Talk:Vertebral artery dissection/Archive 2

Reviews
A few more reviews to flesh out the article: The last one is freely available. Doc James (talk · contribs · email) 02:39, 1 December 2010 (UTC)


 * I don't want more reviews currently. We already have Kim and LancetNeurol. I might use Nedeltchev to inform the trauma-related content and I will have a look at Goyal to make sure it covers the same ground as our present sources. JFW &#124; T@lk  10:04, 1 December 2010 (UTC)


 * The source you overlooked is now part of the Prognosis section. QuackGuru (talk) 06:47, 6 December 2010 (UTC)


 * I didn't overlook it. It does not currently distinguish between mortality and poor outcome. JFW &#124; T@lk  06:55, 6 December 2010 (UTC)


 * Would you like me to delete the Prognosis section with the reference you objected to because it does not currently distinguish between mortality and poor outcome. QuackGuru (talk) 06:58, 6 December 2010 (UTC)

I have not read these reviews. Just to get an idea of weight, how much attention is paid in these reviews to the discussion of spinal manipulation? DigitalC (talk) 02:07, 6 December 2010 (UTC)


 * A little, just like the article in its current form. LancetNeurol avoids the discussion altogether, but Kim has a paragraph on it. JFW &#124; T@lk  06:36, 6 December 2010 (UTC)

Ernst-death once more
reinserted content quoted from "Ernst-death" despite my continuing objections and a de facto lack of consensus. There are two points that we are presently sourcing to this study. Firstly, that there have been 26 deaths reported in the literature since 1937 attributable to chiropractic and that this is unacceptably high for a modality of limited proven benefit. Secondly, that there is "underreporting" of VAD events. Let me pick apart these two claims and explain my ongoing objections against including this content in this article.

Deaths from chiropractic - we know that VAD may result from chiropractic, and we know that VAD can lead to death. There is no suggestion in any source that VAD resulting from chiropractic carries a higher risk of death than VAD from another cause. The fact that chiropractic can kill is a criticism that needs to be discussed in the context of the alleged benefits of chiropractic, and I suggest that the study is discussed in the chiropractic article.

Underreporting - we are presently quoting propulation-based studies from the Mayo clinic and from France (both fairly reliable sources of data). We are also presently quoting the concerns from the Lancet Neurol that people with very mild symptoms may never undergo a definitive investigation and therefore remain without a diagnosis; whether the prognosis in this population is particularly bad is unknown, nor do we know if they should be considered for anticoagulation or antiplatelet treatment. The kind of "underreporting" that Ernst-death is referring to is the fact that not every death from chiropractic-related VAD has been submitted to a peer-reviewed medical journal. That has absolutely nothing to do with the actual incidence. All that is implied is "we suspect that chiropractic has killed more than 26 people but we can't prove it yet". I don't think this is the kind of fact that we can reasonably cite as factual.

I want to stop this article from turning into a WP:COATRACK to bash chiropractic. At the same time I totally agree that chiropractic is without an evidence base and that there are real harms attached to the treatment. JFW &#124; T@lk  07:33, 5 December 2010 (UTC)
 * Ernst identifies spinal manipulation as a possible or likely cause for VBA stroke. Other studies show similar rates of VBA stroke between the regular population and chiropractic patients, suggesting a pre-existing condition to be the cause.  Given the unresolved ambiguity in this area, and their only tangential relevance to this article, a full reference to the Ernst study seems like undue Weight.  This issue is thoroughly detailed at both Chiropractic and Spinal manipulation, where it can be addressed fully.  We should only give it brief mention and provide links for deeper investigation.  The alternative is a full review of studies from the last decade regarding SM/VBA correlation and causality in this article.  Either way, I agree QG's edits are not ready to stand by themselves, nor is there consensus for them to do so.


 * Also, QG added this information with the edit comment, 'copyedit', which it clearly was not. QG, making controversial changes which have been disputed on talk pages and labeling them as copyedits is as close as I've seen you come to doing something blatantly blockable.  Since you know where most of the lines with regard to that are, please add it to your list.  It's one thing for you to have a COI or a SPA, or a POV--all of those I can live with--but if the continuous tendentious editing wasn't enough, that kind of blatant deception is.  Please do not it.  Ocaasi (talk) 08:18, 5 December 2010 (UTC)


 * There is consensus for this change. QuackGuru (talk) 08:31, 5 December 2010 (UTC)


 * How so? I don't think it belongs as is, neither does Jdfwolff.  Because you seem to think otherwise, consensus is something that emerges from the opinions of multiple editors, not just whatever you would prefer it to be.  While there's talk page discussion of this going on, please don't add back the material. Ocaasi (talk) 08:35, 5 December 2010 (UTC)
 * Also, QG, a discussion at Wikiproject Medicine does not mean consensus here. If you want to add the material on this article page, you'll have to get consensus among the editors working on the article, not just over there.  Ocaasi (talk) 09:15, 5 December 2010 (UTC)


 * There is no consensus at all. Several editors have objected to your approach, including myself and VAPhD. I want you to address my points from the above post: whether discussion of deaths is proportionate, and whether underreporting is a separate issue from underdiagnosis. I don't intend to engage in any further discussion unless you (QG) have shown to be addressing my points. JFW &#124; T@lk  10:34, 5 December 2010 (UTC)
 * There is no consensus at all to delete a recent syatematic review. Uninvolved editors want the source restored. See Wikipedia talk:WikiProject Medicine. The text I added as a compromise is sourced in accordance with V. The underreporting sourced. We know that VAD may result from chiropractic is also sourced. It is not our job to conduct our own review of the source.
 * "What’s known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death."
 * "What’s new 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."
 * "Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g. 1,2). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism(2)."
 * "This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death (1,2,26,30)."
 * "Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial."


 * (The compromise is sourced.) "A systematic review stated that the risk of death from manipulations to the neck, typically associated with vertebral artery dissection, by far outweighs the benefits; 26 fatalities are recorded in the medical literature since 1934, and many more seem to remain unpublished. "
 * (The compromise is sourced.) "The frequency for accurate estimates of vascular accidents involving vertebral artery dissection are impeded by the suspected substantial underreporting. " QuackGuru (talk) 04:32, 6 December 2010 (UTC)
 * QG, this is not a V or an RS issue but a Weight issue. Systematic reviews are reliable per MEDRS, and everything you included can be sourced:  Weight is not about either of those issues, however.  It is about whether and how much of those verifiable, reliably-sourced pieces should be included.  You'll have to address the actual arguments presented to you, not refutations of objections that haven't been made. Ocaasi (talk) 05:00, 6 December 2010 (UTC)
 * See WP:WEIGHT: Neutrality requires that each article or other page in the mainspace fairly represents all significant viewpoints that have been published by reliable sources, in proportion to the prominence of each viewpoint. Giving due weight and avoiding giving undue weight means that articles should not give minority views as much of or as detailed a description as more widely held views.
 * A recent systematic review is a significant viewpoint that has been published by a reliable source. QuackGuru (talk) 05:04, 6 December 2010 (UTC)
 * That would be true if it were a systematic review about the article's subject as opposed to about a systematic review about a minor aspect of the article. Then different considerations apply, because context matters when considering Weight.  A viewpoint is not inherently significant solely because it is reliable.  Nor are all aspects of a review relevant; nor do they have to be included with the maximum amount of words or attention.


