Talk:Chiropractic/Mediation

This is a mediation talk page for Chiropractic.

Ground rules

• Assume good faith until your eyes bleed.
• Focus on content; avoid "you" statements in favor of "I".
• To avoid mediation creep, please do not open new topics while a discussion is on-going.

Proposed compromise

I'm sorry that I may not have time to do this properly, with references, but I'm pretty sure all the required references have been mentioned on Talk:Chiropractic at some point. I'm not sure if this same compromise was suggested before, possibly by me. However, I would encourage everyone to seriously consider ending this long-lasting dispute with a compromise such as this. (If I wasn't supposed to post this here, please move it to Talk:Chiropractic.)

I would like to use WP:NPOV to resolve the issue, in the way that this policy is so useful for resolving so many disputes. Rather than edit-warring between "God exists" and "God does not exist", WP:NPOV says to write something like "Source A says that God exists, and source B says that God does not exist," and then all editors can agree that that's accurate. Let's use WP:NPOV in that way here.

We have two points of view: one that studies of the effectiveness of spinal manipulation are relevant to chiropractic treatment, and another that to find out about the effectiveness of chiropractic treatment you have to study treatment by chiropractors specifically.

I'm under the impression that both these points of view have been expressed in published sources. Therefore, the compromise I suggest is not to model the article after one or the other of the two POVs, but to describe the controversy, according to WP:NPOV. Possibly one of the

Here's a skeleton draft. It needs references and details to be added, and the wording modified to fit what the references say, perhaps mention the names of the researchers, etc.:

Some researchers state that studies of the effectiveness of spinal manipulation regardless of practitioner can provide information about the effectiveness of chiropractic treatment. These researchers cite a study ... which finds that ... . They also cite a study ... which finds that ..., and another study ... which finds that ... . Some other researchers also state that conclusions about chiropractic treatment can be drawn from general studies of spinal manipulation, and cite a study ... which concludes that ... . Chiropractors, on the other hand, assert that spinal manipulation by chiropractors is essentially different from that performed by other practitioners and that to study the effectiveness of chiropractic treatment, it's necessary to study treatment by chiropractors only. A study of chiropractors ... found that ... and another study of chiropractors ... found that ... .

An essential element of this compromise is that information can be provided from general spinal manipulation studies which don't mention chiropractic, but only if such studies have been cited by other reliable sources as sources of conclusions about chiropractic. Accepting this compromise will require some concessions from both sides of the dispute. I urge editors to seriously consider it. ☺Coppertwig(talk) 00:36, 13 November 2008 (UTC)

Admirable solution Coppertwig, but we have died-in-the-wool anti-chiro POV pushers here, and rather than try and change them (which won't happen) I think a better solution would be try something else. I had an idea this morning, perhaps we can have a "enmilitarized" zone here on the mediation page that allows limited edit-warring. What I am thinking is that we have a proposed version of the text which it is permissible to edit war upon, and if/when the "EMZ" becomes stable, it is incorporated into the article. I think some common sense ground rules for the EMZ would be "no reversions or repetitions" (ie. you must always change the EMZ text to a new version) and a good faith assumption by all EMZ participants that they are aiming for stable text. Just trying some lateral thinking here, because we have a group of editors that have been editing this article for quite a while and they have so far been unable to establish a useful working relationship. --Surturz (talk) 00:54, 13 November 2008 (UTC)

I actually kind of like Coppertwig's proposal here. I am open to exploring it further if other editors are aboard. -- Levine2112 ^discuss 01:33, 13 November 2008 (UTC)

I SAID this on the talk page. At least I remember saying it (: This isn't a compromise, it's as you say the basic solution to these kinds of things we're supposed to seek. ——Martin^phi Ψ~Φ—— 01:59, 13 November 2008 (UTC)

"Some researchers..." is a violation of WP:ASF. Some researchers implies that there are researchers that disagree. "Chiropractors, on the other hand, assert that spinal manipulation by chiropractors is essentially different..." is completely unsourced and a WP:FRINGE view. It would help if references were provided with the proposed text to better evaluate the proposal. QuackGuru 02:22, 13 November 2008 (UTC)

Don't shoot the messenger? Coppertwig was clear that references would be necessary to implement this idea. I'd suggest QuackGuru, if you're interested in participating in the mediation that instead of discounting possible solutions, you do a bit of the leg work yourself to shore up the sourcing. Shell ^babelfish 02:32, 13 November 2008 (UTC)

A 2002 review of randomized clinical trials of SM[35] was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular;[91] however the review's authors stated that they did not consider this difference to be a significant point as research on SM is equally useful regardless of which practitioner provides it.[90]

Here is the current version in the article that is referenced. Here are a few additional references.[1][2][3][4]

The second part of proposal was: ...which don't mention chiropractic, but only if such studies have been cited by other reliable sources as sources of conclusions about chiropractic. That would essentially delete many reliable refs from the article. I think we should keep the references in the article because they are directly related to the topic of the article per WP:OR. QuackGuru 02:55, 13 November 2008 (UTC)

(outdent) See this is the problem we've been having. We have now expended over 6000 words discussing changes to two sentences. As usual it starts off going well and then someone suggests a completely new version of the text, which prompts everyone else to put in their version, and no consensus is reached. I'm going to try the limited edit war idea... --Surturz (talk) 05:09, 13 November 2008 (UTC)

• Coppertwig's skeleton draft at first sounds like it would be a good one. But it has some problems. The most important problem is that approach taken by the skeleton draft has already been tried, and is embodied in Chiropractic now, but it obviously has not defused the situation. The embodiment in Chiropractic is in the following sentence, already quoted by QuackGuru:

"A 2002 review of randomized clinical trials of SM was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular; however the review's authors stated that they did not consider this difference to be a significant point as research on SM is equally useful regardless of which practitioner provides it."

