Wikipedia:Mediation Cabal/Cases/2010-08-23/Chiropractic

Where is the dispute?
Chiropractic, Talk:Chiropractic (archive 31) (a LOT to read but necessary to completely understand the nature of the dispute), Talk:Chiropractic, User talk:Ocaasi, User talk:QuackGuru (a search of QuackGuru's edit history is required)

Who is involved?

 * User:QuackGuru
 * User:Ocaasi
 * User:Silver seren
 * User:Javsav
 * User:Jmh649
 * User:Sir Anon

What is the dispute?

 * Revert warring - most edits get reverted
 * Reliability of sources (particularly medical sources)
 * Balancing different viewpoints and studies
 * Usage of terms such as "unsubstantiated claims"
 * Constant appeal to policies, over substantive discussion or attempts at consensus
 * Use of WP:ASF to state as fact or to add attribution, particularly on controversial statements
 * Assumption that nearly all in-line attribution is an attempt to undermine sources
 * Scientific or skeptical POV vs neutral or encyclopedic POV
 * Accusing editors of violating or ignoring policy even if they dispute the policy's application
 * Repetition of claims rather than explanation of claims
 * Adversarial/Prosecutorial editing environment, seeking to 'prove' editors wrong rather than focus on discussion and improvements

What would you like to change about this?
Need to stop revert warring, need to remove the emotion and personal comments out of discussion, need structure to discussion.

How do you think we can help?
Help a structured and constructive discussion take place, possibly help come up with compromises in terms of content. Looks to me like a few of the parties involved have strong ties to the subject and have strong opinions, there needs to be a neutral opinion on the sources and phrasing from someone who is neither a Chiropractor nor a Doctor.

Mediator notes
I am conflicted on this case, but will enter a note in the hopes another mediator will arrive. Hipocrite (talk) 13:53, 7 October 2010 (UTC)

I'm working on reading all the material. All involved can contact me via email - dorothybaez@yahoo.com

Dorothy Kernaghan-Baez (talk) 22:34, 28 November 2010 (UTC)

Administrative notes
LTC b2412 Troops Talk MedCab Talk? 09:56, 7 February 2011 (UTC)

Scientific vs Neutral POV
The scientific fact is the neutral POV. TheThomas (talk) 11:30, 13 November 2010 (UTC)

Relevant discussion
Mediator, this is the dispute which was the final trigger to start the cabal, after a month of arguing, from the talk page archive. This cabal was started over concerns of the safety of chiropractic and how it is portrayed on the page, particularly the risk/benefit. Please read and consider carefully. Thanks!! More can be found here Talk:Chiropractic (archive 31) --Javsav (talk) 13:44, 18 September 2010 (UTC)

I guess the most relevant information I can give is that Chiropractic is not effective medicine, and is thus more likely to harm than help, but is not commonly very harmful physically. It is legal to practice in the U.S., due to a legal technicality in the 1800s, and does have active areas of study. The average Chiropractor, or Doctor of Medicine for that matter, does not have enough scientific training to realize they are not practicing effective medicine. Chiropractors they often sell products considered to be pseudoscientific. Anyone entering the fray should know these things as facts.TheThomas (talk) 11:40, 13 November 2010 (UTC)

== Proposed edits to Safety ==

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


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


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


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

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

Comments

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

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

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

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

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


 * Assess evidence quality

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

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

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

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

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

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


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

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

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


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


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

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


 * Uptodate has a great overview:

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


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


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

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


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

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


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

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

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


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


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


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


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


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


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


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

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


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


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

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

--Javsav (talk) 05:04, 18 September 2010 (UTC)

I realise now that you may have already read that, but I posted it before I added the archive 31 link to the "Where is the dispute" heading --Javsav (talk) 21:16, 18 September 2010 (UTC)

Editing environment

 * I wouldn't really call it revert warring - basically, any time Ocaasi or I try to add something to the page to give it a more neutral point of view, QuackGuru reverts it without discussion, and when asked why he responds with misinterpretation of WP:MEDRS, WP:ASF etc. At no stage have Ocaasi or I reverted anything that QG has added to the page. I realise that I have made a few rash comments on the discussion page in the heat of the moment which I regret. -Javsav (talk) 13:16, 26 August 2010 (UTC)


 * It's basically a hostile editing environment. Attempts to address text are met with repetitious policy interpretations about which there cannot be a difference of opinion without the subsequent accusation that opposing editors wish to "ignore" policy altogether.  It's hard to tell what the policy actually suggests, because it is interpreted in such a strict and I suspect biased way, one which backs up QuackGuru's consistent but scientific/skeptical point of view.  He might be right on several points, but his approach towards consensus is pretty much non-existent.  Occasionally, if he sees significant displeasure or privately considers an argument, he'll accept a compromise but only if he must.  This approach creates an adversarial atmosphere and has a baiting effect, drawing editors who are generally unbiased to be more contentious or pov-pushing than otherwise.  An adversarial process can work in some situations, but it can also deflect and exhaust the presentation of opposing views.


