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Sentence needing to be removed/revised?

"Death has occurred following chiropractic spinal manipulation, and the risks surpass its benefit."

The above sentence really seems more like an opinion than a statement of fact and might be worth removing or at least revising in some way. I followed the cited reference and met a dead webpage. Thoughts? —Preceding unsigned comment added by Alikaalex (talk • contribs) 15:44, 27 July 2010 (UTC)

The sentence is supported by the conclusions of the paper cited. The links given (one to an abstract, the other to a pdf of the whole paper) are currently working fine. I've rephrased it slightly to fit better with what it follows. Brunton (talk) 12:08, 3 August 2010 (UTC)

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

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

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

I changed mine to "However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or even fatal complications in rare cases, and the risks of manipulations to the neck outweigh the benefits." However, I agree that it is not the place to make this kind of statement. When I changed mine, Brunton's was: Chiropractic care is generally safe when employed skillfully and appropriately. However, spinal manipulation is frequently associated with mild to moderate adverse effects, with serious or even fatal complications in rare cases, and the risks outweigh the benefits." - what you have described as 'the current' was not what the current was when I changed it. I personally believe that the statement about the risks outweighing the benefits should be removed, but I adjusted it to make it slightly more fair. Javsav (talk) 03:58, 5 August 2010 (UTC)

Great. Obviously the point is not to compare dead drafts, but just propose options and come to a better consensus. If it's ok with you, I'm going to paste your new draft where the old one was, so it's easier to compare.Ocaasi (talk) 04:15, 5 August 2010 (UTC)

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

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

NPOV dispute: "the risks outweigh the benefits"

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

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

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

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

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

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

Argument for attribution

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

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

The WHO article goes further in disputing the perception that manipulation is inherently dangerous:

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

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

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

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

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

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

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

Argument for fact

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

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

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

Comments

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

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

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

• The review stated" The article is the first systematic review of all fatalities reported in the medical literature. Twenty six deaths are on record and many more seem to have remained unpublished." There is no serious dispute with any other review. The is no valid reason to ignore WP:MEDRS. Editors should not argue against MEDRS are judge the source or judge who wrote it as long as it was not written a chiropractic organisation. The source does explain the research anyhow. There is no serious dispute with any other review. See WP:ASF. QuackGuru (talk) 04:54, 7 August 2010 (UTC)

I tried a compromise but I still think it violated WP:ASF. There is no dispute with any other review. QuackGuru (talk) 05:02, 7 August 2010 (UTC)

1) I think your compromise ("a systematic review concluded") is *much* closer to what I would prefer. 2) Do you see my point about the difference between the data in Ernst's results and the argument in his conclusions? 3) Though I don't find it necessary, if I found another medical source which asserted a different outlook on spinal manipulations, would that change your stance? How narrow is the category for which an opposing view must fit: must it be based on a "systematic review"? It seems that medical claims are not excluded from serious consideration solely because they are or are not. 4) I hope you don't mind the talk page refactoring I'm doing. It's only for ease of discussion.

"Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition (32). Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive."

This is another point the source makes to draw the conclusion. Another source would have to be specifically about neck manipulation and fatalities. We can't put a primary source on the same level as a MEDRS source. So there is in fact no serious dispute. Do editors prefer we comply with MEDRS and ASF or ignore all rules? QuackGuru (talk) 05:46, 7 August 2010 (UTC)

Your first point clarifies Ernst's argument but not does not settle the issue of attribution.

Other reviews may make conflicting claims even with a different scope. Explaining the variety of views would require nuance and likely attribution. Ernst's review was not solely of neck manipulations, but rather included all deaths following chiropractic care. At the least, if the other source must be about neck manipulation and fatalities, then the Misplaced Pages text must refer to the risk outweighing the benefits only in the context of neck manipulations.

ASF is not proof but a policy which must be applied in context: I dispute your application of ASF in this context because the conclusion of a systematic review is being presented as a fact. The types of facts mentioned in ASF are "Plato is a philosopher" and "Mars is a planet". "Spinal manipulations have more risk than benefit" is almost obviously a different kind of statement. Your argument depends on a particular and narrow reading of ASF and MEDRS that other editors can and indeed do disagree with. The difference of opinion is in no way an endorsement of ignoring all rules any more than going 56 miles per hour in a 55 mph zone is an endorsement of going 160. Ocaasi (talk) 06:09, 7 August 2010 (UTC)

ASF is a policy which can be ignored according to you. I am waiting for you to show a serious dispute with another systematic review. You can't reach down into primary sources to argue against reviews. QuackGuru (talk) 06:20, 7 August 2010 (UTC)

ASF is a policy which states that facts should be asserted and opinions attributed; everything in between requires editorial discretion. My argument is indeed based on ASF, just a different reading and application of it. I dispute that Ernst's claim is a fact as described in ASF. Please do not characterize my position falsely.

