medical care, exercise therapy or physiotherapy for LBP ." See proposed sources below. DVMt (talk) 22:02, 24 February 2013 (UTC)

Evidence against SMT as a therapeutic intervention for LBP

 * SMT is not effective for LBP and it is a placebo. Authors: 2.  Edzard Ernst, Paul Posadzki.
 * Journals: New Zealand Journal of Medicine (IF 0.6-0.7) and Pain Medicine (IF 2.346).
 * This source written by Posadzki P, Ernst E. say "Collectively these data fail to demonstrate convincingly that spinal manipulation is an effective intervention for any condition."
 * This source, also by Posadzki P. states "Collectively, these data fail to demonstrate that spinal manipulation is an effective intervention for pain management."

Represents the minority/outlier viewpoint.

Evidence for SMT as a therapeutic intervention for LBP

 * SMT is equivalent to standard medical care, exercise therapy and physiotherapy, for LBP. Authors: 41.  Rubenstein et al.
 * Journals cited: Spine (IF 3.290), Cochrane review (IF 5.715), Annals of Internal Medicine (IF 16.7), Journal of Electromyography and Kinesiology (IF 1.969), European Spine Journal (IF 1.96), Clinical Orthopaedics and Related Research (IF 2.533).
 * This cochrane source "High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions...in patients with chronic low-back pain." and the plain language summary expands to say: "...spine manipulation appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy."
 * This secondary source concludes that spine manipulation achieves "equivalent or superior improvement in pain and function when compared with other commonly used interventions, such as physical modalities, medication, education, or exercise, for short, intermediate, and long-term follow-up."
 * This cochrane review concludes "Combined chiropractic interventions slightly improved pain and disability in the short-term and pain in the medium-term for acute and subacute LBP. However, there is currently no evidence that supports or refutes that these interventions provide a clinically meaningful difference for pain or disability in people with LBP when compared to other interventions."
 * This cochrane review cautiously concludes "SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention. SMT also appears to be no better than other recommended therapies. Our evaluation is limited by the small number of studies per comparison, outcome, and time interval."
 * This secondary source concludes "Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation."
 * This secondary source found that manipulation is similar in effe to medical care with exercise.
 * This 2012 systematic review supports the use of SMT in clinical practice as a cost-effective treatment when used alone or in combination with other treatment approaches.
 * Combining spinal manipulative therapy with other interventions (multi-modal) are more beneficial than unimodal therapeutic approaches.
 * There is evidence supporting the cost-effectiveness of the guideline-endorsed treatments of interdisciplinary rehabilitation, exercise, acupuncture, spinal manipulation and cognitive-behavioural therapy for sub-acute or chronic LBP.
 * . Studies of nonoperative treatments demonstrated greater value for graded activity over physical therapy and pain management; spinal manipulation over exercise; behavioral therapy and physiotherapy over advice; and acupuncture and exercise over usual general practitioner care.
 * Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation. From the American College of Physicians.

Represents the mainstream, majority viewpoint.

Comments

 * I find it hard to believe that this is an exhaustive literature search, and not some cherry picked list of sources. People coming to this RfC should note that User:DVMt who opened this discussion is a WP:SPA (See http://wikidashboard.appspot.com/enwiki/wiki/User:DVMt ) to promote Chiropractic as not pseudoscience but mainstream medicine, and he also has a WP:COI being a chiropractor himself. What exactly is the proposed language for this RfC to consider? And what exactly is the dispute? RFC is a process for resolving something that normally can't be resolved via normal discourse and consensus in the article's talk space. — raeky  T  21:10, 24 February 2013 (UTC)
 * First problem I have is "scientific consensus" there clearly isn't a consensus if there's reliable sources that are arguing against, and multiple of them. How is source #4 support your argument when it says SMT is no more effective than sham SMT, it's saying it's placebo effect at best. — raeky  T  21:14, 24 February 2013 (UTC)
 * If you are concerned about the thoroughness of the list of secondary sources, feel free to suggest additions to the list.  Otherwise please discuss proposed edits, and not editors. Source 4 still says no different from other therapies (i.e. standard medical care, exercise therapy or physiotherapy). DVMt (talk) 21:29, 24 February 2013 (UTC)
 * An RFC is about resolving content disputes. Accurately portraying each side of the dispute is vital for commentors to make an assessment. Your editing history is ENTIRELY Chiropractic related (see ) there hasn't been ANY article edits that was not about Chiropractic, so you fit the definition of a single purpose account to the letter, so it's relevant to anyone assessing your motivations behind these changes. You clearly also have a conflict of interest because your profession is Chiropractic. veterinary chiropractor By starting a formal RFC your inviting un-involved people to come make a decision about a content dispute. A full background of what went into the dispute is necessary. It's not a process to decide a question without looking back at everything that caused the dispute. RFC may not be what you thought it was. —  raeky  T  21:37, 24 February 2013 (UTC)
 * Do you have anything to add specifically that is not a personal attack on me, besides misrepresenting my profession? Stick to the content.  DVMt (talk) 21:44, 24 February 2013 (UTC)
 * As I said, I don't think you can say the "scientific consensus" is anything without a source that says that. — raeky  T  21:46, 24 February 2013 (UTC)
 * So you don't have anything else to add to the ref list then? DVMt (talk) 21:50, 24 February 2013 (UTC)
 * That has nothing to do with the RFC, your asking for comment about adding specific wording, I'm stating you can't say what the scientific consensus is without a source, otherwise it's original research. And are you not a Veterinary chiropractor per your user page? — raeky  T  21:52, 24 February 2013 (UTC)
 * The term is already being used at the main chiropractic article. I am a veterinarian (DVM) who incorporates manipulation techniques in my practice. Anyways, back to the issue, the wording is proposed at the top of the page. DVMt (talk) 22:00, 24 February 2013 (UTC)

It doesn't where it's also used, saying something without a source is WP:OR and not allowed. — raeky  T  22:02, 24 February 2013 (UTC)
 * I am not proposing any OR. Why are you suggesting this? DVMt (talk) 22:04, 24 February 2013 (UTC)
 * Ok which source says this is the scientific consensus? — raeky  T  22:05, 24 February 2013 (UTC)
 * This is distraction. So you oppose the wording scientific consensus.  Is that all?  DVMt (talk) 22:08, 24 February 2013 (UTC)
 * Pointing out blatant WP:OR is a distraction? Sorry for the inconvenience, you sure your WP:HERE? — raeky  T  22:10, 24 February 2013 (UTC)


