Talk:Vertebral artery dissection/Archive 4

Suggestion by Byerssm
I suggest revision of the following paragraph in traumatic:

"Vertebral artery dissection has also been reported in association with chiropractic and other forms of neck manipulation.[7] In hospital-based studies this was the underlying cause for 16–28% of cases,[1] but it has been suggested that the true figure may be higher and that there is significant under-reporting.[7] Reports of the association are of weak to moderately strong quality,[8] and many of the reports have methodological flaws.[6][8] It has been suggested that the relationship is causative,[7] but this is disputed by proponents of these treatment modalities,[7] who believe that the dissection is probably already present before people seek treatment.[9]"

For the following reasons: 1. It includes biased undertones referencing chiropractors when many healthcare providers preform cervical manipulation including Physiatrists, Physical Therapists and Osteopaths. 2. It fails to adequately represent both sides of the research

I suggest the following revision:

"Research disagrees about the relationship between spinal manipulation] and vertebral artery dissection. Some systematic reviews have found weak to moderately strong associations between spinal manipulation and vertebral artery dissection [3][4][5][6] while others have failed to conclude any robust association between the two.[7][8][9][10] Many of the reports are criticized for having methodological flaws and any association at all is still unclear. [11][3][12] Still, many have suggested that the relationship is causative [13][14] and given this is true the best estimates suggest that as many as 5 in 100,000 to as few as 1 in 5,800,000 spinal manipulations may result in serious complications such as stroke from a vertebral artery dissection.[15][16][17] In hospital-based studies one suggests that spinal manipulation was the underlying cause for up to 16–28% of vertebral artery dissections [1] and that the true figure might be even higher due to significant under-reporting. [13] Proponents of the treatment modalities dispute any causative relationship [13] and believe that the dissection is likely already present before people seek spinal manipulation treatment given that the symptoms of a vertebral artery dissection include head and neck pain. [18][19]" — Preceding unsigned comment added by Byerssm (talk • contribs) 15:15, 4 August 2011 (UTC)


 * Have you read any of the above discussion, and attempted to understand why this area is so controversial? The opening sentence is very clear that it is not just chiropractic that is associated with VAD. Many of the sources you introduced were not secondary sources (see WP:MEDRS) and don't qualify as references. Please allow more time for other contributors to discuss your proposed changes. JFW &#124; T@lk  20:05, 4 August 2011 (UTC)

I have read much of the discussion and I feel like I have a pretty good handle on the controversy even before reading it. I'll try and take another look over it again since I might have missed something. I understand that the general consensus is that upper cervical manipulation should be approached with caution (particularly from governing bodies in healthcare). But this seems to be more of a discussion about whether upper cervical manipulation causes vertebral artery dissections. I feel the revision better captures both view points in answering that question (as experts remain divided on the subject). What would make the revision better? It's true that I did include both primary and secondary sources--how would including both detract from the article? And how does it add to the article to reference chiropractors specifically while leaving others unnamed? — Preceding unsigned comment added by Byerssm (talk • contribs) 01:09, 5 August 2011 (UTC)


 * I think primary sources should be disallowed entirely. Much of the above discussion focused on whether some of Ernst's reports qualified as secondary sources. Primary sources may be marred by methodological issues; it is the task of a secondary source to place the findings from a primary source in the right context. I refer you to WP:MEDRS, which goes into detail about these issues.
 * Most CSM is done by chiropractors, as borne out by the sources. We would need a high-quality secondary source to tell us which other fields do this also.
 * What would make the revision better? I'd much rather if you just left this alone, after the quagmire with QuackGuru. We run a serious risk of bloating the article with a relatively minor issue (see WP:WEIGHT). JFW &#124; T@lk  06:20, 5 August 2011 (UTC)

I do feel there is wisdom in not bloating the article. After your explanation I would still consider how referencing chiropractic specifically and leaving others unnamed adds to the article--maybe everyone should remain unnamed. I'll leave that to you as the guardian and leave the article alone as you suggested. — Preceding unsigned comment added by 64.143.114.90 (talk) 14:17, 11 August 2011 (UTC)

Lansley
British health secretary Andrew Lansley has repeatedly gone on the record describing his 1992 experiences with cervical arterial dissection causing a cerebellar infarct (e.g. BBC 2010). Troubling is the fact that I can't find a secondary source that actually says in so many words that it was a vertebral artery dissection that was the cause for his symptoms. Help in finding such a source would be appreciated. JFW &#124; T@lk  20:34, 3 March 2012 (UTC)

Cervical spine manipulation and stroke
The article currently contains a section that discusses the suggested association between manipulation of the neck and vertebral artery dissection. The section seems to lean towards a positive association and also gives the most weight to the source: Ernst 2010, referenced 4 times. The Ernst 2010 source has been criticised by some editors in the past because of its questionable methodology, however, WP:MEDRS has supported it's inclusion to date. I started this discussion because a new systematic review has just been published in the same journal, which examined higher-quality studies than the Ernst 2010 source. I believe that it might be time to re-word the current section on neck manipulation because the new systematic review concludes that there is insufficient evidence to either support or reject a strong association between cSMT and stroke. As this source may now represent the newest and highest-quality source on the issue, the theme of the section may have become inconsistent with our current knowledge base. It may also be that the wording is still satisfactory, but the sources could be updated. As this is a controversial issue, I have thought it best to start a discussion here. I look forward to comments and ideas.Puhlaa (talk) 04:44, 30 September 2012 (UTC)