 * NPOV is about relative balance within articles as well as the presentation of specific sources. No one has suggested not using Ernst at all, just using Ernst in proportion to the attention that one important review--in a controversial area which addresses a likely but unproven (and possibly underreported) cause of a small subset of overall VBA incidents--should receive.  The place for significant detail about this is not here, but at Chiropractic and Spinal Manipulation, unless you also want to include the several studies that question the CSM/VBA connection and call on the need for further research.  Keep it short and neutral or expanded but balanced.  Either way is ok with me. Ocaasi (talk) 05:42, 6 December 2010 (UTC)


 * "Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g. 1,2). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism(2)."
 * This is not a minor cause according to the recent sytematic review. Vascular accidents after neck manipulation is a well-recognised problem. QuackGuru (talk) 05:50, 6 December 2010 (UTC)


 * Ernst identifies vascular accidents as a recognized problem for CSM, but not that manipulation is a major source vascular accidents in general. These are different in scope, and significance in one is different than in the other.


 * There are other reasons why shorter is better here. For one, there are studies which question whether a pre-existing condition causes people to seek out Chiropractors, resulting in a misattribution of causality.  And if we want to give a detailed coverage of Ernst, then we have to do it for Spine 2008 ("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."), JMPT 2005 ("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."), and Spine 2009 ("There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue.")... and it just gets long for this article.  Ocaasi (talk) 06:35, 6 December 2010 (UTC)  Missed one Neurologist 2008] ("Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. Ultimately, the acceptable level of risk associated with a therapeutic intervention like CMT must be balanced against evidence of therapeutic efficacy. Further research, employing prospective cohort study designs, is indicated to uncover both the benefits and the harms associated with CMT." Ocaasi (talk) 10:49, 6 December 2010 (UTC)
 * If you want to include other sources they must meet MEDRS. QuackGuru (talk) 06:53, 6 December 2010 (UTC)
 * Oh they do. Certainly Spine does and JMPT is reliable for spinal manipulation.  After proposing a mediocre 2009 primary study as MEDRS but dismissing a quality review from Spine, I'm not sure if you are actually applying MEDRS or just using it for justification.  Can you explain the differences between Ernst 2010, Spine 2008 and 2009, and the 2009 Chiropractic student study you cited at Chiropractic? Ocaasi (talk) 08:03, 6 December 2010 (UTC)


 * Ernst 2010 is a recent systematic review. The 2009 study is the best source available for that study on specifc treatment techniques and on students especially for hand/wrist injuries sustained by chiropractors. If there was a better source we would use that. You did not delete the 2010 Belguim study that was not a review. QuackGuru (talk) 08:19, 6 December 2010 (UTC)
 * The Belgium study was actually relevant to the section because it discussed treatment techniques, not the risk of injuries to chiropractic students a chiropractic college. As for the JMPT injury study, the only relevant piece is "Diversified, Gonstead, and upper cervical adjusting techniques were perceived to be the most injury-related."  If you have other sourced information relating to those techniques (descriptive as well as research), we could add that piece.  It really doesn't need a whole paragraph, though, especially from a lower quality MEDRS source, but I wouldn't object to it. Ocaasi (talk) 09:53, 6 December 2010 (UTC)

The current version does not hide the fact that spinal manipulation can cause VAD. We still need to expand the "prognosis" section to explain that VAD can lead to death. That way, the reader will understand that spinal manipulation can give you VAD, and that VAD can kill.

You keep on going on about the fact that "Ernst-death" is WP:MEDRS. I don't dispute that, and neither do I dispute any of the statements of fact. But I think that it constitutes WP:WEIGHT because we are actually talking about a rare event, even if we take underreporting of 100% into consideration. JFW &#124; T@lk  06:36, 6 December 2010 (UTC)


 * I think that it constitutes WP:WEIGHT because we are actually using a recent systematic review. Do you have a specific response to "Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g. 1,2)." QuackGuru (talk) 06:53, 6 December 2010 (UTC)

We are already saying that, both in the introduction and in the "causes" section. We even give a figure of 16-28%, suggesting that manipulative therapy is responsible for a very significant proportion of cases. I don't think we can inflate this figure further. JFW &#124; T@lk  06:59, 6 December 2010 (UTC)


 * Manipulative therapy is responsible for a very significant proportion of cases. We should include the systematic review per WEIGHT. QuackGuru (talk) 07:03, 6 December 2010 (UTC)

But we are already saying that! JFW &#124; T@lk  07:26, 6 December 2010 (UTC)


 * (The compromise.) "A systematic review stated that the risk of death from manipulations to the neck, typically associated with vertebral artery dissection, by far outweighs the benefits; 26 fatalities are recorded in the medical literature since 1934, and many more seem to remain unpublished. "
 * (The compromise.) "The frequency for accurate estimates of vascular accidents involving vertebral artery dissection are impeded by the suspected substantial underreporting. "
 * I think the 2010 systematic review constitutes WP:WEIGHT because manipulative therapy is responsible for a very significant proportion of cases and vascular accidents after neck spinal manipulation are a well recognised issue. QuackGuru (talk) 07:35, 6 December 2010 (UTC)
 * What source establishes that manipulative therapy is responsible for a significant proportion of vascular accidents? Ernst reports that SM can be dangerous or even fatal but that actual incidents are very rare (even with underreporting).  Also, Spine 2007 disputes Ernst, as does JMPT 2005 and, and Spine 2009 affirms that the data regarding chiropractic and adverse events is really not very good at all, and further research is urgently needed.  Ernst's findings are credible for a risk analysis, but they don't broadly establish significance related to VBA, just an association, a presumed cause, and evidence of underreporting. Ocaasi (talk) 08:03, 6 December 2010 (UTC)
 * Hey. Looked what somehow got in the article. "Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection (16–28% of cases in hospital-based studies).[1]" It seems you forgot to delete it. Thanks. It seems 16–28% is a significant proportion of vascular accidents. You are doing your own review of the systematic review rather than helping to improve the article. The systematic review does say "Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death." I show this source is relevant to this article. QuackGuru (talk) 08:19, 6 December 2010 (UTC)
 * I hadn't found the 16-28%, nor would I have removed it. It is significant although not overwhelming, also considering the general rarity of VBA incidents.  Again, I didn't say Ernst shouldn't be mentioned, only that it be proportional or balanced. Spine 2008 addresses the issue of preexisting conditions that could explain the CSM/VBA correlation and Spine 2009 concludes that adverse incident data still for spinal manipulation still lacks quality.  I see that as a dispute among reliable sources.  And the Weight concern is still there:  including, "Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection (16–28% of cases in hospital-based studies)" seems close to sufficient.  As long as we include a mention of underreporting, and perhaps the lack of quality data, we should be covered.  I'd also argue we should include Spine 2008 and JMPT 2005 which found that the forces experienced during SM are less than other traumas known not to cause VBAs in healthy individuals. Ocaasi (talk) 10:16, 6 December 2010 (UTC)


 * The 16-28% figure has been in the "causes" section since I added it on 25 November (diff). I stand by its inclusion and have no intention to remove it. JFW &#124; T@lk  15:29, 6 December 2010 (UTC)