• This embodiment doesn't exactly match Coppertwig's draft wording, of course, but it is the same basic idea, and it's the closest that we have been able to approach Coppertwig's draft wording under the constraint of supporting each claim by a reliable source.
• As for Coppertwig's proposal that we not cite source X unless we can find another source Y that cites X: there are some downsides to this proposal, which may not be immediately obvious. For example, it would make Chiropractic more out-of-date, since it would exclude sources that are too recent to have been cited by other sources.
• I am unaware of any precedent for this sort of restriction on Wikipedia editing. I'd be more comfortable if I knew of other articles where the strategy "you can't cite X unless you can also find a Y that cites X" has been tried and has worked.
• It might help to try out this proposal on a real example. Let's take Murphy et al. 2006 (PMID 16949948), which some editors have argued is not directly relevant to Chiropractic. Murphy et al. is cited by the following reliable source, which clearly is about chiropractic:

Wilkey A, Gregory M, Byfield D, McCarthy PW (2008). "A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic". J Altern Complement Med. 14 (5): 465–73. doi:10.1089/acm.2007.0796. PMID 18564952.{{cite journal}}: CS1 maint: multiple names: authors list (link)

• The citation to Murphy et al. appears at the end of the following sentence in Wilkey et al.: "Treatment that is available for patients suffering with CLBP [chronic low back pain] appears almost inexhaustible, although the evidence for the effectiveness of many of these therapies is questionable and as such, national guidelines that have been produced vary widely with regard to the timing and type of interventions that are advised." The sentence also cites 8 other sources.
• This citation to Murphy et al. demonstrates that it has "been cited by other reliable sources as sources of conclusions about chiropractic".
• But let me stop now and double-check: is this the sort of procedure that is being proposed for removing some sources from Chiropractic?

Eubulides (talk) 08:47, 13 November 2008 (UTC)

It think that's close but the caveat of "you can't cite X unless you can also find a Y that cites X" is that Y must cite X in relation to the subject of the article. In this case, Y needs to discuss chiropractic and be citing X in the context of such a discussiion. And then, we can only cite information from X which was related to chiropractic by Y. So your example above is of Murphy cited by Wilkey. Even though Wilkey is about chiropractic, it does not necessarily mean that what it is citing of Murphy has anything to do with chiropractic. However, if we decide that in fact it does have something to do with chiropractic, then that will mean that we can cite Murphy only in the context that it is related to chiropractic by Wilkey. Just because Wilkey might correlate one aspect of Murphy with chiropractic, it doesn't make Murphy in its entirity related to chiropractic.

Maybe that's an overly strict way to go with Coppertwig's proposal, but I think that is the best way to ensure that our Wikipedia article is most reliable in its coverage of the subject. That we are not making any assumptions which could introduce misleading information into our article is of the highest importance in terms of reliability. In the end (figuratively... there is no end, right?), I feel that this will make our article as reliable and up-to-date as the sources allow us to be -- Levine2112 ^discuss 09:15, 13 November 2008 (UTC)

In that case it sounds like Coppertwig's proposal may have a problem, as it can be interpreted to exclude Murphy et al. even with Wilkey et al. citing Murphy. By the way, Murphy does mention chiropractic, as most of Murphy's evidence comes from chiropractic studies, so it isn't a good example of Coppertwig's proposal (which is only about "studies which don't mention chiropractic"). Still, there is something odd about an interpretation that would exclude Murphy even though chiropractic researchers publishing in a peer-reviewed journal seem to have no qualms about citing Murphy and sources similar to Murphy. Perhaps we can see whether other editors agree with this interpretation of Coppertwig's proposal. Eubulides (talk) 09:47, 13 November 2008 (UTC)

Question to Levine please, you make this above comment "However, if we decide that in fact it does have something to do with chiropractic, then that will mean that we can cite Murphy only in the context that it is related to chiropractic by Wilkey. Just because Wilkey might correlate one aspect of Murphy with chiropractic, it doesn't make Murphy in its entirity related to chiropractic.". From how I read this, it sounds like you are either contradicting yourself, Wilkey might correlate on aspect of Murphy with chiropractic, it doesn't make Murphey in it's entirity related to chiropractic, or cherry picking what should be used or you are using this to state that the ref is no good because it doesn't use the word chiropractic throughout. To me this doesn't make sense, sorry, could you explain this thought clearer for someone like me who is pretty much just trying to watch and help out with this? I read them to be usable for the chiropractic article together as stated by Eubulides and Fyslee at this point. I am having trouble understanding why this is such an issue still after so many outside opinions have agreed that this is exceptable to policy and not a violation as has been continually been stated. I will of course admit I do not understand all the medical terminologies going on here so I am basing my opinions on my own personal limited knowledge of this. (I hope what I am saying is clear enough to answer, it is a little disorganized but I couldn't find a better way of stating my question, sorry if this is a problem in advance.) Thanks for listening, --CrohnieGal^Talk 13:49, 13 November 2008 (UTC)

Clarity is hard to acheive and I apologize for the confusion. I assure you that there no cherry-picking or contradiction there however. I am not sure how you can be getting confused by medical terminology as we really aren't using any and it sounds like you have a richer background in medical terminology than I do. I'm really just a layman here. It's pretty simple really.