 * What kind of re-wording do you think is required here? We are already using loads of guarded phrases. The first citation to Ernst could be reattributed to several other articles currently in the reference list. The only "hard" claims from Ernst are (1) that some believe that the relationship between chiropractic and VAD is causative and (2) that this is disputed by chiropractic proponents. This is not displaced by the new review, which affirms the conclusion from Rubinstein and Miley. By all means we could cite this additional report, but not to the exclusion of Ernst (who incidentally is cited and acknowledged in this article in reference #19).
 * Very nice, incidentally, of the Fonds de Dotation pour la Recherche en Chiropratique to give Graeme Hankey's group the money required to publish this report. JFW &#124; T@lk  20:44, 2 October 2012 (UTC)


 * Well, as I said above, I am not necessarily looking for new wording, perhaps only source-updating is required. What I have requested is a re-examination of the text in light of a new of a systematic review. I believe that it is such actions that will maintain a 'good article' status? As I am biased (despite best efforts), I often prefer other editors to comment on such controversial topics. I am aware that Ernst is referenced, in fact, it is referenced 4 times in the small section. If editors feel that Ernst 2010 (review of case reports) is the best source for this discussion of VAD (according to MEDRS), and/or deserves such weight, then lets leave Ernst 2010 alone, in all 4 mentions, and skip the new source altogether. However, If we are interested in keeping the article current, then as I said, perhaps we can look at how this new source changes things, even if that is just updating the references used. Puhlaa (talk) 21:39, 2 October 2012 (UTC)


 * With regard to your comment on funding (cause God knows that 'medical' research is all funded by independent bodies - and that 'medical' associations are dying to fund alternative research....I will bet that you arent that ignorant), it does not seem pertinent to this discussion, do you think? Does MEDRS offer criteria around who funded a source published in a respected medical journal? Perhaps I have missed it?Puhlaa (talk) 21:39, 2 October 2012 (UTC)


 * The funding (to cover open-access publication fees) was declared, I don't see that as an issue. It was, however only just published. While it mentions and cites Ernst, it doesn't really address it. So far it hasn't been cited in other publications. We can afford to wait a bit and see how the world reacts to its publication. We have wp:NODEADLINE and WP is wp:NOTNEWS. LeadSongDog come howl!  22:30, 2 October 2012 (UTC)


 * The comment on funding was not directly intended to cast aspersions, but simply as a wry observation. We can trust Graeme Hankey not to publish biased research in this area.
 * As for LeadSongDog's comment, I don't think we need a secondary source to support the relevance of this source, but I want to know from Puhlaa in which way it materially changes what we are saying currently. I am firmly in favour of keeping the article up to date.
 * Puhlaa, could you propose a change to the article so we can debate this, rather than discussing the suitability of the source? JFW &#124; T@lk  22:37, 2 October 2012 (UTC)


 * First, let me apologize. I mistakenly thought that Ernst 2010 (review of case studies) was the study referenced 4x in the VAD wiki article, now I realize that it is Ernst 2010 (perspectives) that is given so much weight in this wiki article. It seems to me that Ernst 2010 used in this wiki article is not a systematic review, but more of a narrative (called a perspective by the journal). As the Haynes source  is newer and of higher-quality than Ernst 2010, at minimum perhaps 1 or more of the 4 references to Ernst 2010 should be replaced with a reference to the new, higher-quality, source.
 * Replacing a reference is one end of the spectrum, on the other, heres an extreme proposal- I still also think that the conclusions of this new systematic review may not align well with the current text in the wiki-article. Where are there problems?
 * "but this is disputed by proponents of these treatment modalities" - this seems POV - It is more than 'proponents' that seem to dispute the association, in fact, any good scientist should challenge the claim until evidence is presented that supports the claim - note that this new source does not necessarily agree that there is an association and it is not a chiropractic, osteopathic or physiotherapy journal, but a clinical medicine journal.
 * "In hospital-based studies this was the underlying cause for 16–28% of cases....but may be higher" - According to the new review, no good evidence exists to support a major association yet, let alone causation (thus the studies reporting these figures are thus flawed/biased according to the authors). Moreover, it seems that over-reporting may be just as likely an issue.
 * "It has been suggested that this association is causative" - again, the new review concludes that 'Conclusive evidence seems to be lacking for a strong association' - if, based on the most recent and highest-quality analysis, we dont have enough evidence to conclude even a strong association, how can we rightfully be opening a discussion of causation in this wiki-article?
 * In my (biased) opinion, this section of the VAD wiki-article should represent our best and most current understanding of the relationship between VAD and neck manipulation. It seems, based on the new systematic review, that our current understanding is: "Vertebral artery dissection has also been reported in association with some forms of neck manipulation (refs). There is significant controversy about the level of risk of stroke from neck manipulation (refs). At this time, conclusive evidence does not exist to support either a strong association between neck manipulation and stroke, or no association and no accurate risk-benefit analysis has been published (refs). Until more evidence is available, a cautionary principle is most commonly suggested for therapist who apply this procedure (refs)." I think that this would be an acurate and NPOV approach to this issue, based on the summation of our current literature. Note that I have not suggested which references be used/retained or discarded. This proposal is to reduce the weight of all of the previous, biased studies (according to the new review) and focus the article's text on the newest and best science.Puhlaa (talk) 23:20, 2 October 2012 (UTC)