 * Does not take into account that it is also "equivalent to inert interventions or sham SMT" per the 2013 review in Spine I am however more or less happy with what we have right now which is "The scientific consensus is that chiropractic/SMT may be on a par with other manual therapies for some musculoskeletal conditions such as lower back pain" Maybe we should add the bit of being equivalent to sham though?  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 21:39, 24 February 2013 (UTC)
 * We should take into account how you are using 2 fringe papers written by 2 authors in low impact journals that directly contradicts 39 other authors in 11 sources. Again, I will ask you for the third time between this page and the WP:MED talk page, do you have any other sources, other than Ernst and Pozadski, preferably from secondary sources in high impact journals, that agree with the conclusions of these authors? DVMt (talk) 21:46, 24 February 2013 (UTC)
 * Okay so the 2013 Spine paper and 2012 Cochrane review which I refer to above is now a low impact journal and fringe?  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 22:27, 24 February 2013 (UTC)
 * -Raeky, being a professional in a related field does not give an editor a COI, otherwise MDs could not edit medical articles and dentists could not edit dental articles, etc. If you disagree, please indicate which category of COI you feel DVMt belongs to and take your concerns to the relevant noticeboard to get consensus and set a precedent at wikipedia for editors editing articles related to their profession. Otherwise, please keep your comments here specific to the text and sources and not about other editors, ie., remain WP:CIVIL.
 * -What needs to be established here is if the few sources that are 'against the grain' and are highly critical of the efficacy of manipulation are noteworthy or simply represent a WP:FRINGE view. IMO, Ernst & Podsanski are the only 2 authors who make bold statements about manipulation, such as 'not effective', whereas the bulk of sources suggest equivalency with usual medical care and other conservative options. Thus, I see Ernst & Podsanski as outliers, or fringe, with regard to this specific topic of manipulation for back pain. Even source #4, which you noted says equal to sham, still suggests equivalency with other therapies for back pain, including usual medical care.
 * -Doc James, you seem to want to omit the common finding by multiple high-quality sources that manipulation is equivalent to usual medical care and physiotherapy for back pain? Doesn't policy indicate that the majority view gets more weight? Which theme has more weight among the available secondary sources? 1) That manipulation is not effective for back pain or 2) that manipulation is equal to 'usual medical care' for back pain? I think that we will need to decide how much weight each idea should get....hopefully this RFC will help. Also, you say you like the current text, but how does the current text "may be as effective as other manual therapies" reflect the well-sourced fact that manipulation is also equivalent to usual medical care for back pain treatment? Puhlaa (talk) 22:09, 24 February 2013 (UTC)
 * It is a conflict of interest if your edits are white-washing away criticism, specifically in a pseudoscience article and field. Keep in mind the general sanctions on pseudoscience articles. — raeky  T  22:13, 24 February 2013 (UTC)
 * What about "SMT is no more effective in participants with acute low-back pain than inert interventions, sham SMT, or when added to another intervention." Cochrane 2012 Are you two trying to say this paper is an endorsement of the practive?  Doc James  (talk · contribs · email) (if I write on your page reply on mine) 22:29, 24 February 2013 (UTC)
 * I am not suggesting the source is an endorsement or not; Doc James, are you suggesting that it is a rejection of the practice of manipulation? Does it matter? If it does matter, I think that we will find that most National medical bodies and medical guidelines have indeed endorsed manipulation for low back pain (eg: & ). I am wondering why you are pushing for the censorship of the text "as effective as usual medical care and physiotherapy" when there are multiple high-quality sources that say exactly this? Moreover, DVMt has listed multiple other sources that also suggest equivalency with all other therapies, but don't specifically mention 'usual medical care' from what I can tell. I agree that Ernst seems to have published 2-5 papers in the recent past that are far more negative ("not effective"), but as has been shown repeatedly, he is the minority with his bold claims of 'lack of effectiveness'.Puhlaa (talk) 00:13, 25 February 2013 (UTC)
 * Agreed with Puhlaa. If we are doing a comparative analysis of effectiveness of interventions, then surely using the terms "standards medical care, exercise therapy or physiotherapy" is fair game considering the sources state this.  I don't see any reason why we need to 'censor' it.  Given that the topic is currently regarding LBP, other Ernst sources aren't suitable for this conversation at this point.  DVMt (talk) 01:31, 28 February 2013 (UTC)


 * RFC Comment It's getting quite WP:TLDR in here and so I hope this comment gets noticed. The specific content being proposed by this RFC is:  "Scientific consensus suggests manual and manipulative therapies are equivalent to interventions such as standard medical care, exercise therapy or physiotherapy for LBP." sourced to the sources above.  I reviewed the sources and my observations are:
 * I'm assuming this content would go into or replace the existing article section on Effectiveness: Back pain.  In reviewing the sources I found that there have been a lot of new primary study results and also meta-analyes in the past  years, so I suggest removing the existing article content and sources dating from before 2010, such as the mention of 2004 Cochrane review and the 2007 ACP guideline.  We have Koes 2010  that can be used for an overview of national guidelines.
 * The Cochrane 2013 update should be considered the strongest, most up to date independent source we have that directly reviews the evidence for the effectiveness of SMT on acute LBP.
 * Because we have up to date, high quality reviews directly studying the effectiveness of SMT on LBP we do not need to be looking at older reviews, and we do not need to be looking at cost-utility studies to source statements about effectiveness. We also should not need to be looking at things like, which is a letter to the editor/comment on the 2011 Cochrane review.  So this eliminates the necessity to look at a number of sources listed in the RFC statement, specifically this eliminates looking at sources numbered 5 through 11.  Also, we wouldn't need to be looking at Ernst 2006.
 * Using Cochrane 2013, the proposed content "SMT is equivalent to interventions such as standard medical care" is not supported:
 * Cochrane 2013 doesn't say "is equivalent, it says "no more effective", which allows room for "not as effective", which would be excluded by "is equivalent".
 * Cochrane 2013 also says that SMT isn't better than sham or placebo interventions.
 * Also, it must be made clear what exactly "standard medical care" is. Cochrane takes pains to explain that "standard medical care" is included in "other recommended therapies", and "other recommended therapies" are not presumed to be effective.  This is important to note.  All that can be said here is that SMT has not been shown to be more effective than therapies that aren't presumed to be effective in the first place.
 * Here are the "other recommended therapies" SMT has not been shown to be more effective than: acupuncture, back school, educational back booklet with or without additional counselling, exercise therapy, myofascial therapy, massage pain clinic, pharmaceutical/analgesic therapy only, short-wave diathermy, standard medical care, consisting of among other things, analgesic therapy and advice/reassurance, standard physiotherapy and ultrasound.
 * Based on this, lining up SMT with "standard medical care" and saying their effectiveness is "equivalent" is misleading, as it gives two wrong impressions, 1) that SMT is "equivalent" to "standard medical care" when Cochrane isn't quite that positive, and 2) that "standard medical care" is presumed to be effective in the first place.
 * Based on this I oppose the suggested content change, and suggest something else that more accurately represents the best quality sources, such as: "For acute low back pain, spinal manipulative therapy does not appear better than commonly recommended therapies such as analgesics, acupuncture, back pain education or exercise therapy."
 * 17:27, 25 February 2013 (UTC)
 * Hay Zad, DVMt proposed this text for the lead of the chiropractic article and I am nor sure where he/she proposed adding it here. With regard to your comments, your assessment of manipulation for acute low back pain, according to this 2012 cochrane review, seems accurate. However, your above comment and your new proposal does not consider this 2010 secondary source specifically about manipulation for acute low back pain. I agree that the 2012 Cochrane source is newer and Cochrane is well-respected, so it could receive more weight, but this 2010 secondary source is recent, high-quality, specific to the topic of acute back pain and should be given some weight considered according to my understanding of MEDRS. Also, your above comments and proposal does not give consideration to chronic low back pain. By the same correct logic that you used to justify the 2012 cochrane source as the best available for acute back pain, the best source we currently have for chronic low back pain is this cochrane review, which says: "High quality evidence suggests that there is no clinically relevant difference between SMT and other interventions...in patients with chronic low-back pain." and the plain language summary expands to say: "...spine manipulation appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy." Can you amend your proposal to consider these other recent, high-quality sources that are specifically with regard to efficacy of manipulation for acute and chronic back pain?Puhlaa (talk) 18:40, 25 February 2013 (UTC)