• Scenario 1: We have source X which doesn't mention chiropractic in its results, discussions or conclusions. Though it relied on some amount of chiropractic evidence to form its results, discussions and conclusions, the author is not stating anything specifically about chiropractic there. Can we cite the results, discussions or conclusions in our Wikipedia article to discuss chiropractic? I'd say no. It wasn't the intent of the author to discuss chiropractic (or at least we cannot assume that was his/her intent), so for us to go and use such a source as a means to discuss chiropractic, we would clearly be violating WP:NOR.

• Scenario 2: We have the same source X from Scenario 1, only now we also have a source Y which in fact directly discusses chiropractic. And in this discussion, source Y cites source X. So what does that mean? Can we cite source Y in our article about chiropractic? Most certainly. Can we cite source X in terms of how source Y related it chiropractic? Yes, with proper attribution. Can we now cite any part of source X, even those results, discussions or conclusions not specifically correlated to chiropractic by source Y? No. Just because one aspect of source X has been related to chiropractic by source Y, does not mean that every aspect of source X is therefore related to chiropractic.

• Scenario 3: This is when it gets a little complicated, so hopefully you are still with me. Okay, similar to Scenario 2, only now we have a source Y which only partially discusses chiropractic. Source Y discusses a couple of things, but not chiropractic exclusively. And in its discussion of one of these other topics, source Y cites source X. Can we cite source X to discuss chiropractic in terms of source Y? No. Why? Because source Y doesn't use source X to discuss chiropractic, so neither can we.

The simplest formulation for us to look at here is given to us by our own WP:NOR policy when it talks about context: Take care, however, not to go beyond what is expressed in the sources or to use them in ways inconsistent with the intent of the source, such as using material out of context. That really says it all. Just because Murphy used some chiropractic evidence -- the amount is hardly important, though Eubulides is wrong when he says, "...most of Murphy's evidence comes from chiropractic studies". Only 2 of the 21 studies looked at were about chiropractic specifically. But even if 21 of the 21 studies were about chiropractic -- it does not mean that Murphy's intent is to discuss chiropractic. And by looking at the Results, Discussion and Conclusion sections of Murphy we can see that the authors are not discussing chiropractic whatsoever. Therefore, for us to use Murphy's results, discussion and/or conclusions to discusss chiropractic goes beyond what is expressed in the source and is inconsistent with the intent of the source. But if we find some source Y which cites one of Murphy's conclusions in a discussion about chiropractic, then the intent of source Y is clearly to use the one conclusion of Murphy to discuss chiropractic and therefore we can cite that one conclusion of Murphy to discuss chiropractic in our Wikipedia article (with proper attibution to source Y, of course).

I hope this clarifies my thoughts on Coppertwig's proposal and why I feel that this will result in us writing the most reliable article about chiropractic that we can source. -- Levine2112 ^discuss 17:51, 13 November 2008 (UTC)

Question for Levine2112: suppose we keep Sentence 1, but give as its source Wilkey et al. (a source that we agree is about chiropractic) rather than Murphy et al. Would that fix the problem you perceive? Eubulides (talk) 18:57, 13 November 2008 (UTC)

Here is sentence 1: There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability.

The question is: Does Wilkey relate this non-chiropractic statement to chiropractic? I don't believe so because Wilkey's use of Murphy is not to say anything specific about chiropractic: Treatment that is available for patients suffering with CLBP [chronic low back pain] appears almost inexhaustible, although the evidence for the effectiveness of many of these therapies is questionable and as such, national guidelines that have been produced vary widely with regard to the timing and type of interventions that are advised. This source would however be good for the Low back pain article. I may be mistaken and Wilkey could be sourcing Murphy to say something specifically about chiropractic. If this is the case, please provide the text from Wilkey. Seemingly, however, Wilkey disagrees with sentence 1 in part (in term of applying it to chiropractic), for Wilkey's conclusions are along the lines of suggesting that chiropractic is effective at treating low back pain and related disability.

I am going to be out of the loop for awhile, but feel free to continue this discussion without me. I will be checking in, but probably won't have access to edit for the next few days. -- Levine2112 ^discuss 19:15, 13 November 2008 (UTC)

(outdent)

• Wilkey et al. is a primary study about the effectiveness of chiropractic treatment, with an "Introduction" section that talks about related work and which cites Murphy et al. as noted above. Wilkey et al. has no explicit statement saying "Murphy et al. is relevant to chiropractic", or anything like that, nor would one normally expect such a statement: it's normally understood that when one source X cites another source Y, the authors of X considered Y to be directly relevant to X's topic.
• Let's take another example, just to make sure I understand Levine2112's interpretation. Ernst 2008 (PMID 18280103), "Chiropractic: a critical evaluation", says this (p. 8):

"Table 3 gives an overview of the most up-to-date systematic reviews by indication. These systematic reviews usually include trials of spinal manipulation regardless of who administered it. Thus, they are not exclusively an evaluation of chiropractic. Collectively, their results fail to demonstrate that spinal manipulation is effective. The only possible exception is back pain. For this condition, manipulation may be as effective (or ineffective) as standard therapy."