 * I have a hunch that QuackGuru really thinks he's right and sees other editors as actually harming the article while misleading readers--that he's the embattled one, trying to fend off hordes of pro-Chiropractic POV pushers. What I'm not sure he realizes is that his response further engenders enemies and unfairly assumes that anyone who goes against him needs to be battered away. Also, it bears repeating that Wikipedia is not the place to right great wrongs, and I don't think QuackGuru's outlook on Chiropractic is as firmly or obviously held by the broad medical community as he sometimes wants the text to suggest.


 * We need some serious and sophisticated opinions about both policy and medical sources, especially from potentially underweighted chiropractors, NGOs, and less prominent but nonetheless reliable studies. Finally, some attention to ASF and WEIGHT are necessary to check the article for bias in light of all sources, particularly to achieve a neutral rather than  a skeptical point of view. Ocaasi (talk) 18:34, 26 August 2010 (UTC)


 * I was only involved for a short while in the discussion and then disengaged myself from it as I saw that there was no way to have a productive discussion with QuackGuru. Originally, I went to the page to weigh in on the proposed changes to the lede and other sections that would balance the new systematic review with other viewpoints on the topic. However, QuackGuru was vehement about the systematic review, feeling that it was the only reference that was needed and that, if we didn't have another systematic review with an opposing viewpoint, that we couldn't use any other references with other viewpoints. He continually requested an explanation on how the other references met the MEDRS guidelines. I took my time to explain how each and every reference met MEDRS by fitting either under the Biomedical journal section or the Scientific organization section. Together, it was adequate to show other viewpoints that were slightly countering to the systematic review, but not directly countering it, of course.


 * However, QuackGuru responded yet again with MEDRS and MEDASSESS, saying that the references were not good enough. I tried once again to explain things to him, but to no avail and to be presented with yet another repetition of the same argument. So, I disengaged from the discussion and haven't gone back since, but it is of my opinion that QuackGuru is far too attached and opinionated toward this systematic review and that he should engage more with the other users involved and not just repeat the MEDRS policy over and over again. His methods are extremely non-productive and he has been actively stalling and reverting changes to the article, as the others above have noted. Without any real discussion on the talk page, this is really not acceptable. Thank you for taking the time to read this. Silver  seren C 18:47, 26 August 2010 (UTC)

NPOV, ASF, and WEIGHT
From the looks of it, this is a simple case of confusing NPOV with Logical POV, that is, even though certain elements of chiropractic may believe that duck liver diluted 10400 times will cure the common cold, which is scientifically ludicrous, we cannot say that it is ludicrous without scientific backing. What we can say is that such beliefs are not supported by medical research. We cannot however, simply dismiss them without reason. In other words, we do not simply offer up the claim without rebuttal, but we do not offer up rebuttal without reasonable evidence. Remember, Wikipedia is first and foremost an encyclopedia, a collection of fact, and fact must stand up to scrutiny. (I'm an MD) Ronk01   talk  17:39, 1 September 2010 (UTC)
 * Agree with Cochrane saying there is no evidence of benefit for manipulation of the C-spine. Any risk means that the risk / benefit ratio is against the performance of this procedure. Doc James  (talk · contribs · email) 17:56, 1 September 2010 (UTC)
 * Dilution of things is homeopathy, not chiropractic.--Anon 02:10, 2 September 2010 (UTC)
 * I just assumed he was using homeopathy as an example not saying that chiropractors do homeopathy. Doc James (talk · contribs · email) 04:16, 2 September 2010 (UTC)