 * My 2 cents: As a review of the case studies, not exactly Cochrane level of evidence, but it is a peer reviewed review of the literature. I think the one sentence on the incidence and likely under-reporting is appropriate here - if we are explicitly clear that we are speaking of the under-reporting of serious complications like death. The other section about deaths does not appear appropriate for the "Trauma" section - if and when the "Prognosis" section is expanded, a one liner there would probably be the right WP:WEIGHT; language about "risks out weight benefits" seems somewhat out of place here, and probably more appropriate in the chiropractic article. Yobol (talk) 15:15, 6 December 2010 (UTC)


 * But what do you mean by "underreporting"? Is there any evidence that VAD due to chiropractic is more lethal than VAD due to any other cause? JFW &#124; T@lk  15:29, 6 December 2010 (UTC)
 * No, nor do I think such language would be appropriately sourced to Ernst 2010. Any discussion of under-reporting from this source would have to be specific to deaths from chiropractic manipulation.  How about move the mention of "under-reporting" and combine it with the deaths section, and place both in the Prognosis section? Yobol (talk) 15:36, 6 December 2010 (UTC)
 * I made this change for now. QuackGuru (talk) 18:55, 6 December 2010 (UTC)
 * QG, there are several contrasting viewpoints in this section about how to handle its Weight, and they are approaching a consensus. While it's being discussed, it should be on the talk page.  For now, you should take it out and paste it as a proposal in a new section.  Ocaasi (talk) 19:05, 6 December 2010 (UTC)


 * Since QuackGuru's viewpoint seems amply clear, I would be very interested to see how this discussion would progress if QuackGuru would abstain from commenting for, say, 24 or 48 hours. A suggestion only, at this point. MastCell Talk 19:18, 6 December 2010 (UTC)


 * Hee hah! LMFAO! You all may wonder why I haven't been contributing here lately. As long as QG is involved with his special method of making edits of controversial material before a consensus is reached, I find it pointless. I hate getting involved because he can keep this circus going for months on end. Let me know when he's been effectively contained. Until then I can't afford losing my 2 cents repeatedly. -- Brangifer (talk) 20:21, 6 December 2010 (UTC)

Proposal
To be placed in the prognosis section (the epidemiology section would be inappropriate as it discussing a complication and good incidence rates are not available): "Deaths due to chiropractic manipulation to the neck, which is thought to be associated with vertebral artery dissection, have been documented in the medical literature, with 26 fatalities since 1934 reported by one review. There is likely under-reporting in the literature of the true incidence of death associated with VAD due to manipulation, although no reliable data on incidence is available. (ref to ernst-death)" I think this is appropriately weighted, without getting in too much details about chiropractic. Thoughts? Yobol (talk) 15:21, 7 December 2010 (UTC)


 * Why is this relevant to the subject of prognosis? JFW &#124; T@lk  22:33, 7 December 2010 (UTC)
 * Death being a possible complication, it might be relevant here. What section do you think it fits better in? Yobol (talk) 22:38, 7 December 2010 (UTC)


 * Have you read even a single one of my posts above? Why should chiropractic-related VAD be any more lethal than other forms of VAD? JFW &#124; T@lk  23:51, 7 December 2010 (UTC)
 * I never said it could, and I do not know the relevance of that question to my question as to where to place this information. Are you saying we shouldn't use this information if we can't prove VAD related manipulation is more likely to be complicated by death? Yobol (talk) 23:58, 7 December 2010 (UTC)


 * Don't you think it comes close to WP:WEIGHT to say something along the lines of "you know, VAD related to chiropractic can also kill, and there have been 26 cases reported over >60 years, but we think there may be more"? JFW &#124; T@lk  00:07, 8 December 2010 (UTC)
 * Presumably we would have other information in the prognosis section to provide proper balance. Otherwise, I don't see anything obviously WP:UNDUE about my proposal.  Could you elaborate on your objection? Yobol (talk) 00:10, 8 December 2010 (UTC)


 * The source doesn't say anything new. All other sources already state that chiropractic can cause VAD, and that VAD can kill. What is new here? The underreporting is only suspected; it presumes that every fatality from a disease is submitted to a registry or published in the medical literature. I have restated this again and again, and I'm still not hearing a good reason why this study needs to be given such emphasis. JFW &#124; T@lk  06:29, 8 December 2010 (UTC)


 * This is uniquely different from other "diseases", where the connection between cause and effect are usually noted by a physician or coroner. Here we have a traumatic cause that is often separated by days and even weeks from the actual stroke or death. This means that it is rare to connect the two. It pretty much only happens when the VAD occurs dramatically in immediate connection with the cervical manipulation. Even then, chiropractors will deny there is any causation in spite of immediate convulsions, foaming at the mouth, and the head turning blue. That has actually happened! That's why underreporting is a problem to a degree not found with other conditions, where the connection between cause and stroke/death is noted. Here the VAD might be noted, but the real cause isn't even guessed. -- Brangifer (talk) 07:10, 8 December 2010 (UTC)


 * In that sense it is no different from any other types of trauma, which may be remote. Again, the evidence for underreporting is very circumstantial. JFW &#124; T@lk  07:33, 8 December 2010 (UTC)


 * The information is not "new"? We have other sources documenting the number of deaths noted in the literature from chiropractic manipulation and that this is likely underreported as to the true incidence? I don't understand how you can say it's not "new" if the information isn't in the WP article already.
 * And I guess I'm not seeing that this information is getting any more "emphasis" than any other piece of information; if you have any other reviews that look at the literature I would expect it to get as much weight as this one. It's two short sentences. Yobol (talk) 14:37, 8 December 2010 (UTC)

"Deaths due to chiropractic manipulation to the neck is associated with vertebral artery dissection; 26 fatalities since 1934 is documented in the medical literature. There is likely under-reporting of the true incidence of death associated with VAD due to manipulation, although no reliable data on incidence is available.(Ernst-death)"

Yobol, I shortened the text for brevity. Editors are doing a good job with the proposals. QuackGuru (talk) 18:38, 10 January 2011 (UTC)

Proposal 2

 * "Serious adverse events including 26 deaths since 1934 have been associated with spinal manipulation to the neck, and vertebral artery dissection or stroke is a suspected cause (neurologist 2008, ernst 2010). Uncertainty remains due to both significant under-reporting of manipulation-related trauma (ernst 2010) as well as the possibility of patients seeking out chiropractors because a pre-existing verterbral artery condition (spine 2008). Evidence suggests healthy vertebral arteries are not at risk from proper manipulation (JMPT 2005).  Better data is needed to understand the connection (spine 2009)."

-Spine 2008 "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."

-JMPT 2005 "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."

-Spine 2009 "There is no robust data concerning the incidence or prevalence of adverse reactions after chiropractic. Further investigations are urgently needed to assess definite conclusions regarding this issue."