• Ernst's Table 3 is of 8 recent systematic reviews of spinal manipulation. 2 of those reviews were of chiropractic SM, and 6 were of any type of SM (mostly chiropractic SM, but non-chiro SM was included). As I understand it, Levine2112's interpretation would also exclude citing this part of Ernst 2008, because this part of Ernst 2008 is not exclusively about chiropractic. Am I correct?

Eubulides (talk) 20:38, 13 November 2008 (UTC)

Take a good look at the second sentence here, with a special eye for the way the words "not exclusively" are used:

• "These systematic reviews usually include trials of spinal manipulation regardless of who administered it. Thus, they are not exclusively an evaluation of chiropractic."

This whole discussion has really led us into a bizarre situation, having painted us into a corner where even a study that is "an evaluation of chiropractic" gets excluded because it is "not exclusively an evaluation of chiropractic." Yes, even though it is "an evaluation of chiropractic", it isn't "exclusively" about what is most fundamental to chiropractic, namely spinal manipulation, because it is an evaluation of more than chiropractic by virtue of the fact that it includes a few studies about spinal manipulation performed by non-DCs, IOW it comments on chiropractic and "more" than it. It's conclusions most certainly deal with chiropractic's main method, and even deal with all spinal manipulation. It's really bizarre that common sense can't even get a foot in the door here because it is being disallowed by wikilawyering over a supposed OR violation. -- Fyslee / talk 05:11, 14 November 2008 (UTC)

Honestly, I would say that "common sense" sides with my position here. If a source is not exclusively evaluating chiropractic, then we cannot use such a source to exclusively evaluate chiropractic (as we are doing currently in the Chiropractic article). If it is exclusively an evaluation of spinal manipulation, common sense would dictate that the source is perfectly suitable for the Spinal manipulation article.

And one man's "wikilawyering" is another man's rational discussion of the proper adherence to Wikipedia policies. -- Levine2112 ^discuss 04:47, 19 November 2008 (UTC)

Let's not revisit the chiropractic SM versus general SM debate, please. Eubulides (talk) 06:11, 19 November 2008 (UTC)

Levine thanks for the lengthy response, very much appreciated. I understand what you are saying but I have to disagree. Oh and for the record I too am a layman here with no medical background other than the researches I do for myself and my family for personal health reasons. The major problem I am having is that you state the refs don't mention chiropractic or only mention it a little. I've never seen the kind of arguments being made here to keep information out with the reasoning being shown. I think the closest I've seen to this type of argument was at the Stephen Barrett and Quackwatch articles and putting in or keeping out that he was not certified. Then consenses agreed that certification wasn't necessary during the time he practiced medicine. So just because a referrence does state throughout that it is about chiropractic treatments or adds other non-chiropractors in it doesn't make it unusuable to me by any policy. Just follow the refs and state what the refs state. If one ref refers to another one then put them next to each other to show what is being said. I see this argument continuing but I honestly don't see a reason to keep it out. I really think with all the outside comments and the comments that have been made throughout this long debate should end already. It is really time to allow editors to start to work on upgrading the article and to let this go. Sorry, this is just my outside opinion on the matter. I say outside opinion because other than minor comments like this and a revert or two, I don't think I have actually given any major input towards this articles. Thanks again, --CrohnieGal^Talk 13:29, 19 November 2008 (UTC)

Moderator - try Limited Edit War?

Moderator, can we try my 'limited edit war' idea? Moderation is clearly failing when there is still no consensus after 6000 words+ discussing two sentences. This subpage (click here) is how I see it working --Surturz (talk) 05:24, 13 November 2008 (UTC)

Encouraging edit wars, even limited ones, doesn't sound promising. If edit wars don't work in articles, why would they work here? Eubulides (talk) 08:47, 13 November 2008 (UTC)

Fine, don't call it an "edit war". Call it "wiki-editing". I think it's a good idea; why not try it? The proposal above includes the idea that you can't revert to a previous version but must always change it to something new. That prevents any edit warring from happening. Every edit will be productive: it will create a new proposed version of that part of the article. Also, the proposal specifies that it must be done in a spirit of cooperation and of trying to arrive at a version everyone will accept. We might want to use some of the rules Elonka had established here; I was going to say but not the 0RR part, but actually maybe we do want to use that part too: no reverting to an identical previous version, but you can change things. ☺Coppertwig(talk) 14:10, 13 November 2008 (UTC)

Oh no, I don't think applying the rules from Quackwatch is a good idea at all. In my opinion that got a lot of editors to cease editing at the article and a lot of problems occurred. Maybe use the talk page and keep adding until the section is at an acceptable version, but wait, this is what they have been doing all along and look where it's at. Maybe each sentence under dispute can be put in this mediation separately and then the sentence, or whatever, can be worked on under the protection of the mediator's descretions to prevent circular arguments. I think Shell has been doing a great job trying to prevent the same arguments to go on here and that the editors need to be specific in there changes, as the mediator has requested often. --CrohnieGal^Talk 14:44, 13 November 2008 (UTC)