Ronk, you obviously haven't read the talk page. We are just trying to add sources to balance the discussion, and they are RELIABLE sources, such as WHO statements. Furthermore, they weren't regarding the efficacy of chiropractic treatments but the SAFETY. I'm also a medical student but I don't like it when I see pages that have a very unbalanced POV -Javsav (talk) 17:45, 11 September 2010 (UTC)
 * Well, in terms of safety issues in Chiropractic, beyond keeping patients from actual medical care, true dangers are rare (cervical manipulation can be dangerous, I actually treated a patient during my residency who nearly died from one such adjustment). Non-cervical spinal manipulation, while little more than placebo is mostly harmless. Ronk01   talk  01:41, 13 September 2010 (UTC)
 * Ronk, as a person who is interested in medicine, alternative medicine, and health in general, I really am interested in your opinions, but I don't see how they can help with the issues of this article. The questions we're asking have to do with how policy applies to sources and whether the current state of the article reflects a fair and accurate balance.  Can we try to move towards some of the nitty gritty details and broader policy questions? Ocaasi 19:14, 14 September 2010 (UTC)
 * As you said Ronk, true dangers are RARE. Quack guru is defiant that the article must say that the risks outweigh any possible benefits, and refuses to let other studies which say the these dangers are rare disagree with his study, which is biased and lacks any risk/benefit formula, rather an opinion of the author -Javsav (talk) 04:33, 16 September 2010 (UTC)
 * Ok, the simple solution would be to have an expert review the study in question, and determine if it is acceptable. Policy on sources in non-BLP articles is rather hazy, though NPOV secondary sources and peer-reviewed medical articles are nearly always acceptable. Ronk01   talk  18:57, 18 September 2010 (UTC)
 * There is talk page consensus for editors to follow MEDRS. A few editors prefer to include unreliable references to argue against recent reviews. See Talk:Chiropractic.
 * Per MEDRS: "Look for reviews published in the last five years or so, preferably in the last two or three years. The range of reviews examined should be wide enough to catch at least one full review cycle, containing newer reviews written and published in the light of older ones and of more-recent primary studies.
 * Within this range, things can be tricky. Although the most-recent reviews include later research results, do not automatically give more weight to the review that happens to have been published most recently, as this is recentism.
 * Prefer recent reviews to older primary sources on the same topic. If recent reviews don't mention an older primary source, the older source is dubious. Conversely, an older primary source that is seminal, replicated, and often-cited in reviews is notable in its own right and can be mentioned in the main text in a context established by reviews. For example, Genetics might mention Darwin's 1859 book On the Origin of Species as part of a discussion supported by recent reviews.
 * QuackGuru (talk) 19:14, 18 September 2010 (UTC)

You are right romp, that is the solution, and someone with a PhD in MEDICAL sciences from HARVARD and who runs a research centre has done so [|Critique of Ernst's review]. The only reason it is in chiroaccess is because they are the target audience for this critique. The website it is in is irrelevant given the author's status. Quack guru refuses to use this, for unknown reasons. And you can see how quickly he goes against your suggestion. Please comment on your thoughts --Javsav (talk) 21:39, 18 September 2010 (UTC)

-Hmm for some reason the direct link from Wikipedia wasn't working for me, only would work when I copied it in to the address bar.. weird. If you have the same problem here's a google search link, it's the first one that comes up (Death by Chiropractic: Another Misbegotten Review) [| Google search for critique of systematic review]Javsav (talk) 08:56, 19 September 2010 (UTC)


 * If there is a reliable review, then the review may be used, however, if there is no reliable review, the source can be used, but only with caution, and in a non-authoritative manner, unless claims are validated by another source. BLPs are very similar. Ronk01   talk  18:11, 19 September 2010 (UTC)
 * The point is that Ernst 2010 is the reliable review, published in the International Journal of Clinical Practice, an unimpeachably reliable source. Editors are trying to "debunk" its findings by using an opinion piece, which is not peer-reviewed and is solely published on a website that has no reputation in mainstream scholarly literature. Try comparing PubMed and Google Scholar hits for "International Journal of Clinical Practice" and "chiroaccess" to see the scale of the disparity. Javsav's novel assertion that "The website it is in is irrelevant given the author's status" flies in the face of WP:RS. It is one of the most blatant violations of WP:MEDRS that I've had the misfortune to see. --RexxS (talk) 19:32, 19 September 2010 (UTC)

The unreliable article does not pass RS. See Talk:Chiropractic. QuackGuru (talk) 19:31, 19 September 2010 (UTC)

Yes I have conceded that this is not a reliable source but had it been published in a peer reviewed journal it would have been and please take into light that it does raise some valid points -Javsav (talk) 03:12, 21 September 2010 (UTC)

MEDRS and MEDASSESS
As per WP:MEDRS only review articles should be used to address medical claims. Cochrane being one of the best sources of reviews usually hold more weight than the rest. I have only provided a quick review of the evidence and am not really involved in this dispute. Doc James (talk · contribs · email) 16:30, 31 August 2010 (UTC)
 * My addition was not a statement of any medical claims. It was a significant criticism of the quality of the Ernst study. It's fine quoting a study but you must not take each "reliable source" as gospel and disallow any criticism of it.--Anon 09:26, 1 September 2010 (UTC)

To help with mediation I started a discussion to get uninvolved editors to comment on the reliability of the references. See Wikipedia talk:WikiProject Medicine. QuackGuru (talk) 04:52, 15 September 2010 (UTC)

QuackGuru, there is no need to start a new discussion. The discussion is HERE, at this mediation cabal. Furthermore, you have started a discussion about effectiveness of chiropractic which was not what we were arguing about, we were arguing about SAFETY. You are clearly trying to sidetrack the discussion and the mediators focus. The focus of this mediation should be the discussions at talk chiropractic. Please stop trying to sidetrack the discussion. I don't have time for this nonsense, I don't have time for you ruining this mediation cabal. I am trying to study for my OSCES (Medical clinical examinations) and I have to come here to deal with you destroying this cabal -Javsav (talk) 04:43, 16 September 2010 (UTC)


 * One does not use poor quality sources to contradict high quality source per WP:MEDRS Doc James  (talk · contribs · email) 06:26, 15 September 2010 (UTC)