 * Commment It's not clear what the purpose of this RfC is. There is too much going on with no clarity at the start, so it's a mess. I mostly agree with Zad's suggestions, which seem consistent with MEDRS, IRWolfie- (talk) 00:05, 11 March 2013 (UTC)

Sources by User:RexxS

 * "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." (J R Soc Med)
 * -This source is the same authors as the other 2 critical sources (Ernst again). Thus, while it ads one more source to the discussion, I dont know that it ads any additional weight to the argument over 'what is the scientific consensus'.Puhlaa (talk) 23:51, 24 February 2013 (UTC)


 * "Numerous deaths have occurred after chiropractic manipulations. The risks of this treatment by far outweigh its benefit." (Int J Clin Pract)
 * -First, this is yet another Ernst source. I wonder why, of all the 100s of authors that publish on manipulative treatments, you only ever present Ernst sources when looking for criticism? Regardless, this is nothing to do with the rfc discussion as it is not about back pain, so I am not sure the relevance or your rationalle for posting it. However, a newer and better (review of higher-quality studies than case-reports and more authors) review in the same journal suggested otherwise : "Conclusive evidence is lacking for a strong association between neck manipulation and stroke, but is also absent for no association." AND "An accurate risk-benefit analysis for cSMT remains unavailable and additional research in this field is needed."Puhlaa (talk) 23:51, 24 February 2013 (UTC)


 * "With the possible exception of back pain, chiropractic spinal manipulation has not been shown to be effective for any medical condition." (J Pain Symptom Manage)
 * -As above RexxS, this source is the once again the same author as the other critical sources (Ernst yet again). Presenting multiple Ernst sources that all examine the same topic and find the same conclusions within the same 3 year window does not really add more value to this perspective. Any sources from anyone other than Ernst or Podsanski that are as critical? There are ~50 authors responsible for the list of sources we have seen here, but only 2 of them ever appear on your highly critical sources. Ernst's sources should definitely be included, however, I think attribution may be justified.Puhlaa (talk) 23:51, 24 February 2013 (UTC)
 * When determining prevalence of a view in the literature, we count sources, not authors, and I actually chose those sources only to show specifically that even Ernst comes to slightly different conclusions in different reviews - see how he (somewhat grudgingly) acknowledges chiropractic spinal manipulation as effective for back pain. He does qualify that as chronic lower back pain elsewhere of course! I think most editors will accept that there is a range of views on this issue reflected in the mainstream literature, and that Ernst and his co-authors may be considered to represent the more skeptic end of a spectrum, rather than some sort of detached "outlier". I would counsel against trying to oversimplify by characterising two "camps", especially as my impression is that mainstream opinion seems to be moving more toward accepting that spinal manipulation has demonstrable advantages when treating lower back pain. If I'm right about that, then it will be difficult to judge just where the prevalent view currently lies, since the age of the literature will reflect differing conclusions over time. I didn't present those sources as evidence for this RfC, but perhaps you will find them - or rather the points I wanted to make with them - of some value in helping to reach a satisfactory conclusion. Happy editing, --RexxS (talk) 14:37, 25 February 2013 (UTC)
 * I'm not sure about this about counting sources. It's one author publishing the same view, ad nauseum.  I don't see how Ernst/Posadzki can get equal weight (let alone more, as the current situation stands regarding manipulative therapy) as 100 different authors who come to an opposing conclusion.  Ernsts views' are definitely outlier than exist within a continuum.  His opinion and conclusions are 2-3 standard deviations away from the mean which generally states effectiveness of SMT for cLBP (specifically).  But as RexxS correctly suggests Ernst is at the "end of the spectrum" (skeptic).  This is more of a weight issue leading to undue and point violations, IMO.  Also, as RexxS has noted the sources introduced do not specifically have to do with SMT and LBP and for the purposes of this RfC, aren't useful (but will be in other matters as we get to them!).  DVMt (talk) 01:22, 28 February 2013 (UTC)

Summary of guidelines
We have a great paper here that gives an overview of what the guidelines in different places say "The one area of therapy that is contentious is the use of spinal manipulation. Some guidelines do not recommend the treatment (e.g. Spanish, Australian), some advise that it is optional (e.g. Austrian, Italian) and some suggest a short course for those who do not respond to the first line of treatment (e.g. US, the Netherlands). For some it is optional only in the first weeks of an episode in acute low back pain (e.g. Canada, Finland, Norway, Germany, New Zealand). The French guideline advises that there is no evidence to recommend one form of manual therapy over another."