-Neurologist 2008] "Weak to moderately strong evidence exists to support causation between CMT and VAD and associated stroke. Ultimately, the acceptable level of risk associated with a therapeutic intervention like CMT must be balanced against evidence of therapeutic efficacy. Further research, employing prospective cohort study designs, is indicated to uncover both the benefits and the harms associated with CMT." Ocaasi (talk) 14:29, 8 December 2010 (UTC)


 * The current article is a WEIGHT violation for not including the relevant 2010 systematic review. There are two different proposals on the talk page and most editors want to include at least something from the reference. QuackGuru (talk) 02:45, 21 December 2010 (UTC)


 * This source is relevant to this article. Therefore, this article failed GA for not including it. When there is an ongoing content dispute this article should not have been nominated for a GA review. QuackGuru (talk) 19:47, 7 January 2011 (UTC)
 * It's one paragraph at most dealing with spinal manipulation. It's not that big of a controversy.  It certainly wasn't worth not improving the rest of the article over.  That's part of the problem: while we stopped discussing that one issue, the entire article came up a grade.  Your campaigns are not without merit, but they are so costly it's not worth getting into. Ocaasi (talk) 20:30, 7 January 2011 (UTC)
 * It's one paragraph at most dealing with spinal manipulation. It's not that big of a controversy.  It certainly wasn't worth not improving the rest of the article over.  That's part of the problem: while we stopped discussing that one issue, the entire article came up a grade.  Your campaigns are not without merit, but they are so costly it's not worth getting into. Ocaasi (talk) 20:30, 7 January 2011 (UTC)


 * They are so costly? I am not the editor who deleted a systematic review against MEDRS that is extremely relevant to the article. The majority of editors want to include the reference in the article. It's not worth getting into claiming the systematic review is not relevant or does not have consensus on this talk page when the reference is reliable and it is obvious whether there is consensus to include. QuackGuru (talk) 15:52, 8 January 2011 (UTC)

A discussion over a line and a reference is not enough to impede this article being a GA.--Garrondo (talk) 09:55, 8 January 2011 (UTC)


 * Is there a reason why you are not commenting on the reliability of the systematic review or any of the proposals. QuackGuru (talk) 15:52, 8 January 2011 (UTC)
 * If you refere to me: well I do not want to get involved in a discussion of an article I have barely edited. I did a review for GA and I believe that the article is either a GA with the reference you propose and without it... you will have to reach consensus with other editors but not me.--Garrondo (talk) 18:46, 8 January 2011 (UTC)

Since we are not understanding each other I am forced to take the discussion elsewhere. See WP:FTN. QuackGuru (talk) 17:31, 8 January 2011 (UTC)


 * I strongly suggest you continue your quest for inclusion of "Ernst-death" on FTN. JFW &#124; T@lk  20:46, 8 January 2011 (UTC)


 * It is irrelevant whether chiropractic-related VAD is any more lethal than other forms of VAD. We have a reliable source that does associate CSM with death. Is there a reason why the reader should not know there is an assocation with death when we are using a recent source in accordance with WP:MEDRS. You claim the proposal is redundant. Can you show me how deaths due to chiropractic manipulation to the neck is associated with vertebral artery dissection is redundant when it is not specifically mentioned in the article. I think we can satisfy WP:WEIGHT with including it. QuackGuru (talk) 19:20, 9 January 2011 (UTC)


 * Please don't surf back and forth between FTN and here. I have explained my position numerous times, and you have not provided a satisfactory justification for your repeated demand to include this study. JFW &#124; T@lk  20:55, 9 January 2011 (UTC)


 * I added only one word from the source. Is that to your satisfactory. QuackGuru (talk) 21:28, 9 January 2011 (UTC)


 * After all the discussion we've had, do you regard that a good faith edit? Can you not concede a point and rest it there, or must you subvert every form of consensus-forming to further your thinly-veiled agenda? JFW &#124; T@lk  21:32, 9 January 2011 (UTC)


 * Can I ask, the sentence is included as: "Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection which can result in stroke." Is there a reason why the part "which can result in stroke" is relevent or adds anything to this article? Doesnt the article already discuss the idea that VAD can result in stroke under prognosis? I fully understand the first part of the statement "Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection", but what is the purpose of the end of the statement other than to attempt to link Chiropractic to stroke, which belongs in another article (like chiropractic)? This article regards VAD, why not just leave it as Chiropractic is linked to VAD?Puhlaa (talk) 21:37, 9 January 2011 (UTC)
 * Ooops! My apologies Jfdwolff, I chimed in with my 2-cents too soon. I see that this is an issue you are already addressing.Puhlaa (talk) 21:39, 9 January 2011 (UTC)


 * It was another attempt by QuackGuru to push his agenda. The offending addition adds nothing and has been removed. JFW &#124; T@lk  21:40, 9 January 2011 (UTC)


 * How is adding only one word from the source not reasonable. There are other editors also making proposals too which do add to the article. QuackGuru (talk) 18:30, 10 January 2011 (UTC)

"Serious adverse events including 26 deaths since 1934 have been associated with spinal manipulation to the neck, and vertebral artery dissection or stroke is a suspected cause.(Ernst 2010) Uncertainty remains due to likely under-reporting of manipulation-related trauma.(Ernst 2010)"

Ocaasi, for brevity I shortened the proposal. QuackGuru (talk) 18:30, 10 January 2011 (UTC)

Proposal 3
Stroke and death due to chiropractic manipulation to the neck is associated with vertebral artery dissection. There is likely under-reporting in the literature of the true incidence of death associated with VAD due to manipulation, although no reliable data on incidence is available.

I think this proposal is appropriately weighted to include in Vertebral artery dissection. The proposal is not redundant when there is no mention of the prognosis of stroke or death due to CSM. QuackGuru (talk) 04:17, 10 January 2011 (UTC)


 * We are already stating clearly that there is probable underdiagnosis, based on LancetNeurol2007. Ernst uses a very unscientific approach to demonstrate underreporting - after a while, case reports about a certain condition cease to be published because there is nothing new to report. I would not be able to get a case report about swine flu published, unless it contained some new and previously unreported.
 * Again, Ernst does not say that all deaths were the result of vertebral artery dissection. That is an inference. You continue to overstate the relevance of that paper to this article, and it simply affirms my view that you are attempting to use it as a WP:COATRACK. JFW &#124; T@lk  11:36, 10 January 2011 (UTC)

Cochrane
Having cited Menon as a treatment trial showing (essentially) equipoise between antiplatelets and anticoagulation, I thought I'd have a look at Cochrane to see if they might have reviewed this. Unfortunately the only review is, which only covers carotid dissection. JFW &#124; T@lk  14:46, 12 December 2010 (UTC)


 * The 2007 American stroke guideline devotes little space to arterial dissection, and seems to discourage anticoagulation but without discussing the evidence! JFW &#124;  T@lk  22:48, 12 December 2010 (UTC)


 * Strangely, the 2009 imaging guideline for stroke seems to suggest that DSA should be performed rather than CT/MRI to confirm or exclude dissection. No idea how this advice is followed in practice. JFW &#124;  T@lk  22:56, 12 December 2010 (UTC)

Almost done...
Having expanded the article significantly in the last few days, I'm just taking stock of what we still need to do before it might be ripe for reassessment (class B or GA, depending mostly on whether I have the time).
 * Signs and symptoms - could still expand on the lateral medullary syndromes, but sources are rather quiet about it
 * Decided not to go into too much detail. Very odd that so little is told in the sources about the actual deficit, as well as the causes for deterioration (i.e. what do people with VAD die of - aspiration pneumonia?)
 * Causes - pretty complete I'd say, unless a consensus emerges on Ernst-death
 * Mechanism - could still mention more about aneurysm formation
 * Diagnosis - pretty complete
 * Treatment - pretty complete, could still expand a bit on surgery, but this is an unusual intervention
 * Prognosis - pretty complete
 * Epidemiology - pretty complete
 * History - could still expand but unsure what other landmarks there are still to discuss