A WHO statement is not a poor quality source, and it was not a contradiction. On the reliable sources page, WHO is considered equivalent to systematic reviews. Stop repeating over and over that one does not use unreliable sources, the sources were NOT unreliable. --Javsav (talk) 04:47, 16 September 2010 (UTC)
 * We were not discussing a ref to the WHO we were discussing Chiroaccess. Refs to the WHO are present at least 5 times.  Doc James  (talk · contribs · email) 06:26, 16 September 2010 (UTC)

"It has required only the very rare reporting of these accidents to malign a therapeutic procedure that, in experienced hands, gives beneficial results with few adverse side effects." This is related to safety and is not quoted in the article, it was removed by QG --Javsav (talk) 04:58, 18 September 2010 (UTC)


 * "Chiropractic care in general is safe when employed skillfully and appropriately. Manipulation is regarded as relatively safe, but as with all therapeutic interventions, complications can arise, and it has known adverse effects, risks and contraindications."
 * "Rarely,[20] spinal manipulation, particularly on the upper spine, can also result in complications that can lead to permanent disability or death; these can occur in adults[21] and children.[149] "
 * "The estimates for serious adverse events varied between 5 strokes in 100,000 manipulations to 1.46 serious adverse events in 10,000,000 manipulations and 2.68 deaths in 10,000,000 manipulations.[148]"
 * This type of information is stated in the article. Which editor do you think added most (or almost all) of this information to the article? QuackGuru (talk) 16:53, 18 September 2010 (UTC)

You may have added that last statistic but you refuse to let us use the Cochrane systematic review that the guidelines say we can use. "For the article we can't use the statistics about 1:400k to 1:2m that are from an older systematic review from 2002." and still, you refuse to use the aforementioned quote. And of course you would add those, they show the negative aspects of chiropractic-Javsav (talk) 19:05, 18 September 2010 (UTC)

This last one you have added doesn't make sense and must be changed. "The estimates for serious adverse events varied between 5 strokes in 100,000 manipulations to 1.46 serious adverse events in 10,000,000 manipulations and 2.68 deaths in 10,000,000 manipulations.[148]" 5 strokes in 100,000 manipulations? A stroke generally causes permanent disability or death, i would definitely consider that a serious adverse effect. So how then could it be 1.46 adverse events in 10,000,000 manipulations? I think you have misinterpreted the source and I am going to investigate it. -Javsav (talk) 19:38, 18 September 2010 (UTC)


 * The source says: "the frequency of serious adverse events varied between 5 strokes/100,000 manipulations to 1.46 serious adverse events/10,000,000 manipulations and 2.68 deaths/10,000,000 manipulations." QuackGuru (talk) 19:51, 18 September 2010 (UTC)


 * You wanted to use an old reference from 2002 against MEDRS for the statistics but I disagreed and used a recent review per MEDRS. Now that there are statistics in the chiropractic page like one wanted you are still complaining about it.
 * This reference for the statistics is from 2009 and is a systematic review specifically about safety. QuackGuru (talk) 19:36, 18 September 2010 (UTC)
 * This reference for the statistics is from 2009 and is a systematic review specifically about safety. QuackGuru (talk) 19:36, 18 September 2010 (UTC)

From WP:MEDRS: Use up-to-date evidence:...Look for reviews published in the last five years or so, preferably in the last two or three years. The range of reviews examined should be wide enough to catch at least one full review cycle, containing newer reviews written and published in the light of older ones and of more-recent primary studies....Prefer recent reviews to older primary sources on the same topic. If recent reviews don't mention an older primary source, the older source is dubious....These are just rules of thumb. There are exceptions:... Cochrane Library reviews are generally of high quality and are routinely maintained even if their initial publication dates fall outside the above window. - MEDRS says this review can be included. Additionally, the range of reviews must be wide enough to catch one review cycle, which means that Ernst's review can not stand alone and must be removed. Also it says to include recent primary studies. --Javsav (talk) 19:40, 18 September 2010 (UTC)


 * I did add the information on statistics from the 2009 safety review. The 2010 review can not stand alone and must be removed? There is talk page consensus to include the 2010 review. MEDRS does not say to use recent primary studies to argue against recent reviews. QuackGuru (talk) 19:51, 18 September 2010 (UTC)

The range of reviews examined should be wide enough to catch at least one full review cycle, containing newer reviews written and published in the light of older ones and of more-recent primary studies. This is why the Ernst review can not stand alone, because the range of reviews examined is not wide enough.

Did you not understand what I was saying about the 2009 safety review? A stroke is a serious adverse event, often causing death. So how could the number be 5 in 100,000 manipulations when serious adverse events are 1 in 10,000,000?