If there are competing reviews it is a bonus but not necessary to require attribution of his finding. I have not even mentioned a primary source, so you need not address it. Ocaasi (talk) 06:47, 7 August 2010 (UTC)

Ernst's claim is not a fact as described in ASF - this much should be obvious to anyone. As such, it should be attributed. Javsav (talk) 19:36, 7 August 2010 (UTC)

• I support the view that the text in the lead should say that the risks by far outweigh the benefits. This is because it is supported by systematic review and is very recent (2010) paper. Additionally Doc James has pulled up a couple of other references which come to a similar conclusion, i.e., that there is little to no data to demonstrate benefit and a small but significant risk of severe harm/adverse effects. There is no valid reason in my view for excluding this content from the lead or the article. It should be included.--Literaturegeek | T@1k? 19:30, 11 August 2010 (UTC)

References Supporting Ernst

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

Ernst's conclusions are fairly clear

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

Another paper PMID:17330693 states:

Since there is a large amount of evidence from many

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

suffering neck pain and headiichc.

This paper PMID: 17142640 reiterates the same points:

Although cervical

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

outweigh the inherent risks.8,9

Finnally we have this 2009 Cochrane paper PMID: 20091561 that concludes:

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

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

References Disputing Ernst

These are worth taking into account:

• Spine: 1 October 2007 - Volume 32 - Issue 21 - pp 2375-2378 http://chiropractorvancouver.files.wordpress.com/2008/11/chiropractic-safety.pdf

"Data were obtained from 28,807 treatment consultations and 50,276 cervical spine manipulations. There were no reports of serious adverse events. This translates to an estimated risk of a serious adverse event of, at worse ≈1 per 10,000 treatment consultations immediately after cervical spine manipulation, ≈2 per 10,000 treatment consultations up to 7 days after treatment and ≈6 per 100,000 cervical spine manipulations. Minor side effects with a possible neurologic involvement were more common."

"Although minor side effects following cervical spine manipulation were relatively common, the risk of a serious adverse event, immediately or up to 7 days after treatment, was low to very low."

• Spine: 15 May 2009 - Volume 34 - Issue 11 - pp E405-E413 http://journals.lww.com/spinejournal/Abstract/2009/05150/Safety_of_Chiropractic_Interventions__A_Systematic.26.aspx

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

• World Health Organization (2005) (PDF). http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf

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

• J Manipulative Physiol Ther. 2005 Jan;28(1):57-63. http://www.ncbi.nlm.nih.gov/pubmed/15726036

"CONCLUSIONS: Perceived causation of reported cases of cervical artery dissection is more frequently attributed to chiropractic manipulative therapy procedures than to motor vehicle collision related injuries, even though the comparative biomechanical evidence makes such causation unlikely. The direct evidence suggests that the healthy vertebral artery is not at risk from properly performed chiropractic manipulative procedures."

• The Journal of Alternative and Complementary Medicine. February 2001, 7(1): 65-78 http://www.liebertonline.com/doi/abs/10.1089%2F107555301300004547

"Ernst et al.'s publication on chiropractic include repeated misuse of references, misleading statements, highly selective use of certain published papers, failure to refer to relevant literature, inaccurate reporting of the contents of published work, and errors in citation. Meticulous analysis of some influential negative reviews has been carried out to determine the objectivity of the data reported. The misrepresentation that became evident deserves full debate and raises serious questions about the integrity of the peer-review process and the nature of academic misconduct."

(re: stroke)

• Spine (Phila Pa 1976). 2008 Feb 15;33(4 Suppl):S176-83. http://www.ncbi.nlm.nih.gov/pubmed/18204390

"The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care."

• JMTP Volume 32, Issue 2, Supplement, Pages S201-S208 (February 2009) http://www.jmptonline.org/article/S0161-4754%2808%2900347-3/abstract

"VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and PCP visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated chiropractic care compared to primary care."