Maybe we should mention somewhere that the utility of spinal manipulation is controversial? Doc James (talk · contribs · email) (if I write on your page reply on mine) 06:02, 25 February 2013 (UTC)
 * First sentence of the effectiveness section for low back pain already says: "Specific guidelines concerning the treatment of nonspecific (i.e., unknown cause) low back pain remain inconsistent between countries.[11"Puhlaa (talk) 06:33, 25 February 2013 (UTC)
 * Seems like this would be good to mention in the lead. It is sort of a summary of different positions from different areas of the world. Some countries consider it somewhat effective in some types of LBP others do not. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 23:24, 25 February 2013 (UTC)
 * Agree that it could be useful for the lead. It seems, from your summary of the review, that only Spanish & Australian guidelines do not advise it, all other feel it is useful for something, there is just disagreement over when and how it is most useful. I think that the key point is that there is still some variation amongst guidelines....this fact could preceed any mention of effectiveness. Puhlaa (talk) 23:42, 25 February 2013 (UTC)
 * The current source is from 2006 and a newer review would be preferred. If I understand Puhlaa correctly and there are only 2 countries who are clearly dissenting (or not recommending) SMT for LBP and the majority of them do recommend it is, it would be justifiable to state that "the majority of European guidelines recommend SMT as a recommended intervention for the management of LBP".  This would depend, however, how many countries' guidelines actually endorse (2, 5, 10?) so the statement can be qualified properly. DVMt (talk) 01:26, 28 February 2013 (UTC)
 * Where do you see the statement "most guidelines"? Doc James  (talk · contribs · email) (if I write on your page reply on mine) 04:35, 28 February 2013 (UTC)
 * I'm sorry I don't understand what you are disputing. DVMt (talk) 04:47, 28 February 2013 (UTC)
 * I do see in the ref above the statement that the majority or most quidlines recommend SMT. Where is the ref to support this? Doc James  (talk · contribs · email) (if I write on your page reply on mine) 04:51, 28 February 2013 (UTC
 * Puhlaa could weigh in, I asked whether or not there were a majority of countries that recommended SMT or vice-versa. It's only a hypothetical at this point.  DVMt (talk) 06:11, 28 February 2013 (UTC)

Sounds like straying into WP:OR again like "scientific consensus" — raeky  T  07:39, 28 February 2013 (UTC)

Is it not possible to create a section discussing the arguments for and against this treatment, instead of using only one viewpoint? A spin through the databases here seem to show that opinions are pretty split with a lean towards the 'pro use as treatment' side.-- T K K  bark !  22:15, 28 February 2013 (UTC)

Reboot?
Due to the radical nature of many of DVMt's edits, usually made without any consensus or collaboration, I'm considering whether a reboot to a previous version might be best. I'm suggesting this spot:


 * http://en.wikipedia.org/w/index.php?title=Spinal_manipulation&diff=533865066&oldid=531693732

Later edits can be reincorporated, but this time AFTER proper discussion. "Bold" has its place, but it also has its limits, and this destabilizing of otherwise stable articles needs to stop. Total revamping is uncalled for, while tweaking is definitely a good idea. -- Brangifer (talk) 07:15, 25 February 2013 (UTC)
 * Since we're dealing with an WP:SPA with a WP:COI, we really can't trust him to be bold. I agree that the version prior to DVMt's edits is more neutral. He's welcome to justify his edits. TippyGoomba (talk) 08:38, 25 February 2013 (UTC)


 * Per usual, Tippy and Brangifer talk about the editor, ("destabilizating articles) while Tippy shows 0 good faith (again) "We can't trust him to be bold". So, WP:PA, WP:AGF ,WP:BITE issues prior to even discussing the actual edit.  First, there is no reason stated for removing 23 additional sources.  It was just deleted with no discussion.  Per WP:BRD I have asked for a discussion and no on has adressed my concern: Deleting systematic reviews and basic science research in spinal manipulation is in poor taste.  I won't bother reverting this old-school version which clearly violates NPOV by not only having undue weight on safety (despite 2012 Cochrane review claiming it 'relatively safe') but several point violations and uses out-dated primary sources which have been replaced by modern secondary sources.  All the while removing the history of manipulative therapy and having an extreme PT bias in the external links. I have already stated my conflict of interest which is am a veterinarian who practices animal chiropractic.  Other editing here should declare their COI, certainly Brangifer, who is/was? a PT and has/had ties to QuackWatch and Stephen Barrett which IMO is far more conflicting than my practicing manipulative techniques.   Given those ties, Brangifer should probably consider recusing himself in material in which he has skeptically written about.   This should give other readers his take on manipulation, chiropractic and sCAM.  Also, he likes to delete systematic reviews see diffs   that severely compromises his ability to neutrally cover chiropractic and manipulation articles objectively (given that it's already a 'sCAM').   This is the real COI folks... DVMt (talk) 03:00, 28 February 2013 (UTC)
 * Please stick to discussing content, not editors. TippyGoomba (talk) 04:18, 28 February 2013 (UTC)
 * Sometimes I wish I was a Mario Brother DVMt (talk) 06:14, 28 February 2013 (UTC)

Summary of findings on manual and manipulative therapy: Current revision
The scientific consensus is that chiropractic may be on a par with other manual therapies for some musculoskeletal conditions such as lower back pain, but that there is no credible evidence or mechanism for effects on other conditions, and some evidence of severe adverse effects from cervical vertebral manipulation. The ideas of innate intelligence and the chiropractic subluxation are regarded as pseudoscience.

— Preceding unsigned comment added by DVMt (talk • contribs) 22:36, 10 March 2013‎ (UTC)

Summary of findings on manual and manipulative therapy: Proposed revision
Manual and manipulative therapies commonly used by chiropractors other manual medicine practitioners are used primarily to help treat low back pain and other neuromusculoskeletal disorders. Spinal manipulation appears as effective to other commonly prescribed treatments for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy. For acute low back pain, spinal manipulative therapy does not appear better than commonly recommended therapies such as analgesics, acupuncture, back pain education or exercise therapy. National guidelines regarding spinal manipulation vary country to country; some do not recommend, while others recommend a short course of manipulative therapy for those who do not improve with other interventions. Manipulation under anaesthesia, or medically-assisted manipulation, currently has insufficient evidence to make any strong recommendations. Spinal manipulation may be effective for lumbar disc herniation with radiculopathy, as effective as mobilization for neck pain, some forms of headache,  and some extremity joint conditions. . There is insufficient evidence regarding the effectiveness of spinal manipulation on non-musculoskeletal conditions. . There is considerable debate regarding the safety of spinal manipulation, particularly with the upper cervical spine. Although serious injuries and fatal consequences can occur and may be under-reported, these are generally considered to be rare as spinal manipulation is relatively safe when employed skillfully and appropriately. Spinal manipulation is generally regarded as cost-effective treatment of musculoskeletal conditions when used alone or in combination with other treatment approaches. Evidence supports the cost-effectiveness of using spinal manipulation for the treatment of sub-acute or chronic low back pain whereas the results for acute low back pain were inconsistent.