I've reviewed Goyal and Derdeyn 2009 (reference above). It doesn't add much to the present content but goes into a lot of detail about aneurysms. The relative relevance of each statement is a bit lost on me. The same applies to, which is currently not cited, another neurosurgical paper that mostly deals with dissecting aneurysms. I will give both papers another read over the next few days and decide if there's anything we are not saying. JFW &#124; T@lk  17:32, 13 December 2010 (UTC)


 * Submitting for GA. JFW &#124; T@lk  17:51, 16 December 2010 (UTC)
 * Thanks for your hard work. Ocaasi (talk) 19:07, 16 December 2010 (UTC)


 * You're welcome. JFW &#124; T@lk  19:17, 16 December 2010 (UTC)

The conclusion of the Ernst 2007 review is not being represented
The 2007 review looks at all the adverse effects, so I don't think it adds nothing when it is apparently relevant to the topic. But even then, look at how the 2007 review is used: the review's results are "In the majority of cases, spinal manipulation was deemed to be the probable cause of the adverse effect", and the review is only used in the article to support "and the association is disputed by proponents of these treatment modalities" - in other words, there's nothing in the article drawn from Ernst's actual conclusions! Policy actually mandates the inclusion of the mainstream view per WP:WEIGHT. MEDRS simply sets standards for sources where there are multiple sources available. From a MEDRS perspective, the 2007 review shows that chiropractic has probably caused stroke, VAD being an important mechanism. WEIGHT is a subsection of NPOV, and it does not demand that every viewpoint is included. This applies especially in extreme or marginal views such as the proponents fringe view.

There is relationship between MEDRS & WEIGHT. The relevant section is Neutrality requires that each article or other page in the mainspace fairly represents all significant viewpoints that have been published by reliable sources, in proportion to the prominence of each viewpoint. However, it does say all significant viewpoints, so the base guidance is that if a viewpoint is relevant and published by reliable sources, then it should be included. WP:WEIGHT guides us on how we treat the viewpoints of minorities, and how much prominence we give them (if any). Unless the argument is being made that Ernst's conclusions represent a minority viewpoint in the published, reliable literature, it needs to be fairly represented as the majority viewpoint. The fact is that his conclusions are not of huge relevance to VAD, but that is not what WEIGHT is about. As long as CSM is described as a cause or risk factor for VAD in the reliable literature, the article remains incomplete without mentioning it.

The following represents Ernst's 2007 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."

Current fringe view at Traumatic.

Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection (16–28% of cases in hospital-based studies). Although reports of the association are of weak to moderately strong quality, many of the reports have methodological flaws, and the association is disputed by proponents of these treatment modalities.

Personally, I believe the part "and the association is disputed by proponents of these treatment modalities" under Vertebral artery dissection gives insufficient weight to the majority viewpoint and excess weight to minority viewpoints.

Proposal for Traumatic.

Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection (16–28% of cases in hospital-based studies). Spinal manipulation, particularly when performed on the upper spine, can result in serious complications such as VAD followed by stroke. Reports of the association are of weak to moderately strong quality, and many of the reports have methodological flaws.

IMHO I think this proposal for Traumatic satisfies WEIGHT and FRINGE. QuackGuru (talk) 18:01, 9 January 2011 (UTC)
 * While I do not now enough about this controversy to decide which proposal is more NPOV I would say that correct grammar and wording for above proposal would be: Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection (16–28% of cases in hospital-based studies). [2] Spinal manipulation, particularly when performed on the upper spine, can result in serious complications such as VAD followed by stroke.[6] Reports of the association are of weak to moderately strong quality [3] and many of the reports have methodological flaws: "Although" did not have much sense since sentence was independent of the precceding.--Garrondo (talk) 18:23, 9 January 2011 (UTC)
 * The word "Although" may be WP:OR. I fixed the gmr issue. This proposal uses the conclusion rather than the fringe view. QuackGuru (talk) 18:55, 9 January 2011 (UTC)


 * The VAD article should remain specific to VAD and not be used as an avenue to push criticisms of spinal manipulation or chiropractic. The addition that has been proposed by QG describes the potential for severe adverse effects of cervical manipulation (which is already found in the VAD article) and speculates about the link between VAD and cervical manipulation, but does not add any new evidence specific to a causational link. The possibility of cervical manipulation having a causational relationship with VAD has already been described in the article, as such, the proposed addition does not add anything new to the discussion. I prefer how the VAD article currently exists, where the controversial association between upper cervical manipulation and VAD has been acknowledged, but is not given undue weight. The section also acknowledges, but does not give undue weight to the fact that causation is disputed in the literature. Thus, I think the article as it currently exists already satisfies MEDRS, NPOV, WEIGHT and FRINGE and does not need to be modified until additional research examining causational is available.Puhlaa (talk) 19:04, 9 January 2011 (UTC)
 * The possibility of stroke due to CSM is not being discussed in this article. You still have not given any good reason why we should ignore the conclusion of a reliable source. Puhlaa, you argument is not based on any policy on Wikipedia. QuackGuru (talk) 19:16, 9 January 2011 (UTC)
 * As I stated on the replica thread that you started in FTN, I have given my opinion (based on my knowledge of wikipedia policies, the science in question, and my personal view), your opinion is also very clear (it was after the first post, the others werent necessary). My approach at this point is that if a majority of other editors agree with your view, then my view is perhaps flawed and not worth arguing further. Thus, respectfully, what other editors have to say is more likely to re-shape my opinion than reading your opinion a second or third time. For the same reason, I dont feel obliged to re-post my position on the issue.Puhlaa (talk) 20:37, 9 January 2011 (UTC)


 * It is nonsense to ignore the conclusion in favor of the fringe view. QuackGuru (talk) 20:52, 9 January 2011 (UTC)


 * I have serious problems with the current version being branded "fringe". The proposed version is based on the misunderstanding that other causes of VAD do not cause stroke. In fact, it follows the same pattern as QuackGuru's other demands, namely that we cite "Ernst-death"; that demand also presumes that VAD not caused by CSM cannot lead to death. Insisting that VAD caused by CSM somehow causes more stroke and more death is not supported by any source.
 * I have modified the article to give more weight to Ernst's actual conclusions. At the same time I regard his paper as an excellent secondary source because he impartially states that proponents of CSM would object to his conclusions.
 * I will not be commenting further on this thread, because I believe QuackGuru's agenda is not the improvement of the article but turning it into a WP:COATRACK to bash chiropractic. JFW &#124; T@lk  21:07, 9 January 2011 (UTC)


 * The proposal does not say CSM causes more stroke and more death. You are misrepresneting the proposal. QuackGuru (talk) 21:21, 9 January 2011 (UTC)


 * Please summarise in one sentence why your proposal is better than the current version, especially after adjustments for the conclusion of Ernst2007. JFW &#124; T@lk  21:33, 9 January 2011 (UTC)


 * "Although" is original research and "and the association is disputed by proponents of these treatment modalities." is WP:FRINGE (tiny minority view not about cause) and WP:SYN (independent from the other sources and taken out of context). QuackGuru (talk) 03:45, 10 January 2011 (UTC)


 * "Reports of the association are of weak to moderately strong quality, and many of the reports have methodological flaws.
 * Here is a new proposal for Traumatic. QuackGuru (talk) 04:00, 10 January 2011 (UTC)
 * I agree with this change to remove the OR. The part "and the association is disputed by proponents of these treatment modalities." needs further discussion or we can go to the OR noticeboard. QuackGuru (talk) 07:30, 10 January 2011 (UTC)