You didn't address what I said about the 2002 review. "Cochrane Library reviews are generally of high quality and are routinely maintained even if their initial publication dates fall outside the above window. It is a Cochrane Library review, as such the window is widened for it. --Javsav (talk) 19:58, 18 September 2010 (UTC)

I'm reading the paper now and I see what it is saying. It is saying from each study they looked at, the numbers VARIED between 5 strokes/100,000 (one small australian study which was a QUESTIONNAIRE - by the way, I'm Australian, and the chiropractors down here are far rougher than anywhere else in the world) to 2.68 deaths per 10 million manipulations. Basically all they are doing is looking at each study and stating the numbers, they didn't even average it out. As such the wording needs to be changed --Javsav (talk) 20:17, 18 September 2010 (UTC)


 * It was not a Cochrane review. It was a dated review from 2002 written by Stevinson C and Ernst E.
 * It varied between 5 in 100,000 manipulations and 1.46 in 10,000,000 for strokes/serious adverse events.
 * Averaging out the studies is conducting your own original research and a clear violation of WP:OR. When they didn't even average it out and you want to average it out, you trying to put words in the cited source's mouth. QuackGuru (talk) 20:27, 18 September 2010 (UTC)

Umm obviously I wasn't going to average it out, I am going to reword it --Javsav (talk) 20:28, 18 September 2010 (UTC)

By the way, averaging it out would not be OR, it would just be manipulation of data, but I don't have the time or energy to do it- Javsav (talk) 20:33, 18 September 2010 (UTC)

Well, it is unlucky for you that it was not a Cochrane review, because that means that the Ernst review is not allowed on the page as per MEDRS: "The range of reviews examined should be wide enough to catch at least one full review cycle, containing newer reviews written and published in the light of older ones and of more-recent primary studies." As such having only the Ernst review is violating MEDRS. -Javsav (talk) 20:58, 18 September 2010 (UTC)


 * Using a Cochrane review does not mean we should ignore other recent reviews because :The range of reviews examined should be wide enough to catch at least one full review cycle. We are not using only the 2010 review. QuackGuru (talk) 21:11, 18 September 2010 (UTC)

Regarding risk benefit, yes we are. In fact, in that very review, the author claims "this is the first review of its kind". The only other review you are using for safety is a 2009 review. That is not an old review in light of a new review, especially considering it was not about risk benefit. --Javsav (talk) 21:51, 18 September 2010 (UTC)


 * There are other references being used for safety and risk. QuackGuru (talk) 19:35, 19 September 2010 (UTC)

Reply to Sir Anon
Two reviews of published studies on chiropractic practices found a lack of good methodology in the studies that were examined.
 * Recent controversial edits/comments to Chiropractic/Talk:Chiropractic (reply to Sir Anon)
 * ASF violation when there is no serious dispute

This is attribution in the text and a violation of WP:ASF. The part "in the studies that were examined" is also editorializing which is a common problem on Wikipedia. "Two reviews of published studies on chiropractic practices" is still a violation of ASF whern there is no serious dispute. Which reference said there are "Two reviews of published studies" in accordance with WP:V. See Talk:Chiropractic. QuackGuru (talk) 17:50, 15 September 2010 (UTC)


 * Unreliable chiropractic literature failed RS

This sourced sentence was deleted from the Effectiveness section: "A 2010 systematic review found there is no good evidence to assume that chiropractic neck manipulation is effective for any medical condition. "

This direct quote did verify the claim you deleted. Without explanation for the second time you removed the above sentence, added duplicate material about risk-benefit that is from the Risk-benefit section, and added an unreliable source from ChiroACCESS. This unreliable article is not a response from a peer-reviewed journal or from an expert researcher on the subject of chiropractic.

Trying to "balance" Ernst's study like this is not good editing: "A 2010 review by Edzard Ernst focusing on deaths after chiropractic care stated that the risks of spinal manipulation "far outweigh its benefit".[23] The study received criticism in chiropractic literature, with one review calling it "blatantly misleading", citing a lack of risk-benefit analysis and the inclusion of deaths that were not related to chiropractic care.[114]" We shouldn't juxtapose peer reviewed literature with the opinions of chiropracters or chiropractic promotional articles. Of course chiropracters won't like a study that says that their practice may not be so safe. The reference is not even peer-reviewed or from a journal. References like this were removed a long time ago from this article. They were replaced with peer-reviewed literature per WP:MEDASSESS. Chiroaccess cannot possibly be considered a reliable source, and not even for the opinions of the author of the article, because they don't meet WP:SPS. See Talk:Chiropractic. QuackGuru (talk) 17:50, 15 September 2010 (UTC)


 * Unreliable references against MEDRS

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

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

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

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

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

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

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

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

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

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

Harvard Medical School, Boston, MA, USA.

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

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

Comment in:

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

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

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

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

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

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

Newer references and text from Chiropractic under Headache:

"A 2006 review found no rigorous evidence supporting SM or other manual therapies for tension headache.[131] A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.[132] A 2004 review found that SM may be effective for migraine and tension headache, and SM and neck exercises may be effective for cervicogenic headache.[133] Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SM.[108]"

This edit added more unreliable references. References from 1978 are not reliable because we have newer sources currently used in the article. These old references do not pass Identifying reliable sources (medicine).