My cynical stance would be that if not for the chiropractic lobby, medical science would already have pronounced that an association existed and that CSM should be avoided. We have haggled over the present wording endlessly, with QuackGuru on one side and several chiropractic-based editors on the other. You are now asking for the section to be essentially rewritten, and you seem bent on completely purging the stance from Ernst, who offers a cogent argument for causality. We cannot now say that there is no causality, because there is a school of thought that maintains that there is causality. I therefore cannot support your proposed version for reasons of WP:NPOV. JFW &#124; T@lk  19:01, 3 October 2012 (UTC)
 * JFW, thanks for entertaining my challenge of the current text, please forgive me if I push a little more. You state (kind-of) that medical science would have already stated an association, if it were not for lobbyists, and yet the new systematic review, published in a mainstream medical journal, says that this is not the case? If you are suggesting that it is only lobbying that has refuted an association and not actual research, then the authors of this new review (which states that there is equal EVIDENCE for both 'sides') are wrong? This is, of course, irrelevant! What is relevant is what we know, not what we think. At the moment, the wiki-article spends the majority of the discussion of the controversy (what people think). That is: "Ernst says this, proponents say this" It seems that the article should focus more on what we know to be the case, as opposed to what Ernst, or proponents, claim to be the case. You will note that the new review ONLY discusses Ernst' source with regard to the controversy surrounding the suggested association, however, Ernst work is not considered high-enough quality by the new authors to warrant making any conclusions about risk or causation. Moreover, the new review gives EQUAL weight (as is given to Ernst) to this review, which is given no weight in our wiki-article. I do not suggest removing the reference to Ernst, only collapsing it into the mention of the controversy surrounding the issue. However, our wiki-article currently uses the Ernst source to make bold assertions. You claim that Ernst makes a cogent argument for causality, yet according to MEDRS his paper is a narrative and should be given a back seat to high-quality studies. If Ernst' viewpoint is dominant, or even prominent (besides just being anti-chiro rhetoric), then why does a mainstream journal publish a systematic review that suggests otherwise? What if our wiki-article mentioned the controversy and provided the sources (as does the new review), but keeps the majority of the text focused on the facts - this is what I believe that my proposal offers. As a final question, based on an examination of all of our sources on the subject, which would MEDRS say are the highest quality? These should be given the most weight, according to policy. I am sorry that so much effort was put into writing what is currently there, but this should not be grounds for failing to embrace continued change with new info. Is it safe to say that you disagree that the new source contradicts the claims of Ernst? Puhlaa (talk) 20:49, 3 October 2012 (UTC)


 * Ernst argues that the criteria for causality have already been met based on the current data; this is a matter of epistemology. I don't think the recent review displaces the crux of that argument. A journal is fully within its rights to then publish a conflicting study, if only to stimulate debate - I am surprised you're even using that as an argument.
 * I have made my point, and I don't think we're going to make any major moves without others weighing in. Again I am not opposed to adding the new study as a reference, but I am not prepared to use its findings as a justification to remove Ernst2010. JFW &#124; T@lk  22:18, 3 October 2012 (UTC)
 * Agreed that nothing can change until other editors weight-in. Again, in my interpretation of wikipedia policy, the question should be what is the best source and what does it say, this is what is given the most weight......or am I incorrect? Can we at least agree that Ernst 2010 is currently given the most weight in the section in the wiki-article and that the new source is a better quality source according to MEDRS? If we cannot agree on this, then perhaps the reliable sources notice-board is a better place to start? Puhlaa (talk) 22:56, 3 October 2012 (UTC)


 * No, Ernst is given some weight because the article contains some information that is useful in navigating the quagmire. I have already conceded that at least one citation instance could easily be replaced for another article, and I have agreed to include the source you have mentioned. You are showing your hand by trying to suppress Ernst2010. JFW &#124; T@lk  23:23, 3 October 2012 (UTC)
 * I think it rather unfair and ad-hominum that you claim I am 'showing my hand' by quoting wikipedia policy and how it applies to the predominance given to Ernst 2010. I 'showed my hand' directly in my first reply to you.... Note that I have never claimed that Ernst should be removed, I have only suggested that it be given the weight it is due consistent with policy. Clearly I disagree (and so does policy) that Ernst 2010 should be the predominant source used in the article, when a newer and higher-quality source is available. Changing a citation is not really a concession on your part, it is the bare-minimum demanded by policy (and may be all that is possible at this time).
 * What I am looking for is the best way to make sure the article is consistent with policy and represents our current knowledge base. Here is another, less radical, proposal: Change 1 or more of the refs to Ernst 2010 and replace with neew source AND What if we change this section- "Reports of the association are of weak to moderately strong quality,[8] and many of the reports have methodological flaws." and instead mention the conclusions of the new review, as the new review deals directly with this same content and replaces the sources currently used here. Do you think there is any value in also including a mention that "no accurate risk-benefit analysis has been published", as is concluded by the new review. Puhlaa (talk) 23:31, 3 October 2012 (UTC)