• I really like the idea presented in Surturz's subpage; since we're already trying to throw back and forth new suggestions to find one that works for everyone, this would let everyone see those changes and make tweaks of their own without filling up copious space on talk pages. Crohnie, the difference here would be editing on a subpage trying to find a compromise within restrictions, not any restrictions on the article itself. Shell ^babelfish 00:50, 14 November 2008 (UTC)

Limited Edit War on Chiropractic#Low back pain

A limited edit war has been declared on this section by User:Surturz. You may change the text in the 'proposed text' section without discussion, subject to the following rules:

• no reversions
• each edit you make on the section must be at least slightly different to any previous version
• You may add chat in the 'discussion' section, but using the edit summary to explain your change is acceptable
• the goal is to develop stable text that improves the article and is tolerable to all concerned

Once the proposed text is stable, it will be assumed to have consensus for inclusion in the main article. This limited edit war is sanctioned by the mediator of this page, Shell --Surturz (talk) 05:18, 13 November 2008 (UTC)

Current text (only change to match current version as necessary)

• Low back pain. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability. A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail, whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help, possibly because the guideline's recommendations were based on a high evidence level. A 2008 review found strong evidence that SM is similar in effect to medical care with exercise, and moderate evidence that SM is similar to physical therapy and other forms of conventional care. A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain. Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review stated that SM or mobilization is no more or less effective than other standard interventions for back pain. A 2008 systematic review found insufficient evidence to make any recommendations concerning medicine-assisted manipulation for chronic low back pain. A 2005 systematic review found that exercise appears to be slightly effective for chronic low back pain, and that it is no more effective than no treatment or other conservative treatments for acute low back pain.

This discussion has been closed. Please do not modify it.
The following discussion has been closed. Please do not modify it.
Proposed text (previous version before it was substantially shortened) Low back pain. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the reliability of the guidelines' recommendations. A 2008 review found strong evidence that SM is similar in effect to medical care with exercise. A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks; a 2007 literature synthesis found good evidence supporting SM for low back pain regardless of duration, and supporting exercise for low back pain lasting more than 12 weeks. Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review stated that SM or mobilization is no more or less effective than other standard interventions for back pain. A 2008 systematic review found insufficient evidence to make any recommendations concerning medicine-assisted manipulation for chronic low back pain. A 2005 systematic review found that exercise appears to be slightly effective for chronic low back pain, and that it is no more effective than no treatment or other conservative treatments for acute low back pain.

Proposed text (may be changed freely subject to rules above)

• Low back pain. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain. A 2008 review found strong evidence that SM is similar in effect to medical care with exercise. A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks; a 2007 literature synthesis found good evidence supporting SM for low back pain regardless of duration. Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review found that SM or mobilization is no more or less effective than other standard interventions for back pain. Methods for formulating treatment guidelines for low back pain differ significantly between countries, casting some doubt on their reliability.

Also, in Chiropractic #Treatment techniques, change this sentence:

Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist.

to this:

Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain.