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

The review is not asserted as fact. The review does have attribution in the text. Please tell us which reference in accordance with WP:MEDRS says the risk of death from neck manipulation is worth the benefit from a recent review. QuackGuru (talk) 17:44, 12 August 2010 (UTC)

The review is not balanced with opposing or contextualizing views in reliable sources. Ernst's broad conclusions as well as the assumptions on which it is based are challenged by reliable medical sources and therefore must be described as such per WP:NPOV, WP:ASF, WP:UNDUE, WP:PARITY, and WP:MEDRS The dispute must be accurately described so readers can make appropriate determinations themselves. All sources identified below qualify under WP:MEDRS.

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

This reference is not even specifically about neck manipulation and risk of death. Again which source says the risk of death from neck manipulation is worth the benefit from a recent review. QuackGuru (talk) 03:42, 13 August 2010 (UTC)

This is the first sysematic review that summarises all cases in which chiropractic spinal manipulation was followed by death. QuackGuru (talk) 03:47, 13 August 2010 (UTC)

• Ernst is not the only one to have stated this risk. See Paciaronia, Maurizio (2009). "Cerebrovascular Complications of Neck Manipulation". European Neurology. 61 (2). Karger. doi:10.1159/000180314. PMID 19065058. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help): "A correlation between stroke and cervical manipulation has been reported with increasing frequency, and each new report seems to reignite debate between neurologists and manual therapists ... Patients undergoing spinal manipulative therapy need to consent to the possible risk of stroke or vascular injury from the procedure." Fences&Windows 23:02, 15 August 2010 (UTC)

There is material in the article about safety of spinal manipulation and neck manipulation. I agree Ernst is not the only one to have stated this risk. But that is not the issue. The issue in not safety in general but about risk-benefit specifically. If there are recent reviews about risk-benefit we can use those references for more views for the Risk-benefit section. QuackGuru (talk) 01:04, 16 August 2010 (UTC)

Attempt at consensus

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

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

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

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

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

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

"I still don't think that either of those is completely fair - it wasn't the review that concluded this, it was the reviewerJavsav (talk) 19:39, 7 August 2010 (UTC)

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

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

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

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

I moved the extra attribution to the body to keep the lead a summary and added a new sentence to the article. QuackGuru (talk) 03:47, 8 August 2010 (UTC)

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

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

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

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

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

The review did explain the risk-benefit balance. "Moreover, there is no good evidence for assuming that neck manipulation is an effective therapy for any medical condition (32). Thus, the risk-benefit balance for chiropractic neck manipulation fails to be positive."

The review was written by a researcher. The review did conclude the risks by far outweight the benefit. The researcher did not attach a separate paper to go along with the review. QuackGuru (talk) 05:09, 9 August 2010 (UTC)

I added by far to the sentence because it is more accurate to the conclusion of the MEDRS source. QuackGuru (talk) 05:34, 9 August 2010 (UTC)

Since editors seem to not be satisified by saying concluded I changed it to determined while maintaining a neutral tone per NPOV. QuackGuru (talk) 05:50, 9 August 2010 (UTC)

For a peer-reviewed source, it isn't (or at least shouldn't be) just the author's view. The reviewers should also have determined that the conclusions are supported by the data in the review. Brunton (talk) 07:59, 9 August 2010 (UTC)

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

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

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

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

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

The review goes beyond "numerous deaths have been associated with chiropractic neck manipulation" I did change the sentence to make it clear that the risk is death to make it more understandable. QuackGuru (talk) 00:24, 10 August 2010 (UTC)

Sure it does, but such a statement is a personal conclusion of the author, not part of the study, and it would seem attribution is necessary if we are going to quote his intuitive assessment in an encyclopedia instead of letting the facts speak for themselves. BE——Critical_{__Talk} 00:39, 10 August 2010 (UTC)

Also, your use of the word "determined" indicates evidence rather than intuition. BE——Critical_{__Talk} 00:43, 10 August 2010 (UTC)

There was not a separate conclusion with a separate attached paper. We don't have two conclusions. This was not an opinion assessment. The facts did speak for themselves before the attribution in the text was added as a compromise. QuackGuru (talk) 00:55, 10 August 2010 (UTC)

Can you give me a diff of the version you favor? BE——Critical_{__Talk} 00:59, 10 August 2010 (UTC)

...and a systematic review determined the risk of death of manipulations to the neck by far outweigh the benefit.