 * I agree with the removal of "Although". This is an error I introduced while trying to give more weight to Ernst2007's conclusions. The word is now gone, with thanks to Garrondo.
 * I will have one further go at rephrasing the current version. Please note any objections here rather than adding tags. JFW &#124; T@lk  11:36, 10 January 2011 (UTC)


 * I changed "but" to "and" per Larry Sanger's NPOV. "Although" and "but" were the same error to me. QuackGuru (talk) 16:57, 10 January 2011 (UTC)


 * The word "but" is the same problem as "Although". So, Jfdwolff does disagree with removing the error. QuackGuru (talk) 19:22, 10 January 2011 (UTC)

I am ok with the most recent revision of the text, however, if it is still challenged by anyone then I have an alternate proposal. We could remove "and the association is disputed by proponents of these treatment modalities.", and instead include a more scientifically acceptable arguement (found in Ernst 2007) to explain the potential limitations of the association. I will propose that the Traumatic section could read:

Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection. In hospital-based studies this was the underlying cause for 16–28% of cases. Reports of the association are of weak to moderately strong quality, many of the reports have methodological flaws, and a temporal relationship is insufficient to establish causality Puhlaa (talk) 15:56, 10 January 2011 (UTC)


 * The current text is taken out of context. "The association between chiropractic neck manipulation and vertebral artery dissection is disputed by proponents of these treatment modalities.[7]"
 * The source says "They suggest that many therapists are now becoming aware of the risks of spinal manipulation.48,49"
 * This text is misplaced and is still a minor point from the source and not about cause.
 * "Dissection of the vertebral arteries was the most common problem; other complications included dural tear, oedema, nerve injury, disc herniation, haematoma and bone fracture. The symptoms were frequently life-threatening, though in most cases the patient made a full recovery. In the majority of cases, spinal manipulation was deemed to be the probable cause of the adverse effect."
 * "The most serious problems, which some experts now describe as ‘well-recognized’,22 are vertebral artery dissections due to intimal tearing as a result of over-stretching the artery during rotational manipulation. This seems to occur most commonly at the level of the atlantoaxial joint.20 Intimal injury can be followed by intramural bleeding or pseudoaneurysm formation, which can result in thrombosis, embolism20 or arterial spasm.22"
 * We could delete the minor point or replace it with something like the probable cause or elaborate from the source.
 * The part "and a temporal relationship is insufficient to establish causality" is confusing and seems to be taken out of context.
 * The 2010 systematic review explains the causality of death associated with VAD is at least likely.
 * Specific proposal using a MEDRS approved source: "The causality between chiropractic neck manipulation and vascular accidents that can result in death is probable."
 * If editors want to include something about the causality we can include this proposal. QuackGuru (talk) 18:08, 10 January 2011 (UTC)

Under-reporting of VAD from CSM is not mentioned in this VAD article, and may be worth at least giving mention to. The Ernst 2007 review indeed discusses this possibility (specifically with regard to VAD) and is already a source in the VAD article, so it may be worth adding a mention. I propose:
 * "Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection, and under-reporting of incidents is likely common. " I would be OK with this proposal if other editors feel it is worth adding.Puhlaa (talk) 23:24, 10 January 2011 (UTC)


 * "Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection, and under-reporting of incidents is likely common. "
 * I thought we could use the newer source from the same author. It is worth all the money in the world to include. QuackGuru (talk) 23:44, 10 January 2011 (UTC)

Once more, we are already saying that VAD may be underdiagnosed and hence underreported. With regards to your words "It is worth all the money in the world to include", you have already amply demonstrated your readiness to include this absolutely rubbish source. It has so many problems I can't possibly justify its inclusion (see all my points above and on FTN). "Ernst-death" is not about VAD, it is about deaths after CSM, some of which may possibly have been mediated by VAD. That is so remote a conjecture that I am surprised you are still pushing for it! JFW &#124; T@lk  23:59, 10 January 2011 (UTC)


 * I have been watching this discussion and considering the overall balance of sources. I think the article struck approximately the right balance before this discussion began, and I think that QuackGuru needs to accept the fact that the point most important to him—no matter how True™ or interesting that point is to himself—is not the the point most important to most reliable sources.  Wikipedia does not exist for the purpose of collecting and highlighting every source that can be construed as anti-chiropractic or that happens to appeal to a single editor.
 * Consequently, I oppose the QuackGuru's proposed changes and the ongoing effort to over-emphasize the Ernst source. WhatamIdoing (talk) 03:02, 11 January 2011 (UTC)
 * I agree with Jfdwolff remark on the fact that "Ernst-death" is not about VAD, it is about deaths after CSM, some of which may possibly have been mediated by VAD. and that this article is not the place to add more info on it. I also agree with WhatamIdoing on saying that the article was balanced already before this discussion.--Garrondo (talk) 07:27, 11 January 2011 (UTC)


 * "What’s known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death."
 * According to the source, CSM "repeatedly been associated with arterial dissection followed by stroke and, in some cases, death." So, Jfdwolff remark is not a fact. The source says VAD with regard to CSM is followed by stroke and, in some cases, death. This is clearly relevant to the article. QuackGuru (talk) 18:42, 11 January 2011 (UTC)
 * As has been stated repeadly, but you repeatedly refuse to acknowledge, the association between VAD and CSM has already been discussed in the VAD article. The prognosis of VAD is the possibility of stroke and death no matter what the cause, and this is also already discussed in the VAD article. Thus, there is no value in trying to further link VAD specifically from CSM to stroke and death because this is no different from the prognosis of VAD from any other cause. Why doesnt the opinion of 4 other editors give you a clue that you may be mistakingly pushing your POV here and not adding value to the VAD article?Puhlaa (talk) 19:19, 11 January 2011 (UTC)


 * You believe "The prognosis of VAD is the possibility of stroke and death no matter what the cause, and this is also already discussed in the VAD article."
 * Please provide the exact text from the VAD article that says this. QuackGuru (talk) 19:28, 11 January 2011 (UTC)
 * Obstruction of blood flow through the affected vessel may lead to dysfunction of part of the brain supplied by the artery. This happens in 77–96% of cases. This may be temporary ("transient ischemic attack") in 10–16% of cases, but many (67–85% of cases) end up with a permanent deficit or a stroke.--Garrondo (talk) 19:36, 11 January 2011 (UTC)
 * Also: "Prognosis of spontaneous cervical arterial dissection involves neurological and arterial results.... The rate of survival with good outcome (a modified Rankin score of 0–2) is generally about 75%" IE: 25% have a poor outcome or die!Puhlaa (talk) 19:39, 11 January 2011 (UTC)


 * Jfdwolff wrote "Once more, we are already saying that VAD may be underdiagnosed and hence underreported."
 * Where in the article does it say CSM is being underdiagnosed and hence underreported? QuackGuru (talk) 18:47, 11 January 2011 (UTC)


 * Nowhere. Neither its talks about all the other undereported diseases in the world. It is not relevant for VAD to say that CSM is undereported, it is relevant fot the CSM article.--Garrondo (talk) 19:39, 11 January 2011 (UTC)


 * Especially since "CSM" (cervical spinal manipulation) is a treatment, rather than a medical condition, and thus CSM isn't "diagnosed" (ever). WhatamIdoing (talk) 23:36, 11 January 2011 (UTC)


