Talk:Chiropractic

RfC: Effectiveness of chiropractic care

This is an updated version of Talk:Chiropractic/Archive 18 #RfC: Effectiveness of chiropractic care. It attempts to address some of the comments brought up in that discussion. There seems to be no serious dispute that there is a serious POV problem in the current coverage of effectiveness in Chiropractic, so I won't repeat Talk:Chiropractic/Archive 18 #POV in existing coverage. Again, this is a controversial issue that may require some work to resolve; please bear with the following exposition as it covers many issues. Eubulides (talk) 08:50, 12 May 2008 (UTC)

To help other editors follow this discussion better, please place comments below, after the the proposal.

Criticisms of earlier proposed fix

Earlier I proposed Scientific investigation 2, a draft that relies on recent high-quality scientific sources, along with a proposal to remove the obsolescent material. This draft has been discussed extensively in Talk:Chiropractic/Archive 18 #Comments on Scientific investigation 3, so far with no consensus. To help move matters forward I have drafted a new section below, #Scientific investigation 3, which attempts to respond to some (but not all) the concerns expressed. These concerns (italicized below) included the following:

• Effectiveness of treatments should not be discussed in chiropractic; it should be discussed under each form of treatment. Most of the literature cited in #Scientific investigation 3 focuses on effectiveness of chiropractic treatment, not simply treatment by any practitioner. It is therefore inappropriate to move it to treatment pages per se. The few counterexamples are highly relevant to chiropractic; if there is a specific complaint about any of them, please mention it. To help underscore the relevance I have added a citation to Meeker & Haldeman 2002 about the relationship between chiropractic and research into SMT effectiveness.

• Undue weight given to spinal manipulation. The weight given is appropriate: spinal manipulation is the core treatment modality of chiropractic, and is naturally heavily empahsized in reviews of the effectiveness of chiropractic care.

• Clinical practice guidelines are omitted. They were present in the 1st draft, and were omitted from the 2nd draft in the interest of brevity. I have restored them in the 3rd draft.

• Ernst is fringe. No, he's a mainstream researcher who gets cited a lot.

• More sources are needed. None were suggested. I did turn up some more sources on my own, which are included in #Scientific investigation 3.

(Again, please place further comments below.)

Revised proposal for fix

The revised proposed fix is to replace the sections Chiropractic #The Manga Report through Chiropractic #Scientific investigation with the following text (between the horizontal lines), to keep Chiropractic #Safety unchanged, and to replace the "===Vaccination===" with "==Vaccination==" (as that section has nothing to do with scientific investigation).

(Again, please place further comments below.)

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Scientific investigation 3

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care. Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims.

Effectiveness 3

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective. Chiropractic care, like all medical treatment, benefits from the placebo response. The efficacy and cost-effectiveness of maintenance care in chiropractic is unknown.

Research has focused on spinal manipulation therapy (SMT) rather than specifically on chiropractic SMT, but the distinction is not significant: chiropractors use all forms of SMT, more than 90% of SMT in the U.S. is done by chiropractors, and SMT research is equally of value regardless of practitioner type. There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks. Many controlled clinical studies of SMT are available, but their results disagree, and they are typically of low quality. It is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect. Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference, a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.

Available evidence covers the following conditions:

• Low back pain. Opinions differ on the efficacy of SMT for nonspecific or uncomplicated low back pain. An authoritative 2004 review found that SMT or mobilization is no more or less effective than other interventions. A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care. A 2007 literature synthesis found good evidence supporting SMT 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.

• Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain. An authoritative 2004 review found that SMT/mobilization is effective only when combined with other interventions such as exercise. A 2008 review found that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis. A 2007 review found that SMT and mobilization are effective for neck pain. A 2005 review found little investigative research into chiropractic manipulative therapy for acute neck pain.

• Headache. An authoritative 2004 review found that SMT may be effective for migraine and tension headache, and SMT and neck exercises may be effective for cervicogenic headache. A 2006 review found no rigorous evidence supporting SMT or other manual therapies for tension headache. A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.

• Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, and a lack of higher-quality publications supporting chiropractic management of leg conditions. A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine) and no scientific data for idiopathic adolescent scoliosis. A 2007 systematic review found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions. Other reviews have found no evidence of benefit for baby colic, bedwetting, fibromyalgia, or menstrual cramps.

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(End of proposed replacement text.)

(Please place further comments below.)

Comments on Scientific investigation 3

(Please put comments here.)

I was editing this article in February, and have been meaning to return when I have time. I've heard that there are difficult disputes here and thought I might at least see what's happening and maybe even help resolve some disputes, as well as participating in editing. For now, I'm offering my opinion for this RfC.

The proposed text above is, in my opinion, a vast improvement over that section of the current article, in terms of being organized in a logical and relevant way. The current article gives undue prominence to the name of a particular study and to funding issues, which are not of fundamental importance and which will become dated. Focussing on effectiveness for various parts of the body is a relevant way to organize the information. It's readable, and I didn't see any problems with it.