Comments: Revised proposal MMT
DVMt, With regard to the first 3 sentences, I don't think that the text you have proposed is an accurate representation of the sources. What if we just stick to an accurate summary of the best sources; that is, the review of LBP guidelines and the newest Cochrane reviews on chronic and acute LBP. For example, I would propose: Any thoughts?Puhlaa (talk) 06:29, 1 March 2013 (UTC)
 * Specific guidelines concerning the use of spine manipulation for the treatment of nonspecific low back pain remain inconsistent between countries. High-quality evidence suggests that spine manipulation is as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy. For acute low back pain, there is moderate-quality evidence suggesting no difference in effect between spine manipulation and other interventions; and low-quality evidence suggesting no difference between spine manipulation and inert interventions.........
 * I disagree, the text is an accurate representation of the source (Rubenstein 2011 for cLBP) you just have different language. Nevertheless, I agree with the majority of your suggestion with the exception of the first sentence.  Readers should know, roughly, what degree the inconsistency is about.  DVMt (talk) 06:41, 1 March 2013 (UTC)
 * That level of detail should be left for the effectiveness section. For the lead, the 'summary' of manual and manipulative therapy is being presented with the suggestions of DJ and Z68.  DVMt (talk) 08:25, 2 March 2013 (UTC)
 * Last call before insertion? DVMt (talk) 04:48, 6 March 2013 (UTC)
 * I have inserted the material in both this article and the chiropractic article where it applies. It can perhaps also go into the osteopathic medicine article as well.  Regards, DVMt (talk) 16:51, 7 March 2013 (UTC)

There is still no consensus. While I agree it is better the ref for neck pain says equivalent to mobilization and for headaches the paid that said no benefit for migraines has been left out. Doc James (talk · contribs · email) (if I write on your page reply on mine) 17:17, 7 March 2013 (UTC)
 * The supportive and critical review aren't in there already? Ok, I'll add them.  The statement did say 'may be' effective for so I thought it was in there.  No biggie, I'll change it.  Thanks. DVMt (talk) 17:21, 7 March 2013 (UTC)  Added Posadski 2011 under the headache blurb.  Posadzki says no benefit, the other source says benefit, so the 'may be' effective is a good compromise.  Any other concerns?  This proposal has far more systematic reviews than any other on WP regarding manual and manipulative therapy.  It's the best one out there and surely better than the current forms at SMT and chiro.
 * I think we all can agree that this revision is up-to-date with respect to the appropriate secondary sources. Is there any concerns regarding the wording?  DVMt (talk) 19:34, 7 March 2013 (UTC)
 * Maybe once the other RfC is done you can than put this version up for a RfC to get more eyes to look at thing? Doc James  (talk · contribs · email) (if I write on your page reply on mine) 03:16, 8 March 2013 (UTC)
 * Is there still an RfC here? I basically see tumbleweeds rolling across the street... Hello ooooooo .  It's pretty much just us and Puhlaa commenting on the research.  We can combine this with the sectional update at chiropractic if you wish since there seems to be more involved editors there.  It's basically covering the same topic, research status of manual and manipulative therapy.  With Zad68, IRWolfie, WAID, II, Fiachra Byrne, myself, Puhlaa and other knowledgeable sources we can get a broad consensus there and stop the edit warring and constant NPOV tags and weight issues.  Let's fix it right (Mike Holmes style!) then move on to less polarizing articles until there is a need for a significant update (1-2-5 year periods?) where the previous medical editors who reached said consensus can re-evaluate the literature, again, to make sure the article remains current with the best sources available.  DVMt (talk) 03:29, 8 March 2013 (UTC)
 * James, since you're the only one who (publicly) opposes this version (with your recommendations now inserted) can you please let me know, specifically, what your concern is prior to posting this? This one paragraph has been under review since early February.  If you don't oppose, may I please insert it? DVMt (talk) 22:50, 8 March 2013 (UTC)
 * This is more or less what the final version is going to be like. If there's going to be tweaks it can happen from the page itself. I've asked other editors to take a peek as well.  If no opposition to the sources or language, I will insert it within the next 24 hours.  Regards,  DVMt (talk) 17:20, 9 March 2013 (UTC)
 * Bump! DVMt (talk) 16:37, 10 March 2013 (UTC)

Notice the RfC going on at alt med? Create something similar for the question here and let it run for a week. Doc James (talk · contribs · email) (if I write on your page reply on mine) 16:42, 10 March 2013 (UTC)


 * That one at alt-med fairly intense and is a significant proposal (rename the article). I'll do an RfC at the chiropractic talk page since that proposal is rather in depth and this is basically a summarization of what's going on there.  Can we compromise that we insert this improved version, and savfe the RfC for the big one at Chiropractic? DVMt (talk) 16:53, 10 March 2013 (UTC)


 * No you must get consensus. Have recently come across some copyright issues with your work that we should deal with first. Doc James  (talk · contribs · email) (if I write on your page reply on mine) 16:55, 10 March 2013 (UTC)


 * We both agree this is an improved version as opposed to the current version which is all of 3 refs long. In all fairness, I don't see you obtain consensus before you edit medical related articles, you simply go ahead and edit away.  If you can explain to me the difference, that would be helpful.  DVMt (talk) 17:15, 10 March 2013 (UTC)


 * I agree with Doc James. There are too many problems with your work that keep popping up. They are systemic in nature and cause editors to distrust it. When one is very close to a subject, it happens easily, so don't get too discouraged. Been there and done that. It just means that one needs to walk through it with others during the development stage, exchanging ideas, discussing details and formulations, etc.. That's what we mean by collaborative editing. (This is why I'm against developing whole sections in user space and then attempting to get others to accept them as they are. That doesn't work. New articles are another matter, and even then it's good to get lots of help before going public with them.)


 * Being bold is good sometimes, and bad at other times. When your edits have been questioned, continuing to be bold becomes disruptive. There is no rush. We're willing to work with you. Do it one paragraph at a time and place the new paragraph beside the old paragraph for analysis. I have been over exactly the same process and reactions which you are seeing, and this seems to be the best way. Then the new content has the backing of everyone and will last for years. Otherwise it gets deleted or revised very quickly and all your work and frustration is for naught. -- Brangifer (talk) 18:53, 10 March 2013 (UTC)


 * I'd appreciate some input from James himself, I don't see consensus for his moves or I don't why it applies in some instances, and not in others. I don't think WP endorses 2-tier editing.  I'm more interested about the content itself at this point.  DVMt (talk) 20:01, 10 March 2013 (UTC)  Also, this is not a 'bold' proposal, in fact, this re-write has been on the table for discussion for the past month.  I'm confused as to why this version, which we agree is superior to the current version, can't be inserted lacking 'consensus'.  DVMt (talk) 22:36, 10 March 2013 (UTC)


 * I agree that BullRangifer's approach makes sense. I edit many (mostly?) controversial articles and this is the standard way people edit. It's slower, but it gets there eventually. IRWolfie- (talk) 00:10, 11 March 2013 (UTC)


 * Ok, sounds fair. Do you see any fundamental problems with sourcing or language in the proposed manual and manipulative therapy (MMT) revision?  DVMt (talk) 19:56, 11 March 2013 (UTC)

Spinal manipulative therapy for acute low back pain: an update of the cochrane review.
This new study needs to be incorporated:


 * Rubinstein, et al, Spinal manipulative therapy for acute low back pain: an update of the cochrane review. Spine. 2013 Feb 1;38(3):E158-77. doi: 10.1097/BRS.0b013e31827dd89d.