Discussion

• Incorporated Eubulides suggested text as a start. --Surturz (talk) 05:29, 13 November 2008 (UTC)
• Altered the proposal to match what I actually proposed here. The proposal was to leave the initial and final parts of the paragraph alone, and change just the middle. Eubulides (talk) 01:45, 14 November 2008 (UTC)
• Sanctioned by mediator Shell, moved to mediation page. --Surturz (talk) 03:51, 15 November 2008 (UTC)
• Coppertwig removed the text "casting some doubt on the guidelines' reliability", saying "I didn't find this in the source (maybe I missed it)". However, the cited source (p. 579) says, "The most surprising finding, and a factor that casts some doubt on the reliability of the recommendations made, was that the levels of evidence and/or grades of recommendation used for formulating treatment recommendations varied so significantly between countries." The recommendations in question are the recommendations made by the guidelines. I am restoring the text to "casting some doubt on the reliability of the guidelines' recommendations", which hews to the original more closely, even though I prefer the brevity of the original. Eubulides (talk) 21:06, 15 November 2008 (UTC)
• Surturz merged the discussion of Meeker et al. 2007 (PDF) and Chou et al. 2007 into the single phrase "Two 2007 reviews found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain". But this isn't an accurate summary of Chou et al.: it did not mention mobilization and (unlike Meeker et al.) it did not find good evidence supporting SM for acute low back pain. Chou et al. did find good evidence for subacute or chronic low back pain, but not for acute. If we're going to trim, I suggest trimming the lower-quality evidence from Meeker et al., as it's arguably not worth mentioning here. This will let us remove the phrase "one of which also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain". Similarly, we can also remove the lower-quality evidence from Bronfort et al. 2008 (PMID 18164469). This will let us remove the phrase "and moderate evidence that SM is similar to physical therapy and other forms of conventional care". We can merge the two reviews more carefully, and explain the "subacute" and "chronic", using the following wording: "A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks; a 2007 literature synthesis found good evidence supporting SM for low back pain regardless of duration, and supporting exercise for low back pain lasting more than 12 weeks." I've made the changes suggested in this bullet. Eubulides (talk) 06:31, 16 November 2008 (UTC)
• I'm holding off editing for the moment to let others have a go, but I'm not sure why we are going into so much pedantic detail. This is an encyclopedia article, not a literature review. The key points are that there is a fair bit of evidence that SM works for low back pain, although there are some contrary views. I'm not sure why the medicine assisted manipulation sentence is included (since it doesn't conclude anything), nor am I entirely sure why there is a sentence talking about exercise (while I am sure some chiros would prescribe exercise, I'm sure many doctors would too, so I don't think it warrants inclusion). I think the discussion about guidelines should be moved to the end, because the source article is really talking about how the guidelines are formulated, not about accuracy of the guidelines themselves (as is stated in the current text). --Surturz (talk) 03:15, 17 November 2008 (UTC)
• This section has been substantially trimmed. It is much shorter compared to the previous version. A lot of text has been deleted. I think it is short enough. QuackGuru 06:36, 17 November 2008 (UTC)
• While I'm fine with the way the section has been trimmed, I'm also willing to explore Surturz's suggestions for further trimming in Chiropractic; my assumption, which I think we all share, is that the deleted text can be moved to Spinal manipulation or other such article where the extra detail can be useful. (Good comments from Surturz, by the way; thanks.) The medicine-assisted-manipulation (MAM) comment is there only because there was consensus a while back that MAM should be covered in Chiropractic. Personally I don't care one way or another, but if MAM is covered, a brief note about effectiveness is in order; perhaps it'd be best to fold this into the earlier mention of MAM rather than to mention MAM again here. Removing discussion of exercise is reasonable, in the interest of brevity. Moving the guideline discussion to the end is fine too. I've made edits along these lines to the draft above. Eubulides (talk) 06:46, 17 November 2008 (UTC)
• I added the previous version to make it easier for editors to compare both versions. QuackGuru 17:46, 17 November 2008 (UTC)
• Why? The shorter version is the current proposal. Introducing a previous proposal confuses things. Why don't you just change the current proposed version according to the rules that have been endorsed by the mediator? --Surturz (talk) 23:29, 17 November 2008 (UTC)
• We have a difference of opinion. I propose the medium short version is the best proposal. QuackGuru 00:38, 18 November 2008 (UTC)

• The shorter version is still evolving; let's see where it goes before deciding. Eubulides (talk) 03:07, 18 November 2008 (UTC)

• I apologize for removing the "casting some doubt" bit. I should have looked more thoroughly for it in the source. ☺Coppertwig(talk) 00:55, 18 November 2008 (UTC)

• No problem. I see Surturz went back to the shorter version. Short is good. Eubulides (talk) 03:07, 18 November 2008 (UTC)

• Coppertwig inserted the text "Some researchers contend that research results about the efficacy of SMT in general are indicative of the efficacy of chiropractic treatment." (fact tag added by Coppertwig). This text has two problems. First, the inserted claim is about efficacy of SMT in general, and therefore belongs in the paragraph that talks about that subject, not in this paragraph (which is merely about low back pain). Second, the inserted claim is unsourced. As a general rule in this area it's better to find reliable sources first, and summarize what they say, rather than summarize first and find the sources to match the summary. I took the liberty of undoing that insertion for now. Eubulides (talk) 03:07, 18 November 2008 (UTC)
• Well, this is the whole chiro vs non-chiro SM issue, isn't it? The section purports to explain the efficacy of chiropractic of low back pain, yet we are only describing the effectiveness of general SMT on low back pain. I don't blame Coppertwig for wanting the distinction to be made. --Surturz (talk) 04:39, 18 November 2008 (UTC)
• The low-back-pain effectiveness bullet is parallel to other bullets, one on whiplash and other neck pain, one on headache, and one on "other". SM is discussed in each of the other bullets. Concerns about chiro vs non-chiro are not specific to the low-back-pain bullet; they apply equally well to the other bullets. A much better place for such concerns is in the intro to the bullets, i.e., the first paragraph of Chiropractic #Effectiveness. The last two sentences of that paragraph are already about this issue; and Coppertwig's proposed sentence would be appropriate as a rewrite of or addition to those last two sentences. Those two sentences are well-sourced, though, whereas Coppertwig's addition is not. For reference, here are the two sentences in question: "Most research has focused on spinal manipulation (SM) in general, rather than solely on chiropractic SM. A 2002 review of randomized clinical trials of SM was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular; however the review's authors stated that they did not consider this difference to be a significant point as research on SM is equally useful regardless of which practitioner provides it." Eubulides (talk) 04:49, 18 November 2008 (UTC)
• While I agree that a trimmed version is much better than what is currently in the article, this section does not mention chiropractic, and does not mention any other treatment modalities other than SM. As such, it is clearly much better suited for the spinal manipulation article. This article on chiropractic should not discuss the efficacy of SM any more than any other (NPOV) article on chiropractic does, or we would have a WP:UNDUE violation. DigitalC (talk) 22:49, 18 November 2008 (UTC)
• Please see #What weight to give to effectiveness? below. Eubulides (talk) 02:02, 19 November 2008 (UTC)
• Some may hate it, but I removed several statements from sources which are not explicitly about chiropractic, but rather spinal manipulation in general. The way this was reading before was something which was clearly suited for Spinal manipulation and was only tangentially (at best) related to Chiropractic. -- Levine2112 ^discuss 04:43, 19 November 2008 (UTC)
• Using that argument, one should remove all the sources, as all the statements, even the statements supported by Meeker et al. 2007, are statements about spinal manipulation in general. It wouldn't be reasonable to do that. Nor is it reasonable keep only the lowest-quality source we have on the topic, the only source that is not published in a peer-reviewed journal, merely because that source happens to be sponsored by chiropractors with the word "chiropractic" in the title. We should be using the stronger sources, not the weaker ones. I restored the more-reliable sources and the claim they support. It would be reasonable, I suppose, to remove the lowest-quality source, but I didn't take that step. Also, I ask again not to resurrect the argument about chiropractic SM versus general SM; rearguing that is not likely to lead to consensus. Eubulides (talk) 06:11, 19 November 2008 (UTC)
• While I agree with Levine that the chiro SM vs non-chiro SM is a suppurating sore in this section, can we lower our expectations and aim for text which is merely better than the extant text. At this stage, can everyone ask themself, "would I prefer the proposed text to the current text?". If we can get everyone to answer "yes" to that question, we have consensus for a change. If we are unable to achieve that, the editorial dysfunction will continue. --Surturz (talk) 23:47, 19 November 2008 (UTC)
• QuackGuru seems insistent that we install the current proposal into the article. Does anyone oppose its installation? ie. does anyone think it is worse than the current article text? --Surturz (talk) 07:18, 20 November 2008 (UTC)
• It's better than what is there now for sure. Why? Because it contains less WP:OR. Yes, it still contains OR violations, but at least there is less in this version. Currently, there is only one source used in the prose which is directly related to chiropractic. The others are not. Therefore including them at Chiropractic still violated WP:NOR. -- Levine2112 ^discuss 01:37, 21 November 2008 (UTC)