 * You have suggested a new version for the section that does not mention the POV from Ernst2010 (that the Bradford Hill criteria for causation have been met), which amounts to de facto suppression. If you can guarantee that this perspective is included, I see no problem with working the new review into the section (although Miley et al already say something very similar).
 * The point about the absence of risk-benefit analysis is not really something we should discuss in this article but in the article about CSM, because this article is not the place to discuss the benefit of CSM (absent according to mainstream medicine). JFW &#124; T@lk  06:51, 4 October 2012 (UTC)
 * I believe that the new review can replace the older reviews by Rubinstein and Miley without violating policy, as the conclusions have not changed significantly, it is more the tone of those conclusions that seem more balanced in the new review. I believe that this change in tone reflects the mainstream acknowledgement of the fact that there is not more, or better-quality evidence, for either side of the debate.
 * I accept and agree with your analysis of the risk-benefit discussion.
 * What are your thoughts on this sentence: "In hospital-based studies this was the underlying cause for 16–28% of cases....but may be higher" - This seems highly biased towards an association. To include this sentence thus seems to give more weight to one side of the debate, which is contradictory to the findings of the new review. We currently qualify that these studies are methodologically flawed, however, this fact will be removed in favor of the new reviews conclusions which, provide a much more balanced perspective (equally weak evidence for both sides) rather than a view that is critical of only one side or the other.Puhlaa (talk) 19:50, 5 October 2012 (UTC)
 * Why not describe the changing state of the research as a timeline, rather than eliminating the old source? Be— —Critical  22:51, 5 October 2012 (UTC)
 * Thanks for your comment Becritical! However, I don't know if presenting a timeline is appropriate. MEDRS asks us to update literature with newer and higher-quality research to prevent older and biased research from getting too much weight. Some of the older research here makes biased conclusions due to 'flawed' methodology (according to the new review); this is my concern over these 'hospital studies', where flawed methods produce radical results that may not be correct according to newer and higher-quality research. For example, the older hospital studies say ~20% of strokes seen are from neck adjusting; whereas, the new review says that only 2 studies exist that are of moderate-quality to assess the relationship and neither of them were those hospital studies. I really feel that this section should reflect our complete lack of answers on the topic. Right now I feel that the section makes it seem like we do have answers (ie. that cSMT causes stroke) and then there are some counter-arguments thrown-in. Would you be willing to offer a unique proposal for text that we can work-together on to get right? I still think the section needs change to better and more-fairly reflect our current understanding, it is just a matter of ensuring that we do it right according to policy. Perhaps you would also comment on my challenge that the section does not accurately reflect our current understanding? Jfdwolff suggests that this new review does not change anything, so I wonder if it is just my personal bias that is making this section in our wiki-article seem so unbalanced? Puhlaa (talk) 00:44, 6 October 2012 (UTC)

I don't really have the hours it would take to form a proper opinion on this. But, Am I right in saying


 * Ernst is used as the primary source for the text there now.
 * Ernst did meta-analysis of the available studies to form his conclusions.
 * Ernst is considered a reliable source.
 * The new Journal of Clinical Practice source is an equally reliable source.
 * The JCP source uses many of the same sources as Ernst, but evaluates the reliability of the studies.
 * The new JCP source found that some of the studies are of poor quality.
 * The new JCP source thus disagrees with Ernst, saying that conclusions cannot be drawn due to poor study quality.

This is as I understand it without doing research. Can you confirm or deny? Be— —Critical 01:28, 6 October 2012 (UTC)
 * Your assessment is VERY close! The only things that I would change in your description of the issue is that Ernst2010 (currently the primary source used) is NOT a meta-analysis, or even a systematic review! It is a narrative review that uses Hill's criteria for causality to suggest that a causational relationship exists between cSMT and stroke. The journal calls it a 'perspective' . Thus, according to MEDRS, the new review is higher-quality than Ernst2010. Second, the new review found that out of everything that exists on the topic, only 2 studies were considered moderate-quality, everything else low-quality. The 2 moderate quality studies found opposite outcomes; one says there is an association, one says there is no association.Puhlaa (talk) 01:39, 6 October 2012 (UTC)
 * Oh, now I'm remembering why I left this article some time ago... it was Quack Guru. Didn't he get banned?  If he is going to appear here, I'm gone.  Be— —Critical  02:15, 6 October 2012 (UTC)
 * I also did not participate in the last discussion of this article for the same reason. I think his ban is over by now, but havent seen him in well over a year. I hope to keep things civil here, so that multiple editors will contribute their perspective - to give a better result. When things get ugly, no one wants to offer their perspective and the article suffers.Puhlaa (talk) 02:27, 6 October 2012 (UTC)
 * JFW says above that Ernst makes a cogent argument for causation. I don't dispute this, but two points: per MEDRS aren't we supposed to go with actual science over augmentation, and second my memory from before is coming back and I seem to remember Ernst expressed extreme dislike of this subject.  So as a source he could not be considered neutral even if his feeling is justified.  I'm not arguing that he be eliminated from the article, but it seems like a description of the debate or process is in order here.  JFW's belief that lobbying has kept people from coming to a conclusion on the subject needs support if it is to influence our text.  I'd like to hear JFW's view on whether the new source is of greater of lesser quality than Ernst per MEDRS.  If it is of greater quality, let's give a historical rundown of what's been said, and expound more on the newer analysis than on Ernst.  But keep Ernst as the starting point of the process, and note the need for caution.   Be— —Critical  02:38, 6 October 2012 (UTC)
 * I agree with your suggestion to wait for JFW; to review what we have discussed here and give his assessment of the 2 sources, per MEDRS. We all may need to discuss the fine details of your proposal for text, but yours sounds like a reasonable approach to me.Puhlaa (talk) 02:56, 6 October 2012 (UTC)
 * But he doesn't seem to be around. You might post this issue on a noticeboard.   Be— —Critical  20:00, 7 October 2012 (UTC)
 * It is the weekend, lets at least give it till Monday or Tuesday before we go to another forum. Would you be willing to propose some wording, under the assumption that the new source is higher-quality and we can work together on having something for JFW to comment on either way. Puhlaa (talk) 20:19, 7 October 2012 (UTC)
 * Having read over the new source material and proposed changes, I think that Critical and Puhlaa are both right in to include the new review. If there's any suggestions needed or a set of "third eyes" let me know.  DVMt (talk) 18:21, 8 October 2012 (UTC)