...the risk of death of manipulations to the neck by far outweigh the benefit.

I think the version without attribution is the one I favor but the version with attribution is the version I think editors can live with. QuackGuru (talk) 05:25, 10 August 2010 (UTC)

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

Secondly, I'm agreeing with critical in that this is an opinion of the author. This author, Ernst, is clearly antichiropractic (look at his other papers), and in fact when he claims that there have been no benefits, he is referencing another of his OWN papers, which was shown to have some methodological flaws. You can't say that the study "determined" or "concluded" that the risks outweigh the benefits, because a study can't really conclude that. All it can conclude was that there were 26 deaths in the literature since 1937. Whether or not the risks outweigh the benefits is completely subjective - for example, this is a huge exaggeration for the case of proving a point, but to a suicidal person, death would actually be a benefit - and I'm saying this just to show how completely subjective this conclusion is. If you find out how many deaths medicine has caused since 1937, as a percentage per patient treated compared with chiropractic, it will be higher. And yes I know that the potential benefits of medicine are much higher, but as I said before, the study can't really conclude that, only a PERSON can. By the way, I'll again point out that I am a medical student - I have no bias here. Javsav (talk) 07:54, 10 August 2010 (UTC)

Yes, well put. Using the word "determined" is wrong for a subjective conclusion. There isn't even an attempt at quantification of how risks outweigh benefits. I would have the same, though smaller, objection to the word "concluded." But the same impression can be given without violating NPOV by simply stating what was actually determined, that is the number of deaths. The reader can then draw their own conclusions. BE——Critical_{__Talk} 19:58, 10 August 2010 (UTC)

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

The lead is supposed to be a summary and the proposal does not summarise the body. QuackGuru (talk) 23:41, 10 August 2010 (UTC)

Ah, so this is only in the lead? Then why do we have it at all? BE——Critical_{__Talk} 02:47, 11 August 2010 (UTC)

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

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

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

Open questions

I think the issues are basically these:

• Does every word of a systematic review of literature have equal weight--the results as well as the interpretation of the results as well as the conclusion of the review?

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

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

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

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

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

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

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

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

There is attribution in the text against ASF as a compromise. I'm not sure your point. If another systematic review contradicted this systematic review we would not need to change the way it is currently attributed in the text. No serious dispute has been presented and this systematic review cites reliable sources (Di Fabio RP. Manipulation of the cervical spine: risks and benefits. Physical Ther 1999; 79: 50–65.) like other systematic reviews do. QuackGuru (talk) 00:24, 10 August 2010 (UTC)

Attribution is an improvement. These are open questions related to the arguments you have used. I think many of them exceed what policy actually supports or was intended to support, so I want to clarify them for future issues. Ocaasi (talk) 06:07, 11 August 2010 (UTC)

I think a new section in MEDRS covering ASF for medical information would clarify the issue for future content disputes. QuackGuru (talk) 06:19, 11 August 2010 (UTC)

Conclusion of the systematic review

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

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

The article body is the conclusion of the systematic review. The WP:LEAD is a summary of the body and a summary of the conclusion. E Ernst (2010). "Deaths after chiropractic: a review of published cases" (PDF). Int J Clinical Practice. 64: 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715. QuackGuru (talk) 00:17, 11 August 2010 (UTC)

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

We reflect the source and not argue whether there is medical consensus among other sources. QuackGuru (talk) 06:12, 11 August 2010 (UTC)

We reflect the source 'and argue whether there is medical consensus among other sources; otherwise, whether the statement is disputed cannot be determined. (my problem with this discussion's heading is that it sounds like its concluding the discussion rather than addressing the review) Ocaasi (talk) 06:20, 11 August 2010 (UTC)

We reflect the source per NPOV and debate whether there is a serious dispute among other reliable sources per ASF. QuackGuru (talk) 06:26, 11 August 2010 (UTC)

ASF is not the only relevant section. We reflect the source per NPOV and debate disputes among reliable sources per NPOV, and RS. ASF is a guide for attribution of facts/opinions only. It does not settle more complicated disputes, or clarify how many (or which) sources qualify in a dispute. MEDRS is useful, but it is not welded to ASF and requires all of NPOV as well. Ocaasi (talk) 07:19, 11 August 2010 (UTC)

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

The body has now more specific information. The lead accurately summarises the body. QuackGuru (talk) 06:12, 11 August 2010 (UTC)