 * CONCLUSION: SMT is no more effective for acute low back pain than inert interventions, sham SMT or as adjunct therapy. SMT also seems to be no better than other recommended therapies. Our evaluation is limited by the few numbers of studies; therefore, future research is likely to have an important impact on these estimates. Future RCTs should examine specific subgroups and include an economic evaluation.

Brangifer (talk) 16:36, 28 April 2013 (UTC)
 * I agree that the newest study for acute LBP needs to be included, but we should include this source instead, because it is the original cochrane review. The paper you link, BR, is just a re-publication of the 2012 cochrane review in the journal Spine. Also, we should include the most recent cochrane review on chronic LBP, which says in the plain-language summary that " SMT appears to be as effective as other common therapies prescribed for chronic low-back pain, such as, exercise therapy, standard medical care or physiotherapy. However, it is less clear how it compares to inert interventions or sham (placebo) treatment because there are only a few studies, typically with a high risk of bias, which investigated these factors." Puhlaa (talk) 17:05, 28 April 2013 (UTC)

Review finds spinal manipulation no more effective than exercise for chronic low back pain
Review finds spinal manipulation no more effective than exercise for chronic low back pain


 * An analysis of studies that compared spinal manipulation and prescribed exercise for patients diagnosed with chronic low back pain has concluded that no conclusive evidence favors one over the other. Only three randomized controlled trials met the inclusion criteria of the review. One favored manipulation, one favored exercise, and the third study judged them equal. The authors called for more studies to determine which intervention is more effective.
 * Merepeza A. Effects of spinal manipulation versus therapeutic exercise on adults with chronic low back pain: a literature review. Journal of the Canadian Chiropractic Association 58:456-466, 2014

Definitely a MEDRS compliant source about chiropractic spinal manipulation. -- Brangifer (talk) 15:37, 19 January 2015 (UTC)
 * It's not a MEDLINE-indexed journal as detailed here (http://www.ncbi.nlm.nih.gov/nlmcatalog?term=%22J+Can+Chiropr+Assoc%22[Title+Abbreviation]). Also appears to be a low impact journal with an IF of zero. TylerDurden8823 (talk) 17:07, 19 January 2015 (UTC)
 * The review's conclusions are fairly inconclusive "There is no conclusive evidence that clearly favours spinal manipulation or exercise as more effective in treatment of CLBP.", so I am not sure what value the review adds here. We already have a cochrane review in the article that says "spinal manipulation is no more or less effective than other commonly used therapies such as pain medication, physical therapy, exercises, back school or the care given by a general practitioner."70.65.253.158 (talk) 21:44, 19 January 2015 (UTC)
 * We obviously don't have to use it. It's interesting that even chiropractors don't find clear evidence of the vast superiority often claimed. -- Brangifer (talk) 03:47, 20 January 2015 (UTC)

Copy and paste
This was added "Evidence suggests that spinal mobilization can cause neurophysiological effects that result in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation, and improved muscle function. These findings suggest the involvement of an endogenous pain inhibition system mediated by the central nervous system. The existing evidence does not support an effect of spine mobilization on segmental vertebral motion."

Source says "Evidence suggests that spinal mobilizations cause neurophysiological effects resulting in hypoalgesia (local and/or distal to mobilization site), sympathoexcitation, and improved muscle function. ... These findings suggest involvement of an endogenous pain inhibition system mediated by the central nervous system... Evidence does not support an effect on segmental vertebral movement." Doc James (talk · contribs · email) 02:39, 13 January 2016 (UTC)


 * How many words are allowed to be the same. It seems to me that the main similarities are between technical terms; can the point of the review be made without using the words 'neurophysiological', 'hypoalgesia', 'sympathoexcitation', 'muscle function', 'endogenous pain inhibition system', and 'central nervous system'? If I change a few more 'and' and 'there' will it be ok? or do I need to find other terms for central nervous system, etc.
 * You must read the text, understand what it is getting at, and than put it into your own words. Doc James  (talk · contribs · email) 02:55, 13 January 2016 (UTC)

Incidence of serious adverse effects
Taking toghether, this information is sufficient to support the sentence "probably low":

''"Neither of  the  prospective  studies  included  in  this meta-analysis report a single case of serious, more permanent injury. This might suggest that such events are rare. One could, however, also postulate that only patients who returned for treatments were asked about adverse reactions after the previous intervention. Patients who did not return might have suffered serious complications.  We  also  can  comment  on  the  fact  that  when questionnaires  were  answered  by  the  patients,  they present a higher frequency of side effects, meaning that the  practitioners  may  underestimate  the  adverse events.43,44 ... Adverse reactions are  frequent  after  spinal  manipulation  ranging  from 33% to 60.9%, mostly increased pain or stiffness. However, the frequency of serious adverse events is not established varying between 5 strokes/100,000 manipulations to  1.46  serious  adverse  events/10,000,000  manipulations and 2.68 deaths/10,000,000 manipulations, with stroke  being  the  most  frequent. Safety in  chiropractic manipulation is far from being achieved. Further investigations are urgent to assess definite conclusions regarding this issue."''

"The survey data indicated that even serious adverse effects are rarely reported in the medical literature. Conclusions 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. ... The three surveys disclose more complications. They suggest that many therapists are now becoming aware of the risks of spinal manipulation.48,49 Two of the surveys49,52 also confirm that under-reporting is frequently close to 100%."

Perhaps it is more accurate to replace the word "low" by "rare". In fact, those are the conclusions reflected in NHS Choices: "These more serious complications of spinal manipulation are probably rare." I will do it.

Best regards. --BallenaBlanca (talk) 08:47, 22 September 2016 (UTC)
 * The www.nhs.uk is not a review. We should not add a source to argue against reviews or use to compliment reviews. The part "probably low" is not supported by the two reviews. Taking different parts of the source together is coming to a WP:SYN conclusion. I replaced it with "may be rare". QuackGuru  ( talk ) 16:48, 22 September 2016 (UTC)
 * NHS is a major governmental body and this is a statement by them. Thus paraphrasing stuff like "Around 50% of patients report experiencing adverse effects after spinal manipulation." would be fine IMO. Doc James  (talk · contribs · email) 04:09, 25 September 2016 (UTC)
 * All three do not make the same claim. Two refs verify different parts of the claim. Placing the refs at the end of the sentence was a source of confusion. It is also important to avoid any potential copy violations. QuackGuru  ( talk ) 00:14, 26 September 2016 (UTC)

See "Collectively, these data suggest that spinal manipulation is associated with frequent, mild and transient adverse effects as well as with serious complications which can lead to permanent disability or death."