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

Per MEDRS: "These guidelines are appropriate for actively researched areas with many primary sources and several reviews, and may need to be relaxed in areas where little progress is being made and few reviews are being published".

We should not relax the reference selection because there are currently plenty of sources on the topic of hand. There has not been little progress and there has not been a few reviews being published. In fact, there has been a lot of progress and there has been more than a few reviews on the topic. MEDRS is not a policy but for alternative medicine articles like Chiropractic editors have followed MEDRS.

Using dated unreliable references to argue against much newer high quality references like the 2004 Cochrane Database Syst Rev is against MEDRS. See Talk:Chiropractic. QuackGuru (talk) 17:50, 15 September 2010 (UTC)
 * Failed verification

The direct quote did not verify the claim "did not identify substantial benefits" per WP:OR or WP:V. So the text did fail verification. See Talk:Chiropractic. QuackGuru (talk) 17:50, 15 September 2010 (UTC)

QuackGuru, I don't know why you are talking about effectiveness, we never argued about effectiveness. We argued about one biased review by a biased author who said that the risks outweigh the benefits, and the study has been shown to lack any risk benefit analysis, rather an opinion by the author. To say in the lead of a chiropractic article that "The risks outweigh the benefits" which is how you had originally put it, is ludicrous. There is no need for you to be quoting extensive literature here. -Javsav (talk) 04:37, 16 September 2010 (UTC)
 * You do not have the authority to smear a review published in International Journal of Clinical Practice as 'biased'. The publication is peer-reviewed with a clearly-defined editorial policy. Contrast that with chiroaccess.com, which has no editorial policy and zero impact in the mainstream literature; even Google Scholar only finds 17 hits for it (against 1,860,000 for International Journal of Clinical Practice). PubMed says "Your search for chiroaccess retrieved no results". There is no serious dispute among reliable secondary sources about Ernst's review, and by WP:ASF, these are to be asserted as facts. Anything more than a note that criticism occurred is a violation of WP:UNDUE. --RexxS (talk) 23:08, 18 September 2010 (UTC)
 * No evidence of bias in either the review or the author has been provided. BTW the Cochrane collaboration also found no benefit from neck manipulation. Doc James  (talk · contribs · email) 23:12, 18 September 2010 (UTC)

Intro attribution
Question: If a systematic medical review concludes x, can x be 'simply asserted' per WP:ASF without attribution?

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 * If the systematic review is published in a recognised peer-reviewed journal with a reputation for accuracy and a defined editorial policy, then it is a reliable secondary source per WP:RS. If it is within the current review cycle for the topic, then it's views must be considered per WP:MEDRS. If there is no serious dispute with other similar reliable secondary sources, then it's findings should be "asserted as fact" (not attributed as if mere opinion) per WP:ASF. If multiple recent, reliable, secondary sources differ in their findings, then the views of each should be attributed and presented with a weight determined by their prevalence in the mainstream literature per WP:UNDUE. --RexxS (talk) 23:21, 18 September 2010 (UTC)
 * Would that hold even if: the research was overwhelmingly conducted by one individual (E.Ernst), that individual has an anti-CAM history which includes critiques of Chiropractic (Chiropractic: A Critical Perspective) as well as other forms of alternative medicine (Trick or Treat), if the systematic review was published within the last year, and if the findings were criticized by practitioners of Chiropractic? Again, not asking to exclude the study by any means, only to report it as the finding of a 2010 systematic review, or even less attributively, as "Current scientific consensus..." Oh, also, does ASF "prohibit" attribution in the case you described, or only permit its absence? Ocaasi 07:56, 19 September 2010 (UTC)
 * In a word: "Yes". Ernst did not conduct research; he conducted a review of the literature. The authority of a review does not depend on the number of authors, nor their credentials, nor their history, nor their affiliations (unless commentary on those exists in another high-quality source). Its authority depends primarily on our trust in the process of peer review and editorial oversight in the journal where it was published. Our convention here (as described in ASF) is to assert such findings as facts. Attribution is reserved for the cases where equal-quality reliable sources differ in their findings, or when a primary source offers a new finding not yet considered by the secondary sources in the current review cycle. In Wikipedia terms, attribution is a means of converting a disputable statement into the verifiable fact that X made that statement. It is misleading to use that device when no serious dispute exists. --RexxS (talk) 08:46, 19 September 2010 (UTC)

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1978 studies
Question: Can two older studies be directly incorporated into a section on treatment effectiveness per WP:MEDRS and WP:NPOV, if newer studies (including systematic reviews) have been conducted since?

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 * When making a medical claim, sources older than the current review cycle for the topic are superseded by newer reliable secondary sources and should not be included, unless they are being used to describe a historical overview of the topic, per WP:MEDRS. --RexxS (talk) 23:28, 18 September 2010 (UTC)

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VBA/stroke studies
Question: Are both sides of the VBA/stroke debate fairly represented per WP:MEDRS and WP:NPOV?