I edited both the intro and the body to reflect this discussion. The intro just has two sentences, because I thought it was easier to read. The body has some minor cleanup for grammar, as well as a small expansion about Ernst's cost-benefit logic. Ocaasi (talk) 07:19, 11 August 2010 (UTC)

This and this make it a lot better (: It's pretty specific as to how things stand. BE——Critical_{__Talk} 07:32, 11 August 2010 (UTC)

Agreed. But hello, what about the lead? It is still not ok Javsav (talk) 09:07, 11 August 2010 (UTC)

Right. How do people want to fix that? BE——Critical_{__Talk} 20:10, 11 August 2010 (UTC)

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

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

Proposed edits to Safety

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

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

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

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

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

1. http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2841070/pdf/1746-1340-18-3.pdf
2. ^ E Ernst (2010). "Deaths after chiropractic: a review of published cases" (PDF). Int J Clinical Practice. 64: 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715.
3. http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf.
4. ^ Ernst E (2007). "Adverse effects of spinal manipulation: a systematic review". J R Soc Med. 100 (7): 330–8. doi:10.1258/jrsm.100.7.330. PMC 1905885. PMID 17606755. {{cite journal}}: Unknown parameter |laydate= ignored (help); Unknown parameter |laysource= ignored (help); Unknown parameter |laysummary= ignored (help)
5. Vohra S, Johnston BC, Cramer K, Humphreys K (2007). "Adverse events associated with pediatric spinal manipulation: a systematic review". Pediatrics. 119 (1): e275–83. doi:10.1542/peds.2006-1392. PMID 17178922.{{cite journal}}: CS1 maint: multiple names: authors list (link)
6. http://www.ncbi.nlm.nih.gov/pubmed/19444054
7. Hurwitz EL, Carragee EJ, van der Velde G; et al. (2008). "Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders". Spine. 33 (4 Suppl): S123–52. doi:10.1097/BRS.0b013e3181644b1d. PMID 18204386. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
8. Paciaroni M, Bogousslavsky J (2009). "Cerebrovascular complications of neck manipulation". Eur Neurol. 61 (2): 112–8. doi:10.1159/000180314. PMID 19065058.
9. Miley ML, Wellik KE, Wingerchuk DM, Demaerschalk BM (2008). "Does cervical manipulative therapy cause vertebral artery dissection and stroke?". Neurologist. 14 (1): 66–73. doi:10.1097/NRL.0b013e318164e53d. PMID 18195663.{{cite journal}}: CS1 maint: multiple names: authors list (link)
10. http://www.ncbi.nlm.nih.gov/pubmed/18204390
11. http://www.ncbi.nlm.nih.gov/pubmed/15726036
12. http://www.ncbi.nlm.nih.gov/pubmed/15726036
13. http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf
14. http://www.ncbi.nlm.nih.gov/pubmed/15726036
15. http://www.ncbi.nlm.nih.gov/pubmed/18195663

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. Silverseren 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. Silverseren 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." 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.

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. Silverseren 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

• WP:MEDASSESS

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

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. Silverseren 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". Silverseren 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 Misplaced Pages 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. Silverseren 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. Silverseren 04:22, 14 August 2010 (UTC)

You think it is ridiculous and far too restrictive to have to have a systematic review to counter the views of another systematic review. Then you think MEDRS is ridiculous. QuackGuru (talk) 04:29, 14 August 2010 (UTC)

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

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

You can't use low-quality references to argue against systematic reviews. I did delete not half but all the lower quality references recently added against MEDRS. QuackGuru (talk) 05:00, 14 August 2010 (UTC)

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

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

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

This reference was written by the Palmer College of Chiropractic West. Do editors seriously think this reference is reliable per MEDRS from Jan 2005. QuackGuru (talk) 06:36, 14 August 2010 (UTC)

Yes. Do you have a reliable source which suggests otherwise? The review is given full in-text attribution so that if users have any doubt they can immediately see who published the article and make their own determinations. I believe that concept lies at the very core of NPOV. Ocaasi (talk) 09:09, 14 August 2010 (UTC)

• WP:MEDRS: "Peer-reviewed medical journals are a natural choice as a source for up-to-date medical information in Misplaced Pages 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 designs to uncover both the benefits and the risks associated with chiropractic manipulation. 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 Guru-_ 00:26, 15 August 2010 (UTC)

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