 * LMFAO! This one is obviously a typo by QG, who probably meant what he wrote further up: "Under-reporting of VAD from CSM is not mentioned..." He even quoted JFW right but then managed to write write his question as a misquite, writing CSM rather than VAD, when "VAD" must have been his intent. Let's not waste anymore time on this typo. Let's get this back on track by just writing what he intended to write:
 * Jfdwolff wrote "Once more, we are already saying that VAD may be underdiagnosed and hence underreported."
 * Where in the article does it say VAD is being "underdiagnosed and hence underreported"?
 * My comment: it only says "underdiagnosed" once and never "underreported". That is being addressed in the section below, where Puhlaa has proposed a Solomonic and simple solution. -- Brangifer (talk) 04:16, 12 January 2011 (UTC)

Still no mention of underreporting
I have refrained from entering this fray for some time because I don't want to get in the middle of a shitfight between QG and JFW, and I don't want JFW to tar and feather me for siding with QG to a certain degree, simply because I usually disagree with QG's aggressive way of pushing a POV, his stonewalling, IDHT, circular discussion style, and his far-too-bold editing style (making controversial edits before a discussion has resulted in a consensus). Frankly I'm rather irritated with both editors for not reaching a compromise (JFW, NO mention of underreporting isn't a compromise) so I just stay away, even though I possess a large amount of knowledge about these subjects.

I still feel a need to voice some concerns and let others at least read them, so here goes:


 * 1) All I can find of mention of underreporting in this article is the single word "undiagnosed". Are there other mentions?
 * 2) The Ernst study, which included ALL members of the Association of British Neurologists, is published in a MEDRS and is the only study dealing exclusively with the subject of underreporting I know of, and it is not controversial, except to chiropractors and JFW. I know of no mainstream, non-chiropractic sources that question it.
 * 3) I have never seen an article depend so heavily on one source, and in this case one about anticoagulant treatment.

Here's what the VAD risk matter boils down to:


 * 1) There is a very small risk, regardless of which profession does it (and I'm a PT);
 * 2) When injury occurs it can easily be catastrophic;
 * 3) Preliminary testing to reduce risk gives the therapist a false sense of security and has no certain, proven legitimacy, especially for younger people, since traumatic VAD affects primarily the under 45 population which generally has full neck mobility with no significant arthritic joint pathology. They will usually test negative and then be manipulated;
 * 4) There are safer methods mentioned in the literature to treat the same neck-related conditions for which high cervical manipulation is commonly used;
 * 5) Even with a very small risk, it is never justifiable to use a method when it isn't absolutely necessary or even slightly indicated. This definitely applies to high cervical manipulation commonly used as treatment for LBP, allergies, suspected otitis media, dysmenorrhea, or any number of other conditions for which it is commonly used by Upper Cervical (UC) chiropractors. For them, every single ailment indicates use of upper cervical manipulation per BJ Palmer's "Hole In One" philosophy. (The worst example I treated was a mother whose neck was manipulated as treatment for her baby's crying. The reasoning was applied kinesiology's "surrogate" method. AK is a commonly used chiropractic method.) Pretty much all straight chiropractors, and many other chiropractors, including non-UC chiros, use high cervical manipulation regardless of the patient's complaint, and they do it EVERY visit. That's inexcusable. PTs, DOs and MDs don't use it in that way.


 * To summarize

Regardless of my opinions about VAD....


 * 1) Underreporting is ignored except for lip service on this talk page.
 * 2) Contrary to a comment above, underreporting is very relevant to VAD, not to CSM.
 * 3) Too much dependence on one source.

These matters still need to be addressed. -- Brangifer (talk) 21:29, 11 January 2011 (UTC)


 * I will give my opinion with regard to each of Brangifers 3 nicely summarized issues (only regarding VAD to avoid furthering a discussion of upper cervical manipulation here):
 * I agree that under-reporting is important and not specifically given mention. To this regard, I would propose adding a mention of the problem of under-reporting specific to VAD from manipulation. Ernst 2007 discusses under-reporting specifically with regard to VAD from manipulation and is already a source in the VAD article. Thus, I propose changing the first sentence addressing the manipulation issue in "Traumatic" to:"Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection, and under-reporting of incidents is likely common. "
 * As I have agreed that under-reporting is important, I have already agreed with Brangifers second point.
 * I have not examined the entire VAD article to determine how much the entire article relies on the one source about anticoagulant treatment. However, the short discussion of VAD from manipulation alone cites 4 references (IE: Ernst(2007); Kim & Schulman(2009); Miley etal(2008); Rubinstein etal(2005)) and meets FRINGE, WEIGHT, and NPOV, so I am more that satisfied with this particular section as it currently exists other than the mention of under-reporting as described above.
 * Puhlaa (talk) 22:03, 11 January 2011 (UTC)


 * A Solomonic and simple solution that certainly satisfies me, and hopefully QG and JFW. Can we accept this and start doing something else that's constructive? This has gone on for far too long. I'd sure like to see this section marked "resolved". -- Brangifer (talk) 04:20, 12 January 2011 (UTC)


 * Anything that is underdiagnosed is necessarily underreported. Using both words is therefore redundant.  WhatamIdoing (talk) 07:39, 12 January 2011 (UTC)


 * (ec) No one is proposing to use both words. The suggestion uses only "under-reporting" and uses the Ernst ref:
 * Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection, and under-reporting of incidents is likely common. 
 * Underreported and underdiagnosed don't necessarily mean the same thing anyway, even though they often overlap. In this case, Ernst's study of all the neurologists revealed that many cases were actually diagnosed but still unreported, ending up with a 100% rate of underreporting in England. They weren't "underdiagnosed", but definitely "underreported".


 * JFW has just taken care of this in a satisfactory manner. Thanks! -- Brangifer (talk) 09:50, 12 January 2011 (UTC)


 * I am happy with the current state, and I have found the circular arguments a bit draining. However, my gut feeling says that QuackGuru will not rest until his POV is satisfied and "Ernst-death" is linked, despite the lack of applicability to this article and the numerous methodological drawbacks. Do all other editors here agree that it is unsuitable, and that pushing for its inclusion amounts to WP:COATRACK? JFW &#124; T@lk  09:47, 12 January 2011 (UTC)


 * I agree that we have a COATRACK problem. QuackGuru appears to be looking for hooks in as many articles as possible to hang his POV on.  WhatamIdoing (talk) 05:33, 13 January 2011 (UTC)


 * I won't revert it, but I think "under-reported" is a poor word choice. Some readers will think these suspected cases were all diagnosed, which does not appear to be supported by the source.  WhatamIdoing (talk) 05:30, 13 January 2011 (UTC)


 * We follow the sources, hence the use of that word, which is well-understood in medical circles, and even in the general English speaking population. (There is no firm rule as to whether it refers to diagnosed or undiagnosed cases. It can include both.) We can't change everything because of a few readers. A few won't even understand much of what's here! Note that the current text, which is an improvement, isn't what was suggested above, which is considerably shorter and milder: "...and under-reporting of incidents is likely common." Still, any improvement is good.