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Poor studies/need for further research
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Spine manipulation vs. Chiropractic
Question: Does the article distinguish between research on spinal manipulation and chiropractic safety in general (not all spinal manipulation is performed by chiropractors)? If research itself conflates the two, should the article comment on that? If critiques of research comment on it, but they are less reliable than the research (e.g. Published commentary vs a systematic review), can they be included?

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 * It should be remembered that chiropractic techniques are not the sole domain of chiropractors, and many parts of the world may have no requirement for 'accredited chiropractor'. It is true that not all spinal manipulation is performed by chiropractors; equally not all chiropractic techniques are spinal manipulation. It may be that the article would benefit for making such distinctions clearer. --RexxS (talk) 23:49, 18 September 2010 (UTC)
 * If research conflates the two, and a reliable secondary source comments on that, then the article can use that commentary. Drawing our own conclusions is prohibited per WP:OR. --RexxS (talk) 23:49, 18 September 2010 (UTC)
 * In a particular context, sources in Wikipedia are either reliable or not. There is no scale of reliability, as sources are either published in recognised, peer-reviewed media with clear editorial oversight, or they are not. However we do distinguish between 'quality' of sources, preferring secondary sources (reviews, meta-analyses, etc.) over primary (published case studies, etc.), and relegating "expert opinion" to cases where the author's reputation is demonstrably significant, per WP:PSTS. Primary sources may not be used to contradict secondaries, and criticism should only be included where it clearly represents a broad mainstream disagreement with the secondary, per WP:MEDRS & WP:RS. --RexxS (talk) 23:49, 18 September 2010 (UTC)

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WHO on Chiropractic
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The word 'critics'
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Attribution (ASF) on the number of studies
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Reliability of Ernst
Question: Ernst 2010, "Deaths after Chiropractic: A Review of Published Cases" is a review of 26 case reports. If one case report is considered anecdotal or 'less reliable', is a systematic review of case reports more reliable?

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 * Chiropractors have been criticized for decades for attempting to use case reports to support the efficacy of their treatments, and yet a critic has now used this very tactic to attempt to provide evidence for a lack of safety. Further, this review is being used to sum up the safety section of the Wikipedia article? This review is very weak evidence, and should be considered equivalent to a collection of case reports. It is not evidence for lack of safety, but a reason to do more real research. — Preceding unsigned comment added by 173.206.208.87 (talk)
 * The authority of any particular review lies in the quality and reputation of the publisher. There is no doubt that the International Journal of Clinical Practice is a highly regarded publication with a defined policy of peer review and editorial oversight. No editor on Wikipedia is qualified to substitute their individual opinion on a reliable secondary source for the process involved in publishing that source. Until such time as differing findings are published in an equally high-quality journal, it is disruptive to edit-war in an attempt to enforce that individual opinion against the global consensus that Wikipedia's policies enjoy. --RexxS (talk) 00:04, 19 September 2010 (UTC)
 * There is no doubt that the International Journal of Clinical Practice is credible, and that the case reports cited in Ernst' review are published works, thus not subject to opinion after the fact. That being said, the level of evidence that such a work represents is not an opinion, but is established in the literature itself. Case reports represent the lowest level of evidence, the review by Ernst is a collection of case studies, thus also represents the weakest level of evidence possible. As such, the impact of such evidence must be considered in the wikianswer article. To wrap up the safety section with the "findings" of a study that represents the weakest possible form of evidence is inacurrate, especially when it is placed and stated in a manner that is intended to refute much higher quality evidence that is presented before it in the same paragraph (safety). — Preceding unsigned comment added by 173.206.208.87 (talk)
 * There is no concept of "level of evidence" on Wikipedia. You need to point to where such a distinction is made in policy if you wish your view to have any credibility. Find a reliable secondary source that says that Ernst's review is weak evidence and your point is made for you. Without that, you are repeating only your own opinion, and I'd ask you to stop because you are disrupting the consensus-finding process. A secondary source, published in a quality journal is the highest quality of source in Wikipedia, and it is unhelpful to try to belittle it by comparison to another unnamed source. Specify which source you are referring to and discuss precisely why you think that other source disagrees with Ernst 2010. If it then becomes clear that equal sources differ in findings, then we can survey their prominence in mainstream literature and decide on due weight. That's the Wikipedia scheme for arriving at a consensus, and it needs to be followed. --RexxS (talk) 04:15, 19 September 2010 (UTC)
 * If there is no evidence of benefit from C spine manipulation ( which there is not ) any evidence of harm ( even of poor quality ) means that the potential risk out way the benefits. Thus goes risk benefit analysis. Doc James (talk · contribs · email) 02:45, 19 September 2010 (UTC)