I really don't know enough to propose text, however I'll help edit and NPOV text if you propose it. Be— —Critical 16:09, 9 October 2012 (UTC)
 * I don't think the sentence "Reports of the association are of weak to moderately strong quality,[8] and many of the reports have methodological flaws.[6][8]" is neutral. Methodological limitations is more neutral that methodological flaws, in my opinion. And this information is unnecessary. The strength of the data has already been described. Low to moderately strong evidence would already, of course, mean that some studies were methodologically lacking strength. Biosthmors (talk) 18:08, 9 October 2012 (UTC)
 * Agreed, however, the sentence before it is also not neutral IMO (ie: the cause of 20% of strokes), as the study that reports these numbers is highly biased and methodologically 'limited' (according to the newest systematic review). Thus, I suggest we remove both sentences. As I have said above, I dont think that much is neutral in this section; It is all 'he said, she said' from each perspective of the controversy. This is why I am petitioning to remove the undue weight given to the weak studies that ad no value except to detail controversy, and focus the weight on the highest-quality science we have available (as per MEDRS). BeCritical- I will propose another draft for us to work on. Puhlaa (talk) 18:27, 9 October 2012 (UTC)
 * New proposal based on above discussion:
 * Vertebral artery dissection has also been reported in association with some forms of neck manipulation (ref: ?). There is significant controversy about the level of risk of stroke from neck manipulation (ref: 2012 sys rev). It has been suggested that the relationship is causative [ref: Ernst 2010], but this is disputed by proponents of this form of therapy, who believe that the dissection may already be present before people seek treatment [Ref: Neck pain task force]. At this time, conclusive evidence does not exist to support either a strong association between neck manipulation and stroke, or no association [ref: 2012 sys rev].
 * This proposal introduces the association, gives the most weight to the newest systematic review (as per MEDRS), but retains significant weight for Ernsts' 'perspective' paper and the counter argument by 'proponents'. Thoughts? Puhlaa (talk) 19:40, 9 October 2012 (UTC)
 * It looks fine to me but I'm not up to speed on the more subtle POV issues. Certainly, we should emphasize the most scientific and latest findings.  I guess that the effectiveness of neck manipulation is mentioned elsewhere, and I thought you had something about the cautionary principle which I thought was good.  A mention of the cautionary principle and the effectiveness of treatment might be appropriate.  Be— —Critical  14:54, 10 October 2012 (UTC)
 * I had previously included the risk-benefit issue and the idea for a precautionary principle; that is, the new review says no accurate risk-benefit analysis exists and Ernst says therapists should be cautious. However, JFW had expressed his concern that this was not the right article to discuss risk-benefit, or therapy, etc., as there is a spinal manipulation article that discusses the ideas. I am not necessarily opposed to adding these ideas, I was just trying to be consistent with some of JFW's previous concerns. Do you disagree with this sentiment and feel it is still worth adding? I am always open to discussion.
 * I also think this latest proposal is good. It removes the weight given to the older, more-biased studies in favour of the conclusions of the new systematic review. I have retained the critical perspective of Ernst and the rebuttle by proponents, that each rely on moderate-quality science. The section would then reflect the conclusions of the new systematic review, which indicates that there is equal evidence for both sides of the debate. Puhlaa (talk) 15:16, 10 October 2012 (UTC)

Apologies for my temporary absence and hence lack of response. Another editor has already removed some content based on Miley and Rubinstein. I am happy with an addition based on the Haynes source, but I will not accept erasure of Ernst's view that criteria for causality have been met. JFW &#124; T@lk  15:45, 10 October 2012 (UTC)
 * I think the question here is whether that view is still notable given that an actual scientific study has been done which does not support it. I can see using non-scientific literature in the absence of scientific literature, but opinion or argumentation should take a back seat or not be included per WEIGHT when there are scientific studies available.  So I assume there there is discussion of this somewhere above which established Ernst's notability in this new context.  Be— —Critical  16:50, 10 October 2012 (UTC)
 * I plead ignorance on the details here, but perhaps both are just opinion. Are you sure one is science and the other is not? I don't want us to ignore the richness of expert opinion (see NPOV and history) and perhaps create a new POV issue by being "textbook". Biosthmors (talk) 17:34, 10 October 2012 (UTC)
 * It is not so much that 'real research' has not supported Ernsts' perspective, based on the new review it is more that there is an equal body of evidence that supports the opposite perspective. This is why I am ok with maintaining the discussion of Ernsts' view, as long as it is balanced with the opposing arguement. I think that my proposal has offered this. Puhlaa (talk) 17:41, 10 October 2012 (UTC)
 * I thought JFW was disputing because he thought you erased too much of Ernst... I took his post as an objection, but perhaps I misinterpreted. Be— —Critical  20:55, 10 October 2012 (UTC)
 * Hmmm, perhaps I misinterpreted. I assumed that he hadnt read the newest proposal and was just making a general comment about what we are doing. In the most recent proposal I did not remove any of the text that was from Ernst 2010. Puhlaa (talk) 21:16, 10 October 2012 (UTC)
 * Well I don't see why you shouldn't put it into the article. If there are any objections I'm sure they will become apparent, but there isn't enough participation here and no objections.  So no need to wait.   Be— —Critical  21:12, 11 October 2012 (UTC)
 * OK, I have made the change. Feel free to edit if needed. Otherwise, lets see if anyone objects per WP:BRD. Puhlaa (talk) 00:48, 12 October 2012 (UTC)