Previous wording "It is frequently associated with mild to moderate adverse effects, and serious or fatal complications which can lead to permanent disability or death"

Current wording "Research indicates it is frequently associated with mild to moderate adverse effects, and serious or fatal complications which can result in permanent disability or death" QuackGuru  ( talk ) 02:56, 26 September 2016 (UTC)

The text was still too close to the source and different sources make different claims. To avoid a SYN violation it is easier to put one ref after each sentence. QuackGuru ( talk ) 17:46, 9 October 2016 (UTC)

Part of the text was from one source and the other part was sourced to another source. It is a bad idea to use more than one source at the end of the sentence when they make different claims. QuackGuru ( talk ) 20:17, 23 October 2016 (UTC)

Recent revert
This edit just reverted the addition of a reliable source that contained information about spine manipulation instruction in US physical therapy programs. The revert was paired with an edit summary that suggested it was a low quality source; however, it is a peer-reviewed article, with a robust result, published in a mainstream journal, and makes no controversial claims, so I am confused what makes it low quality? Could CFCF, or someone else, please explain how this is a low quality source?2001:56A:75B7:9B00:D92D:72EB:A87E:E84 (talk) 02:04, 18 October 2016 (UTC)
 * Please see WP:MEDRS. We prefer secondary sources such as reviews. Carl Fredrik  💌 📧 20:27, 19 October 2016 (UTC)
 * CFCF, you suggest the source is low quality because it is not a secondary source per MEDRS. However, MEDRS is for medical claims and the documented fact that PT programs in the US teach spine manipulation is not a medical claim. I understand that secondary sources would be preferred in general, but I believe that a peer-reviewed source that is not making a controversial claim is ok here. The topic of the source is very relevant to the wikipedia article and there are no sources that dispute the claim being made. Is there a policy that I am missing that restricts non-controversial and non-medical content to secondary sources? 2001:56A:75B7:9B00:5126:F27E:3621:D9FC (talk) 23:27, 19 October 2016 (UTC)
 * Any statement that is controversial should be sourced to a secondary source — 99% is a ridiculously controversial number and in addition the statement that it is taught is unacceptably imprecise. What does taught mean? That it is taught that alt-meders use the practice? Or that they are taught to use it? Teaching something because you are expected to handle complications or in order to address the pseudoscientific nature of the concept is not that same as being taught to practice it. And it is a medical statement, if we were discussing which treatments were taught in medical school and are practiced by doctors it would be obvious — it is no different with physical therapy. Carl Fredrik   💌 📧 03:55, 20 October 2016 (UTC)
 * I admit that I do not understand your concerns with "alt-medders" or "pseudoscience". This is an article about spinal manipulation and I am suggesting what seems to me to be a good source about the instruction of spinal manipulation to physical therapists, which this wikipedia article describes as one of the main providers of spinal manipulation. Maybe you can suggest a way to alter the text using information from the source to appease your concerns over the imprecise nature of the claim "taught" and the number "99%"? I have asked for additional comments at the reliable sources noticeboard here.2001:56A:75B7:9B00:5126:F27E:3621:D9FC (talk) 04:21, 20 October 2016 (UTC)
 * What if we attribute the information, so that the relevant facts are there, but are qualified? EG: "A 2012 survey of faculty from accredited US physical therapy programs found that the vast majority of programs teach spinal manipulation"2001:56A:75B7:9B00:5126:F27E:3621:D9FC (talk) 04:43, 20 October 2016 (UTC)
 * I have re-added the reliable source with some attribution and more accurate text, per discussion at the reliable sources noticeboard here. 2001:56A:75B7:9B00:3D66:2C97:BB73:A045 (talk) 22:53, 9 November 2016 (UTC)
 * This is a primary source  and does not comply WP:MEDRS.
 * Best regards. --BallenaBlanca [[Image:BallenaBlanca.jpg|25px]] [[Image:Mars symbol (bold blue).svg|12px]] (Talk)  02:31, 10 November 2016 (UTC)
 * BallenaBlanca, Thanks for your comment. Indeed, it is not a secondary source per MEDRS; however, when there is not a medical claim being made then this is an irrelevant point. In this case, the claim is not medical it is a claim about education curricula (so MEDRS does not apply) and no secondary sources exist (so a reliable primary source, published in a mainstream journal is fine). Please see the comment at the Reliable Sources Noticeboard. Alternatively, if another reliable source is available that contradicts the education claim then perhaps the content is controversial and requires balancing with alternate viewpoints (but I have not seen another source that contradicts this source). In the absence of a contradictory source, this is not controversial content (what is being taught at PT school according to PT school faculty is not controversial unless you have a source that suggests it is controversial). 75.152.109.249 (talk) 18:26, 10 November 2016 (UTC)
 * For once, I actually agree that a MEDRS-compliant source isn't necessary. To document the results of a survey on the proportion of courses teaching something, probably just needs a reliable source. It is important however to accurately reflect the results. it is not the case that the source indicates "99% of programs were now teaching some form of spine manipulation". I've amended our article text to reflect what the source actually says. Nevertheless, I have no opinion on whether a survey with 148 respondents is significant, so my edit in no way should be seen as an endorsement for the inclusion of this piece of information. --RexxS (talk) 20:17, 10 November 2016 (UTC)
 * The cited paper refers to the 99% immediately after saying that 70% of programs responded, so the implication is that 99% of responding programs teach it. Clearly they cannot have meant to say what the non-responding 30% teach. LeadSongDog come howl!  20:56, 10 November 2016 (UTC)
 * Yes, and I hope my edit made it clearer that it referred to the respondents. Only 148 of 205 responded and the 205 isn't necessarily all of the accredited physical therapy programmes. Additionally, the source reported that 99% taught some form of thrust joint manipulation, but that the proportion teaching cervical spinal manipulation was less. Hopefully I clarified that as well. --RexxS (talk) 21:09, 10 November 2016 (UTC)
 * The recent edits from RexxS seem reasonable to me; what did not seem reasonable was completely rejecting the information that seemed very relevant to this section in this article. With regard to LeadSongDog's comment about response rate, when a response rate is greater than 60% the data is commonly assumed to be generalizable to the population sampled; in this case the response rate of 70% allows a decent generalization to all programs in the sample, even those that did not reply. For example, all journals in the JAMA network suggest 60% response rate as acceptable to avoid non-response bias EG: . Thanks for your help. 2001:56A:75B7:9B00:FC52:6CE8:6010:FF27 (talk) 22:55, 10 November 2016 (UTC)
 * That's because JAMA understands medicine, not statistics. Three responses out of a sample of five would be completely insufficient for any statistical inference. To make some sort of generalisation from a sample to the underlying population, you need to have a truly random sample so that you can do the maths to estimate the confidence you can have in your results; and you need samples of more than about 30 for the Central Limit Theorem to allow us to approximate a binomial distribution with a normal one. In this case, we do not know how the 205 faculties that were surveyed were selected. Next, we have no information on how likely a positive response would be to affect the chance of responding. It's an example of selection bias (self-selection). If the returns were a truly random sample of all of the PT courses taught, we could say with 95% confidence that the proportion of PT courses teaching some form of TJM was 99%±1.6%. But we have no idea how random the survey returns were, so we can't say anything about the underlying population. That's why all we can state is that 99% of the respondents taught some form of TJM. Hope that makes it clearer for you. --RexxS (talk) 01:19, 11 November 2016 (UTC)
 * I understand what you are saying RexxS and I find no flaw in your general logic; however, I am confused because your commentary does not seem to apply to our discussion here at all and I must question if you have even read the source that we are discussing? The study sampled "the Program Director of each United States physical therapy programs (n = 205 at the time of the data collection) recognized by CAPTE as accredited or candidate." Based on your extensive commentary regarding statistics above, I would suspect that you understand that the one thing better than a 'random sample of US programs' is a 'complete sample of US programs'. In this case, the authors surveyed the directors of ALL the physical therapy programs in the US, thus a 70% response is valid because it represents 70% of ALL US programs. If you care to read the study, the discussion goes into detail about the ability/validity to generalize the data to the 46 US programs that did not respond to the survey. 2001:56A:75B7:9B00:FC52:6CE8:6010:FF27 (talk) 03:59, 11 November 2016 (UTC)
 * Yes, I read the source cited and that's why I raised the two issues. Is "each United States physical therapy programs recognized by CAPTE as accredited or candidate" in 2012 the same thing as every PT programme (presumably recognised by CAPTE or not) in the US in 2016? Are there just 205 of them at present? I can see no evidence of that and yet that's what the original edit was suggesting. Even if the survey aimed for complete coverage, it still ended up with a sample, and that was self-selected (i.e. by the decision to reply or not). Unless there's evidence that indicates that self-selection has no effect on the randomness of the sample, we don't have the justification to extrapolate from the 70% responding to the complete population. There's no maths to help us do that, so it becomes a guess with no idea of what confidence we can have in the figure. It's better for us to report on what the survey actually found, IMHO. Does that help? --RexxS (talk) 12:05, 11 November 2016 (UTC)