What weight to give to effectiveness?

DigitalC commented that Chiropractic should not give more weight to efficacy of SM any more than other NPOV sources do. To try to gauge how much that might be, I visited Google Scholar, typed in the query "chiropractic", and looked for all sources that were cited 100 times or more. I found 11, which are listed below.

• Cherkin DC, Deyo RA, Battié M, Street J, Barlow W (1998). "A comparison of physical therapy, chiropractic manipulation, and provision of an educational booklet for the treatment of patients with low back pain". N. Engl. J. Med. 339 (15): 1021–9. PMID 9761803.{{cite journal}}: CS1 maint: multiple names: authors list (link) (351 citations)
• Meade TW, Dyer S, Browne W, Townsend J, Frank AO (1990). "Low back pain of mechanical origin: randomised comparison of chiropractic and hospital outpatient treatment". BMJ. 300 (6737): 1431–7. PMC 1663160. PMID 2143092.{{cite journal}}: CS1 maint: multiple names: authors list (link) (254 citations)
• Meade TW, Dyer S, Browne W, Frank AO (1995). "Randomised comparison of chiropractic and hospital outpatient management for low back pain: results from extended follow up". BMJ. 311 (7001): 349–51. PMC 2550426. PMID 7640538.{{cite journal}}: CS1 maint: multiple names: authors list (link) (164 citations)
• Rothwell DM, Bondy SJ, Williams JI (2001). "Chiropractic manipulation and stroke: a population-based case-control study". Stroke. 32 (5): 1054–60. PMID 11340209.{{cite journal}}: CS1 maint: multiple names: authors list (link) (162 citations)
• Lee KP, Carlini WG, McCormick GF, Albers GW (1995). "Neurologic complications following chiropractic manipulation: a survey of California neurologists". Neurology. 45 (6): 1213–5. PMID 7783892.{{cite journal}}: CS1 maint: multiple names: authors list (link) (122 citations)
• Haldeman S, Chapman-Smith D, Petersen DM. Guidelines for chiropractic quality assurance and practice parameters. Gaithersburg, Md: Aspen Publishers, 1993. (114 citations)
• Meeker WC, Haldeman S (2002). "Chiropractic: a profession at the crossroads of mainstream and alternative medicine". Ann. Intern. Med. 136 (3): 216–27. PMID 11827498. (110 citations)
• Balon J, Aker PD, Crowther ER; et al. (1998). "A comparison of active and simulated chiropractic manipulation as adjunctive treatment for childhood asthma". N. Engl. J. Med. 339 (15): 1013–20. PMID 9761802. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link) (104 citations)
• Skargren EI, Oberg BE, Carlsson PG, Gade M (1997). "Cost and effectiveness analysis of chiropractic and physiotherapy treatment for low back and neck pain. Six-month follow-up". Spine. 22 (18): 2167–77. PMID 9322328.{{cite journal}}: CS1 maint: multiple names: authors list (link) (104 citations)
• Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG (1998). "Use of chiropractic services from 1985 through 1991 in the United States and Canada". Am J Public Health. 88 (5): 771–6. PMC 1508935. PMID 9585743.{{cite journal}}: CS1 maint: multiple names: authors list (link) (102 citations)
• Hufnagel A, Hammers A, Schönle PW, Böhm KD, Leonhardt G (1999). "Stroke following chiropractic manipulation of the cervical spine". J. Neurol. 246 (8): 683–8. PMID 10460445.{{cite journal}}: CS1 maint: multiple names: authors list (link) (101 citations)

As can be seen, effectiveness/efficacy is by far the most important topic in highly-referenced scholarly sources about chiropractic.