Looks fine to me currently. Apologies for delays in responding. JFW &#124; T@lk  21:19, 14 October 2012 (UTC)

Here we go again
I've come late to this little exchange, but I don't think we need to say explicitly that the "[C]hairman of the UK General Chiropractic Council and the President of the British Chiropractic Association" are opposed to the link between VAD and chiropractic. This would give the impression that non-British chiropractors are not dissident in this matter. That is not the impression I am getting. JFW &#124; T@lk  22:41, 21 December 2013 (UTC)
 * I agree with Jfdwolff, as is evident by my previous attempts to revert the inclusion of the low level details. Puhlaa (talk) 23:14, 21 December 2013 (UTC)
 * Since the last edit, the text now says "...this is disputed by chiropractic proponents of this treatment modality", but this is grammatically incorrect; I suggest that it would be more appropriate to say:
 * "...this is disputed by proponents of chiropractic" OR
 * "...this is disputed by proponents of this treatment modality" Puhlaa (talk) 23:22, 21 December 2013 (UTC)
 * No response from involved parties, so perhaps there is no preference to how the grammatically incorrect sentence is fixed? I have fixed the sentence by restoring the previous consensus version for now (i.e., "...disputed by proponents of this treatment modality"). Puhlaa (talk) 02:35, 24 December 2013 (UTC)
 * No response only because I first see this. Will respond below. -- Brangifer (talk) 07:59, 24 December 2013 (UTC)
 * I disagree - the version you reverted was grammatically sound ("chiropractic" used as an adjective modified the noun "proponents"). There might be other reasons to revert that language, but grammar is not a sound justification. -- Scray (talk) 02:48, 24 December 2013 (UTC)
 * Scray, I believe that you are suggesting that the phrase "chiropractic proponents" could be written as "proponents who are chiropractors"; I can definitely see your perspective. I would suggest that "chiropractic proponents", as used here is actually meant to be short for "proponents of chiropractic"; I suggest this because this is the wording used in the source and when taken this way, the wiki text seemed repetitive. Puhlaa (talk) 03:51, 24 December 2013 (UTC)
 * To use "chiropractic" as an adjective for proponents would not give the full reality and would be less similar to the source's wording. Researchers like Walter Herzog is a non-chiropractic proponent of cervical manipulation who has produced much of the biomechanical research for the manipulation/stroke relationship. The most recent systematic review found insufficient evidence to suggest a strong association (or no association) between stroke & manipulation, and this study's corresponding author was also not a chiropractor. As individuals, they may hold no weight, but the issue is that more than just chiropractors question the causational relationship between manipulation and stroke - any good researcher would question the relationship, at least until there is sufficient evidence to indicate such a relationship. If an adjective for 'proponents' were to be added, I would suggest "some", as this is consistent with the source ("some proponents of...") Puhlaa (talk) 04:14, 24 December 2013 (UTC)

The fact that chiropractors are the ones who have always objected makes the need for inclusion of such wording quite necessary. We can't leave it hanging for readers to just guess. The sources (and history) also make this clear. Other professions, like Physical Therapists and MDs, have recognized the danger and made patient consent mandatory. Only chiropractors have been in denial. (Why we still refuse to include the largest studies, such as Di Fabio's, which clearly show the great preponderance of chiropractic involvement in injuries and deaths, is beyond me. Regardless of that fact, I, as a PT, have always urged caution by all professions, and I stopped using cervical manipulation entirely, since other methods are more effective, safer, and longer lasting.)

As far as Herzog goes, I'm not sure that he's a "proponent", but he was hired to defend the profession from lawsuits filed by patients and their surviving families. Until he and his lab were figuratively and literally "bought" by the Canadian chiropractic profession, he did objective work. Then he started doing agenda-driven (pseudoscience) work for them and their lawyers. I communicated with him before his involvement, and later was saddened to see such a change of a fine researcher when this happened. Doing biomechanical studies on a cadaver for this purpose, especially when actual, incontrovertible, cases with living and formerly living (until their "adjustment" killed them) patients showed that it is definitely possible to cause strokes in living people?? No, the opposition to admitting any possibility of actual causation is pretty much exclusively limited to chiropractors for obvious reasons. Their stance is exactly the same type of stance originally adopted by the tobacco industry, and for the same reasons: "Deny, deny, deny. Never admit." Any non-chiros who might doubt the causal connection are the exception which proves the rule. Whatever the case, our sources mention chiropractors, and we should mention them. A straight quote should do the job. -- Brangifer (talk) 08:30, 24 December 2013 (UTC)