"Ranking the quality of evidence Evidence-based medicine categorizes different types of clinical evidence and [1] them according to the strength of their freedom from the various biases that beset medical research. For example, the strongest evidence for therapeutic interventions is provided by systematic review of randomized, triple-blind, placebo-controlled trials with allocation concealment and complete follow-up involving a homogeneous patient population and medical condition. In contrast, patient testimonials, case reports, and even expert opinion have little value as proof because of the placebo effect, the biases inherent in observation and reporting of cases, difficulties in ascertaining who is an expert, and more." The review by Ernst presents all 26 incidents of death following manipulation in a single table entitiled: "Table 1. Published case reports of deaths after chiropractic treatments" As such, the review is clearly a list of reports which represent the lowest possible level of evidence. I fail to see how I am presenting my opinion on this matter as opposed to the reality of peer reviewed literatures use in evidence based medicine. If this does not adequately support the issue I have raised then I apologize for wasting your time again. 173.206.208.87 (talk) 11:45, 19 September 2010 (UTC)
 * I don't knnow whether or not there is a Wikipedia policy on levels of evidence, but it is a reality in the literature and cannot be dismissed in this highly controversial article. The best association I can make with Wikipedia to the concept of levels of evidence are found in the Wikipedia article entitled "Evidence Based Medicine", which states:


 * I would certainly agree that in many fields such as Law and Science, evidence needs to be presented in order to make a case; and the evidence may be weighed against many criteria by expert judges. But how would that work on "the encyclopedia anyone can edit"? You'd have "I'm an expert and I judge this evidence to be strong" vs "No, I'm a greater expert and I judge that evidence to be weak". We substitute expert judgement here with a reliance on the outside world to make the judgements for us. It is because we can identify and agree on a well-regarded publication with a good review process that we can surmount those problems. Evidence-based medicine illustrates the mechanisms used when a source is peer-reviewed prior to publication, but we would be foolish to think we are qualified to duplicate those ourselves. In the case of Ernst's review, we should not be trying to make our amateur detailed analysis of his methodology. If it is weak or flawed, then scholarly literature will make those points. You simply don't have anything to support your deduction that "the review is clearly a list of reports which represent the lowest possible level of evidence". If I were to say "the review is a well organised survey of several hundred pieces of research over a period of five years, with high quality analysis and selection, representing the highest level of evidence", then we'd be left with one opinion against another, and nowhere to go. But neither of us are qualified (on Wikipedia) to make such judgements. I merely say that "the review is a secondary source published in a journal we trust, and no other reliable source refutes it", which is demonstrable. Your view on Ernst does not rely on the mechanism of actual scholarly peer review (which does not criticise the work, as far as I can see), but on your attempt to use those tools yourself and arrive at your own conclusion. That is why I characterise it as your opinion. --RexxS (talk) 18:21, 19 September 2010 (UTC)

As such, I am still challenging the significance/quality of the Ernst review, as the review itself states that it is a review of case reports. All of the published works that are included in the review are listed in a single table entitled "Table 1. Published case reports of deaths after chiropractic treatments" If one case report is considered low-quality evidence, is a list of case-reports suddenly considered higher-quality evidence? 173.206.208.87 (talk) 22:51, 19 September 2010 (UTC) The above being said.... with further thought I can appreciate your view that it was published under the title of "review", and I guess this makes it legitimate until someone publishes a statement that supports my "opinion" that a list of case reports is not evidence. I will drop the issue. 173.206.208.87 (talk) 23:13, 19 September 2010 (UTC)
 * My apologies for continuing to challenge this issue, but I have been reading the MEDRS, and have found that it also states that: "Knowing the quality of the evidence helps editors distinguish between minority and majority viewpoints, determine due weight, and identify information that will be accepted as evidence-based medicine. In general, editors should rely upon high-quality evidence, such as systematic reviews, rather than lower-quality evidence, such as case reports, or non-evidence, (e.g., conventional wisdom)."

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Global differences of opinion (EU vs. US)
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Safety vs. risk assessment
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Neutrality in talk page section headers
Question: Should talk page headers be neutrally titled? Can an editor change someone else's to try to achieve better neutrality?

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 * Talk_page_guidelines: Keep headings neutral: A heading should indicate what the topic is, but not communicate a specific view about it.
 * Talk_page_guidelines: Section headings: Because threads are shared by multiple editors (regardless how many have posted so far), no one, including the original poster, "owns" a talk page discussion or its heading. It is generally acceptable to change headings when a better header is appropriate, e.g. one more descriptive of the content of the discussion or the issue discussed, less one-sided, more appropriate for accessibility reasons, etc. To avoid disputes it is best to discuss a heading change with the editor who started the thread, if possible, when a change is likely to be controversial.

Specific citations and article text: "Failed Verification", "Violation of ASF when there is no serious dispute", "Violation of MEDRS when citing the 2010 systematic review". They are generally QuackGuru's objections to edits, and he titles the discussion with his judgment, typically a final verdict of why something someone did is against policy.

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