From the source: "Of the body regions, the cervical spine received the least amount of emphasis, with 35% of programs not currently teaching cervical manipulation. In contrast, the greatest percentage of time is devoted to teaching lumbar spine TJM with 99% of programs including this content in their curriculum."
 * I would like to propose making the text more specific to spinal manipulation. I suggest adding: "A 2012 survey in the US found that 99% of the first-professional physical therapy programs that responded were teaching lumbar spine manipulation and 65% were teaching cervical spine manipulation.[8]" We could make the statement more general and say "99% teach some form of spinal manipulation" as I originally suggested, but I know that there is controversy regarding cervical manipulation and so think the specifics are better to include. 2001:56A:75B7:9B00:FC52:6CE8:6010:FF27 (talk) 05:25, 11 November 2016 (UTC)
 * That seems to me to be a reasonable summary of the survey findings, so I'd have no objection. I'd prefer "A 2012 survey in the US found that of the first-professional physical therapy programs that responded, 99% were teaching lumbar spine manipulation and 65% were teaching cervical spine manipulation.[8]" for complete clarity, but it's no big deal. I should caution you, however, that at some point, other editors may find that the amount of emphasis placed on a single survey in a single country - even if it is the USA - could be WP:UNDUE. I was drawn here by a post at WikiProject Med and saw the statistical issues, but I have no idea of what has previously been discussed. --RexxS (talk) 12:05, 11 November 2016 (UTC)
 * I have a similar concern to that of RexxS regarding extrapolation to the 30% non-responders. (For example, the non-responders might think that TJM is unimportant, and thus the survey itself is unimportant and not worthy of a response.) However the most recent suggestions show that the figure refers only to the responders. <b style="color:#808000">Axl</b> ¤ <small style="color:#808000">[Talk] 10:40, 12 November 2016 (UTC)
 * I agree with this edit by  Best regards. --BallenaBlanca [[Image:BallenaBlanca.jpg|25px]] [[Image:Mars symbol (bold blue).svg|12px]]  (Talk)  10:05, 14 November 2016 (UTC)

Zero impact journal
We tend not to use these so removed per  Doc James  (talk · contribs · email) 16:12, 14 January 2017 (UTC)


 * I understand the point your making regarding journal impact, but journal impact is not the sole measure of importance of a journal let alone an individual article. NIH considered this review relevant enough to use on their page of "What the science says about chiropractic" https://nccih.nih.gov/health/chiropractic/introduction.htm#hed5. Jmg873 (talk) 18:02, 14 January 2017 (UTC)
 * It is from 2010, it has no impact factor, and it is written by the journal Chiropractic & Manual Therapies. QuackGuru  ( talk ) 18:06, 14 January 2017 (UTC)


 * Being from 2010 still makes it more current than 83% of the evidence in the effectiveness section. The bulk of that evidence is from 2007 and 2008, with only two other studies coming from 2010. It is from a journal with no impact factor data, that's true, and the only relevant point presented so far. Using the fact that it is written in the journal of "Chiropractic and Manual Therapies" as a justification for exclusion is a genetic fallacy.Jmg873 (talk) 18:26, 14 January 2017 (UTC)
 * We can start with using more recent sources and gradually replace the older ones. QuackGuru  ( talk ) 19:27, 14 January 2017 (UTC)


 * I think the American Journal of Emergency Medicine is an unusual place to find research on spinal manipulation, but fair enough. I agree that more current tends to be better. However, if currency is your concern, I believe anything more current than what's currently there is an improvement; that includes the 2010 review I discussed earlier.Jmg873 (talk) 20:06, 14 January 2017 (UTC)
 * If the article contains unsourced content that does not mean others should also add unsourced content. It should not be hard to find more recent reviews. QuackGuru  ( talk ) 22:03, 14 January 2017 (UTC)

2015 source
QuackGuru ( talk ) 20:25, 16 January 2017 (UTC)
 * Not sure if it adds much, but ultimately the lede should be converging on: no evidence for most things, very small effect sizes, terrible studies, massive bias, recorded risks, denial of risks, lack of adverse event reporting, the trajectory of evidence is downward, and overall the risk-benefit equation looks increasingly poor. Guy (Help!) 20:31, 16 January 2017 (UTC)
 * I added a little bit of content to the lede to get started. QuackGuru  ( talk ) 20:54, 16 January 2017 (UTC)