 * BR, we dont use Di Fabio's narrative review for a few reasons; first, it is 15 years old and we have newer sources; second, it is not mentioned in any of the newer systematic reviews on the topic of manipulation and stroke; and third, it does not clearly show what you claim! Indeed Di Fabio found that only 2% of the cases of death were with a PT, but does not examine the relative proportion of manipulative treatments performed by PTs over that time period, so Di Fabio does not make any claim about relative safety. With regard to your use of the term 'pseudoscience' above to describe Herzog's work. You are claiming that this well-published biomechanist has become agenda-driven and you equate this to pseudoscience? Even if true, is this how we define pseudoscience? You were clear in that you want to include the word 'chiropractic' in this article; however, you were not fully clear how you would like to see it used. I have suggested that it would be incorrect to use it as an adjective for proponents, but I would be ok with using it as Ernst used it in his source (the relationship is disputed by some proponents of chiropractic) if this becomes consensus; is this what you are suggesting by a quote? Personally, I think that including the chiropractic profession here would be a coatrack for chiropractic and would disregard the fact that other providers use cervical spine manipulation besides chiropractors. For example, the newest secondary source says "Other health care practitioners, such as physiotherapists (5), osteopaths (6) and some medical practitioners (7) also provide cSMT.". Puhlaa (talk) 17:42, 24 December 2013 (UTC)


 * Thanks for redacting your comment, because that saves me from correcting misunderstandings. Don't feel bad about that, because my writing at times tends to ramble, so such misunderstandings can also be my fault. There are a few points I'll discuss:


 * The review by Di Fabio is far more comprehensive than any later reviews, and is of a different nature not covered by later reviews, which makes it forever relevant for all those studies it analyzed. No other study even comes close to this: "One hundred seventy-seven published cases of injury reported in 116 articles were reviewed. The cases were published between 1925 and 1997. The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases." It identifies providers, and even takes into account Terrett's partially correct concerns about mislabelling cases not involving chiropractors as being performed by chiropractors, so Di Fabio's methodology (using "Terrett's adjustments") is extremely generous and careful toward chiropractors. That's very good. As such, his statistics are quite accurate and reliable.


 * The importance of these statistics is to simply provide documentation, as the review is specific for the subject of this article. Let the chips fall where they may. Obviously chiropractors perform far more manipulations, so it is no surprise to anyone (except chiropractors, who consistently deny any possibility of potential harm) that they would figure higher than other professions. We need not perform any form of improper synthesis or draw any conclusions. We can simply note the study and some of the key findings. The graphs in the figures and tables are very interesting.


 * My comment about agenda driven research as pseudoscience applies generally. Agendas, such as religious (as in creation "science" research), political/professional during conflicts, and economic/greed driven research, tend to cloud judgment and impede the objectivity required for accurate research results. Whenever an agenda, such as the new demands (on Herzog's department, suddenly funded by chiropractic) by chiropractic lawyers to find results which would help them acquit chiropractors in actual Canadian court cases, one can seriously doubt whether we are observing real science or pseudoscience. Many of us were shaking our heads. Trying to compare a cadaver to living people is obviously of questionable value when dealing with the dynamics of circulation and living tissues.


 * Using "chiropractic" as both a noun and an adjective is correct. It's that type of odd word. Using the exact wording in Ernst's intro is problematic because it is strictly limited to claims by those two individuals. My wording (partially preserved by Jfdwolff) was more general, which is the case and still faithful to the whole source, and other sources. There is no coatrack problem, since, as you have mentioned, chiropractors perform the most manipulations, and failing to mention their opposition to any possible connection is a grievous sin of omission. As editor's we must not do that. We must follow the sources. We can fix that problem very simply by just mentioning that "this is disputed by chiropractic proponents of this treatment modality," (diff of Dr. Wolff's version). That's very simple and we can go on to edit other things.


 * The issue here is not who provides manipulation besides chiros, but who objects to mentioning a causative association. Those are two very different subjects. (The first is not directly on topic here, but in some situations could still be relevant to mention.) Our sources, as well as common sense and history, make it clear that chiros should be mentioned in that connection. MDs and PTs have admitted the danger of such a connection and taken proactive measures. The chiropractic profession is much like the tobacco industry in this regard - they dare not admit anything. Such an admission would have legal consequences, and it would undercut the huge reliance on cervical manipulation as a key treatment method.


 * So I propose we fix this issue and close this thread by just mentioning that "this is disputed by chiropractic proponents of this treatment modality," using Dr. Wolff's version. -- Brangifer (talk) 08:49, 25 December 2013 (UTC)


 * BR, Merry Christmas! Yes, I had to redact some of my last comment; I realized that you didn't claim what I originally thought you had claimed. We will have to agree to disagree on the relevance/usefulness of Di Fabio's narrative. With regard to this thread, there is no rush to close it; I would at least like to hear back from involved editors like jfdwolff. I am not convinced their intent was to endorse the version you like and I would like to know their opinion on the proposed changes from the previous consensus version, simply to ensure chiropractors are specifically named.
 * I think we agree that chiropractors are the most notable critics of the causation claim and also that chiropractors are the most notable 'users' of cSMT. If consensus is to have our text exclude the possibility of other 'users' of cSMT (ie: physios, osteopaths, some MDs ), or others that question the causational relationship (ie: non-chiropractor scientists), because they are not notable enough, then I can accept this. However, as I mentioned earlier to Scray, I find the sentence you are proposing to be painfully repetitive. If DCs are the most notable critics of causation AND the most notable 'users' of cSMT, then to me, your proposed text: "this is disputed by chiropractic proponents of this treatment modality" sounds like: "this is disputed by chiropractic proponents of chiropractic". Why not just shorten it to "this is disputed by chiropractors", or, as I had suggested above, follow the actual source and state "this is disputed by some proponents of chiropractic". While I have suggested that a mention of the chiropractic profession may be coat-racking, I have not stated any resolve to keep it out; can we at least find a less repetitive way to state that chiropractors disagree, if that is what we want to say? Puhlaa (talk) 20:53, 25 December 2013 (UTC)