Of course this is just one rough measure, and shouldn't dictate our treatment. However, it is a strong indication. If we were to judge just by the top 11 sources, about half of the space in Chiropractic should be devoted to effectiveness. Currently by my count, effectiveness gets only 18% of the words in Chiropractic, which suggests that the coverage of effectiveness should be strengthened, not weakened.

I'm not saying we should cite these sources. Far from it! Many of them are old primary sources, and as per WP:MEDRS we should prefer recent reviews. However, they strongly suggest that effectiveness is a key issue, perhaps the key question, in chiropractic.

Eubulides (talk) 02:02, 19 November 2008 (UTC)

• I think you've misunderstood the issue. The issue is that the section currently equates "effectiveness of SM" with "effectiveness of chiropractic". Not only that, it equates "efficacy of all SM" with "efficacy of chiro SM". Chiropractors adjust more than just the spine. Also, I'm not sure that treatments such as SOT "blocking" would count as SM. They also provide non-manipulative therapies such as prescribing orthotics to fix gait, etc. That said, I don't think this article should be exhaustive in answering the question of efficacy. The basic problem is that, at the moment, we are not answering the question "does chiropractic work?", we are answering the more narrow and different question "Does generic spinal manipulation work?" --Surturz (talk) 03:15, 19 November 2008 (UTC)

• Of course, we have seen problems with using google scholar previously. In addition, as Surturz states, the question "Does chiropractic work" (chiropractic efficacy) is different than "does spinal manipulation work" (SMT efficacy). If we do a google scholar search for chiropractic, 84,700 articles come up. Of these, only 12,900 mention the terms effectiveness or efficacy, which works out to about 15%, slightly less than the 18% you suggest we currently devote to coverage of effectiveness here. However, that still leaves the question of whether they are discussing the efficacy of chiropractic, or the efficacy of spinal manipulation. If we search google scholar for articles that contain Chiropractic, "spinal manipulation" or "spinal manipulative" AND "efficacy" or "effectiveness", only around 2,500 articles show up. That works out to be around 3%. Certainly, none of this suggests that the coverage of effectiveness should be strengthened. DigitalC (talk) 03:46, 19 November 2008 (UTC)

• The query I did emphasized the highest-quality articles, the ones with the most citations. The queries DigitalC covered all articles, even though that only glancingly mentioned chiropractic; this is a less reliable way to estimate the most important topic in highly-referenced scholarly sources. You can see a similar effect by searching for "homeopathy" in Google Scholar; at a quick glance, all the top-10-cited articles are about effectiveness, even though less than half the articles that mention "homeopathy" also mention either "effectiveness" or "efficacy". At this point I'd rather not rediscuss the issue of chiropractic SM versus general SM. Eubulides (talk) 04:47, 19 November 2008 (UTC)

• I don't know why the straw man impossible question "Does chiropractic work?" is now resurfacing. It's an absurd question that can't be answered. We have therefore chosen to focus on its primary method, the one and only thing upon which all chiropractors agree, and the method by which the professsion is known - spinal manipulation. That's why a discussion of its effectiveness is related to chiropractic, and why it is included in this article. -- Fyslee / talk 05:21, 19 November 2008 (UTC)

I can see how you feel that "Does chiropractic work" is a straw man, in that it is a profession, and not a treatment. However, we should only discuss chiropractic effectiveness the way sources on Chiropractic (in general) discuss effectiveness. Respectfully, I submit that we are not allowed to chose to focus on its primary method - we have to follow the sources. We have to look back to sources on Chiropractic (again, in general) to determine what weight they give to discussing the effectiveness of Chiropractic. DigitalC (talk) 00:29, 20 November 2008 (UTC)

Eubulides said, "As can be seen, effectiveness/efficacy is by far the most important topic in highly-referenced scholarly sources about chiropractic." Sorry if this is a stupid question, but does that mean that some of those sources you just found can be used as good-quality sources about the effectiveness of chiropractic treatment which actually mention chiropractic rather than just being about general SMT? ☺Coppertwig(talk) 00:50, 20 November 2008 (UTC)

The effectiveness-related sources are not nearly as good as the sources already used in Chiropractic #Effectiveness. They are older primary sources, and as per WP:MEDRS and WP:RS more-recent reviews (secondary sources) should be used. Let's take as an example Cherkin et al. 1998 (PMID 9761803), the most-cited source above; it is an older primary study that is reviewed (along with 38 other randomized controlled trials) by Assendelft et al. 2004 (PMID 14973958), a Cochrane Collaboration review. Eubulides (talk) 04:20, 20 November 2008 (UTC)

References

Please keep this section at the bottom. TO ADD A NEW SECTION, just click the EDIT link at the right and add the new section ABOVE this one. Then copy the heading into the edit summary box.

(The following resolve otherwise-dangling references: )