 * Also note that any coatrack problem doesn't relate to this "under-reporting" detail. That's a different matter. -- Brangifer (talk) 06:28, 13 January 2011 (UTC)
 * I don't have a particular problem with under-reporting, even though it stems from the same review. I do think we should avoid Ernst-Death further unless we intend to contextualize it with the sources listed in Proposal 2 above.  Ocaasi (talk) 08:31, 13 January 2011 (UTC)

The mention of "under-reporting" would be problematic without context, but the previous sentence makes it clear that this is problem with the studies performed so far. Any alternate wording that clarifies this further is welcome, but otherwise let's simply agree that this is sufficient.

With regards to "Ernst-death", I think it would be completely wrong to contextualise is with loads of extra sources. It is not a useful source, even with extensive embellishment and addition of extra context. The study is not about VAD, it is about death from chiropractic. It makes a number of inferences about VAD that are not supported by the sources. In absolute terms it discusses a very rare event, even when you take into account significant underreporting. JFW &#124; T@lk  10:00, 13 January 2011 (UTC)


 * I really don't know how much weight we should be giving to discussing CSM in the VAD article. I am in no way attempting to whitewash the issue, but if it is going to be discussed, there is a lot that should be discussed. For example, QG seems to really want to mention death from VAD from CSM, despite the fact that other sources have stated that "The current understanding, based on the evidence to date, suggests that while there is a clear, though rare, temporal relationship between CMT and VADS, no plausible causal connection can be made" [Murphy, Donald. Cervical manipulation and stroke: Where are we now? Clinical Chiropractic, March 2010 13:1 85-88.], or that "it is not clear whether manipulation was a cause or contributing factor to the dissection or whether the patient had an asymptomatic arterial dissection prior to the chiropractic visit" [Murphy, Donald. Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession? Chiropratic & Osteopathy, August 2010 18:22] and that "the weight of the evidence suggests that CMT is not a cause of VADS" [Ibid]. If we are going to mention that there is an association between Chiropractic and VAD, shouldn't we mention that there is a similar association between seeing and MD and stroke? ("In persons younger than 45 years, there is an association between chiropractic care and vertebrobasilar artery (VBA) stroke; there is a similar association between family physician care and VBA stroke." [Guzman et al. Clinical Practice Implications of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 2008 33:4S] and that "This suggests that there is no increased risk of VBA stroke after chiropractic care, and that these associations are likely due to patients with headache and neck pain from vertebral artery dissection seeking care while in the prodromal stage of a VBA stroke." [ibid]. ? Yet, to make what we say balanced and NPOV, we add more and more weight to the issue, when this article is supposed to be about VAD, not how chiropractic may or may not cause stroke, not how there is an association between family physician care and stroke. TL;DR:I strongly object to using this article as a coatrack. DigitalC (talk) 21:33, 15 January 2011 (UTC)


 * Ouch, needs more boldface! JFW &#124; T@lk  22:27, 15 January 2011 (UTC)


 * I agree with DigitalC's objection to writing more about this matter, at least at present. To counter the chiropractic studies mentioned above, there are a few facts and considerations to ponder:


 * Even though Murphy says there is "no plausible causal connection", such a connection has been made several times with clear and unambiguous events followed by autopsy evidence. So yes, it can and has happened, even though it's rare. Herzog's study (which Murphy is depending on) was on cadavers, so it really doesn't seal the case against the possibility, something which subsequent chiropractic articles have tried to do. Saying that "the weight of the evidence suggests that CMT is not a cause of VADS" is not the same as saying that it is "never" a cause, even though it seems to be used in that manner, which isn't correct. The association of VAD with seeing a chiropractor or an MD is somewhat of a red herring since the MD truly hasn't done anything that has an earthly chance of being a "plausible causal connection", in contrast to the chiropractor who has often repeatedly done something aimed with microscopic precision at precisely the structures where an autopsy shows the damage has occurred. There is a vast difference. Just because association does not equal causation doesn't mean that it never does. In fact it is usually considered a hint to be investigated, not denied, as the chiropractic profession has been doing very vigorously. The patient has gone to the chiropractor with what might be a stroke in progress (a contraindication to CSM) and then has been subjected to contraindicated treatment(!), whereas the same type of patient goes to a family practice MD and may or may not get treated properly. (MRIs aren't routinely ordered for a headache!) At least they aren't subjected to a procedure that is strongly suspected (enough to be considered contraindicated) of being a possible cause of VAD. There's a huge difference, but chiropractors are trying to gloss that fact over with ten yards deep of concrete paving, which is a very different attitude than the rest of the medical profession, where one heeds such hints, then examines the matter, develops tests and statistics, uses informed consent, and avoids methods with known or suspected risks when there are better methods available. We're looking at a mentality where habitual circling of the wagons is so deeply engrained that it's still being used, with patient safety looking on from outside the circle and being attacked as if it were an attacking Indian.


 * I still agree that there is no really good reason to do more about this in the article at present. Mention of underreporting (without a hyphen, per source) is mentioned, and I'm satisfied with that. Can we move on to other things yet? -- Brangifer (talk) 23:30, 15 January 2011 (UTC)


 * This won't change things for the VAD article, which I think has struck the right balance, but BR, how can we say even from autopsies that there is a causal connection? I don't want to sound obtuse, but if there is a pre-existing VA condition, then how would an autopsy show whether the Chiropractic treatment was the trigger, a counter-indicated practice, or completely unrelated?  (btw, I got the counterindicated part from you above, which is a nice point, since Chiros likely aren't checking for pre-existing VA problems, even if they are the root problem). Ocaasi 07:53, January 16, 2011 (UTC)


 * It's really rather simple. Signs of trauma without other pathologies are evident. Frozen sections of those who have died may even show signs of bruising, microtrauma to bones and blood vessels, and minor or major bleeding in the area. There are people who have stroked right on the chiro's table with bleeding at the site of injury.


 * Traumatic VAD figures noticeably in the statistics for the under 45 age group, in spite of the fact that these people don't usually have significant pathologies yet, but the signs of trauma tell the cause. That combined with the patient history makes the conclusion fairly certain in many cases. These are results that are seen with many different types of trauma, not just neck manips, but also whiplash, falls, etc.. It's interesting that it's in the under 45 age group that the statistics raise eyebrows, because these are the ones who shouldn't be getting them. They are the ones with great ROM, strong supple arteries, strong musculature, little to no significant pathologies, no vertebral foramen occlusion because of degenerative arthritic changes, no bone spurs to rip the arteries, etc.. The ones who should be at most risk for getting a traumatic VAD from a neck manipulation are the aged with their arthritic changes, brittle and thinning arteries, poor ROM, etc..


 * I have some theories for why this is, just based on basic knowledge of the biomechanics of the neck, pathology, the aging process, and actual practice by PTs and probably by many chiros. The actual incidence in the aged should be higher than younger people because of the above named factors, but the VAD statistics get drowned and pushed lower because of other factors that cause strokes in the older group, and there are many other causes than VAD. VAD figures as a smaller piece of the statistical pie chart. Older people are also less active and don't crank their necks around as much. Also PTs are taught not to manipulate the necks of older people. One is taught to be very cautious, and I suspect that many chiros are familiar with this precaution and use more gentle methods like Activator, which actually moves nothing. Therefore we don't see VAD in that age group as much. Those are my thoughts on the subject. We can't really use them, but in the absence of hard facts, and we are indeed dealing with an area with little understanding, one has to develop working hypotheses and extrapolate from what we do know so one doesn't endanger patients. -- Brangifer (talk) 09:03, 16 January 2011 (UTC)