 * We must follow the source: "this is disputed by chiropractic proponents of chiropractic". Vague text is not following the source.  QuackGuru  ( talk ) 21:24, 25 December 2013 (UTC)


 * Happy Holidays to everybody! I hope you've all had a good time with family and friends. Yes, I'm basically just interested in "stat[ing] that chiropractors disagree". (For the sake of this thread, the question of "who performs neck manipulation" is irrelevant.) It's just a matter of documenting the primary "disputers" of a causal connection between neck manipulation and VAD. The sources document that it's primarily chiropractors. Dr. Wolff shortened my version by removing the names of the specific chiropractic leaders, leaving this version:


 * "There is significant controversy about the level of risk of stroke from neck manipulation....It has been suggested that the relationship is causative, but this is disputed by chiropractic proponents of this treatment modality,...."


 * While I don't understand the last part of the sentence in the way you do, we could shorten it as you suggest. Here's what that would look like:


 * "There is significant controversy about the level of risk of stroke from neck manipulation....It has been suggested that the relationship is causative, but this is disputed by chiropractors,...."


 * That is still faithful to our sources and does the job even more simply. Oftentimes, simple really is better! -- Brangifer (talk) 00:35, 26 December 2013 (UTC)

Notable cases
Is it really a good idea to turn this medical article into a place for "Notable cases"? This is all sourced to popular press coverage. Where does this stop? I see this type of material as very relevant in each individual's biography, but not here. What are your thoughts? -- Brangifer (talk) 03:59, 28 November 2014 (UTC)
 * I think your suggestion is a good one.... they belong in the biography (if there is one). Regards, Ariconte (talk) 04:37, 28 November 2014 (UTC)  .... I removed the section, hopefully not upsetting anyone too much.... can be reverted and discussed some more if wanted. Regards, Ariconte (talk) 04:46, 28 November 2014 (UTC)
 * Sometimes a few cases are notable such as that of Lou Gehrig and ALS. MEDRS compliant sources are not needed when documenting who had what disease. I am okay with the popular press for this. I think we should however keep the bar fairly high for inclusion Doc James  (talk · contribs · email) 05:01, 28 November 2014 (UTC)
 * I agree that MEDRS isn't always necessary for this type of thing. My concern is that this section could become a dumping ground and include cases which don't really build any knowledge of the subject. Lou Gehrig and ALS are intimately tied together in the USA, so a mention there is quite logical.
 * I think we need some type of logical connection here. Just the event or mention of a notable person getting a VAD isn't significant enough for mention here. Also the case of cricket batsman Phillip Hughes can confuse people, as it says something about only 100 cases. That is very confusing. VAD is relatively rare, but much more common than that, but it's uncommon for it to lead to a "subsequent subarachnoid bleed". It more commonly leads to blood clots, which, because they form over days, can later (sometimes over a month later) suddenly loosen and travel directly to the brain, causing a stroke. In Canada the risk of stroke was rated at 500% following cervical manipulation, and in California it was 600% increased risk, all compared to figures from strokes not associated with any cervical manipulation. User:Doc James and User:Jfdwolff can correct me if I'm wrong.
 * My point is, we shouldn't include any case which can be misleading, simplistic, or not serve any special purpose in explaining the nature of VAD or increasing knowledge of VAD. I'm open for including special cases which serve these needs. -- Brangifer (talk) 06:24, 28 November 2014 (UTC)
 * I often give way to these sections simply as an effort to stop people from continually adding this content to the wrong spot. Doc James  (talk · contribs · email) 09:15, 28 November 2014 (UTC)


 * I support "Notable cases" sections if there is some evidence that a famous person's case has led to a widespread awareness of a condition (e.g. as with Lou Gehrig, and Michael J Fox and premature Parkinson's disease). While it is quite early to judge, I think there is sufficient news coverable to support the inclusion of Hughes' case.
 * Unfortunately I have never been able to find a good source for the reasonably well known case of Andrew Lansley (UK politician) who had a cerebellar infarct after sustaining VAD playing sports.
 * Perhaps we need to talk about more stringent criteria on WT:MEDMOS. Again. JFW &#124; T@lk  12:16, 28 November 2014 (UTC)
 * Sounds good. BTW, has any information been released from x-rays, CTs, or MRIs about whether the blow caused a fracture of the upper cervical vertebrae, or was the blow strong enough to simply amount to a powerful "spinal adjustment"? I'm interested in the sequence of symptoms he developed. -- Brangifer (talk) 15:30, 28 November 2014 (UTC)

CADISS
I missed this result, but it contributes little. 10.1212/WNL.0b013e318264e36b JFW &#124; T@lk  08:11, 15 May 2015 (UTC)