Re "Effectiveness of treatments should not be discussed in chiropractic; it should be discussed under each form of treatment." Different articles can have some overlap of content; see WP:SUMMARY. If any particular section forms too long a stretch of text which overlaps between two articles, one of them can be shortened to a summary, with a {{main}} hatnote directing the reader to a section-link of the other article for more information. I don't think any one of the above short sections about each condition or body part is long enough to merit such summarizing. In my opinion, effectiveness is of fundamental relevance to this subject and belongs in this article (though it can also occur in other articles too).

Re "Undue weight given to spinal manipulation": I agree that spinal manipulation is fundamental to chiropractic; it's hard to imagine how it could be given undue weight in this article. I'd have to see specific arguments about what else needs to be mentioned. ☺ Coppertwig (talk) 10:20, 12 May 2008 (UTC)

Thank you Coppertwig, for coming back to weigh in on this edit! Please stick around as long as you can. I agree with your points. Spinal manipulation is fundamental and needs to be here in this article. Another objection often made is that studies of non-chiropractic manipulation are not relevant in considering effectiveness of SMT. Even Dr. Meeker, a prominent chiropractic researcher says that "research on spinal manipulation, like that of any other treatment method is equally of value regardless of the practitioner"(from #111, above)--—CynRN ^(Talk) 16:24, 12 May 2008 (UTC)

While I do feel that this version is better than the previous versions, I am unsure about two things:

1. That even though one researcher is saying it is okay to correlate general SMT studies with the effectiveness of chiropractic, our following this researcher's advice still may cause a WP:SYN violation. Even though we are spelling it out for the reader that these studies are about SMT and not chiropractic specifically, we are also implying (or rather now directly stating) that the conclusions of these general SMT studies can be applied to the effectiveness of chiropractic.
2. DigitalC, CorticoSpinal, and several others have raised objections that Chiropractic is an occupation which employs many services and modalities and not any one specific modality. As such, the inclusion of the above material would be like the inclusion of an effectiveness section at the Dentistry article based on the effectiveness of Fluoride as administered by dentists, hygienists, the gov't via tap water, etc.

Levine2112 ^discuss 17:26, 12 May 2008 (UTC)

I hear the argument (re #2), but the fact is that SMT is the centerpiece of chiropractic. Is there much controversy about the effectiveness of a dentist removing caries from teeth? Is there a long, involved holistic philosophy connected with dentistry? Apples and oranges. There is controversy surrounding chiropractic, in part because of the whole subluxation paradigm. As long as the section explains again that chiropractors do a range of treatments besides SMT, the effectiveness of SMT really belongs here.There are plenty of studies, and reviews of same, regarding the effectiveness of SMT.--—CynRN ^(Talk) 18:37, 12 May 2008 (UTC)

Actually, yes there is much controversy surrounding dental caries: Dental amalgam controversy. And holistic dentistry has been around for at least 30 years; specifically founded by the anti-mercury/amalgam movement. So you see, it's not apples to oranges after all. -- Levine2112 ^discuss 18:51, 12 May 2008 (UTC)

Of course, I figured you'd bring that up! How many holistic dentists are there as a percentage of all, vs 'holistic chiropractors'? Are there any non-holistic chiropractors? What is non-controversial, I would think, is 'treatment of dental decay'. Whether we choose composite fillings or amalgam is a different issue.--—CynRN ^(Talk) 23:00, 12 May 2008 (UTC)

Holistic dentistry is quite different from Dentistry, just as Chiropractic is quite different from mainstream Medicine. If there were an article on Holistic dentistry (there isn't, yet), I'd expect it to cover effectiveness in some detail, as that's an important part of the controversy about holistic dentistry. Eubulides (talk) 07:35, 13 May 2008 (UTC)

"There are plenty of studies, and reviews of same, regarding the effectiveness of SMT". Agreed. There are pleny of sources discussing the effectiveness of SMT. However, SMT is not chiropractic, and the effectiveness of SMT belongs over at the SMT article. DigitalC (talk) 00:03, 13 May 2008 (UTC)

The cited sources in #Scientific investigation 3 are by and large not talking just about SMT. They are mostly talking about chiropractic care. Is there any particular source being objected to here? Eubulides (talk) 07:35, 13 May 2008 (UTC)

• Re Levine2112's #1, it's not just "one researcher"; Meeker & Haldeman are two of the very top chiropractic researchers. For example, Haldeman is the editor in chief of PPC, the leading chiropractic textbook. These reliable sources say there's no significant distinction between chiropractic and non-chiropractic SMT. There doesn't seem to be any real controversy over this issue among reliable sources. It is not WP:SYN to report what these sources say. That being said, if there is a specific source being objected to on the grounds that it talks about SMT and not chiropractic SMT, which source is it and why? If this is just a matter of a few sources and how they're characterized perhaps we can come up with compromise wording that will address this concern.
• Re Levine2112's #2:

• Chiropractic is not just a profession: it is also a philosophy, and a way of doing treatment.
• As far as Wikipedia goes, the Chiropractic article is much closer to the Traditional Chinese medicine article than it is to the Dentistry article. Chiropractic and Traditional Chinese medicine are both somewhat out of (but also somewhat in) the mainstream, and there are serious questions about effectiveness of the main forms of treatment for both Chiropractic and Traditional Chinese medicine. Criticisms of dental care (as in the amalgam controversy) are not in the same ballpark: they do not seriously question the effectiveness of core dental care methods.
• There is ample precedent in Wikipedia for covering effectiveness and safety of treatment for professions that are not entirely mainstream. This includes not just Chiropractic and Traditional Chinese medicine, but others such as Ayurveda, Naprapathy, and Osteopathy.
• Chiropractic #The Manga Report and Chiropractic #Worker's compensation studies contain extensive discussion of effectiveness and cost-effectiveness of chiropractic care, and this coverage has been in Chiropractic for quite some time. It seems very odd to raise the objection "chiropractic is a profession" now. The proposal is not to add discussion of effectiveness; it is to replace the existing obsolete and biased coverage.

More generally, the question is not whether #Scientific investigation 3 is perfect; it's not. The question is whether it's better than what's in Chiropractic now. It is. It's way better. It fixes serious POV problems, among other things. We should not let the relatively minor problems of the current proposal blind us to the fact that it's a real improvement and it therefore should go in. We can always improve it later. Eubulides (talk) 07:35, 13 May 2008 (UTC)

Well, I guess that's your opinion - that chiropractic is closer to Traditional Chinese medicine than it is to Dentistry. I don't share that opinion; not do I think that either of our personal opinions should dictate what kind of information we include in this article. -- Levine2112 ^discuss 16:15, 13 May 2008 (UTC)

• All I meant was that chiropractic is neither fully mainstream (like dentistry) nor fully fringe science (like homeopathy). It has elements of both, as does traditional Chinese medicine. Even a cursory treatment of chiropractic needs to address the issue of whether it is effective, because this is a serious question as to commonly-practiced parts of chiropractic care. In this sense, chiropractic is more like traditional Chinese medicine than it is like dentistry.
• One doesn't have to take my word for this. Just type "fringe chiropractic" into Google Scholar and you'll find lots of papers about chiropractic vis-a-vis fringe medicine. Type "fringe dentistry" and you'll find lots of papers about fringe benefits and fringe patterns, and precious little about fringe medicine. Or, please see Keating 1997, where it's explicitly stated that chiropractic uses scientific, antiscientific, and pseudoscientific rhetoric. One doesn't find similar articles about dentistry.

Eubulides (talk) 19:59, 13 May 2008 (UTC)

Again, I find that this section fails to mention the many other treatments provided by Chiropractors, and the efficacy of such other treatments. There is no mention of Ultrasound, Laser, IFC, Orthotics, Prescribed Exercises, or even soft tissue therapy.DigitalC (talk) 23:59, 12 May 2008 (UTC)

Actually, #Effectiveness 3 mentions laser, and supervised / customized exercise. It also mentions many other non-SMT treatments provided by chiropractors, including mobilization, assurance and advice to stay active, educational videos, acupuncture, and the entire clinical encounter of chiropractic care. It does not cover the other treatments you mention (ultrasound, IFC, orthotics, soft tissue therapy) because as far as I know the cited sources don't say anything definitive about those forms of treatment. If someone can dig up reliable sources for those treatment forms, that would be nice; in the meantime, the #Effectiveness 3 is much better than the effectiveness material that is in Chiropractic now. Eubulides (talk) 07:35, 13 May 2008 (UTC)

We should certainly think carefully about the WP:SYN issue raised by Levine2112. Note that the Meeker et al. (2007) study uses the word "chiropractic" as well as the phrase "spinal manipulation", so I see no SYN problem in citing it. For the other studies, I think it would be an improvement if we simply cited the studies, implying but not stating outright that SMT studies shed light on chiropractic effectiveness. I would delete the sentence "Research has focused on spinal manipulation therapy (SMT) rather than specifically on chiropractic SMT,[18] but the distinction is not significant: chiropractors use all forms of SMT, more than 90% of SMT in the U.S. is done by chiropractors, and SMT research is equally of value regardless of practitioner type." I think this is good information for us to use here on the talk page while deciding whether the SMT studies can be used, but that including it in the article perhaps contributes to a SYN violation. If that sentence is deleted, the rest of the paragraph may need to be reorganized to flow smoothly.

Thanks, Eubulides, by the way, for your patience and diligence in coming up with yet another draft version.☺ Coppertwig (talk) 09:29, 13 May 2008 (UTC)

You're welcome. I removed that sentence from the draft in #Scientific investigation 3C. I agree that it's better to leave it out in future drafts as well; the citation was there only because of Levine2112's continuing concerns about generic SMT research versus research specifically on chiropractic care. Eubulides (talk) 20:55, 13 May 2008 (UTC)

I think that sentence was added to avoid any synthesis and to make it clearer to the reader. QuackGuru 09:36, 13 May 2008 (UTC)

I think that sentence is an attempt to justify the synthesis. Essentially, it may be the opinion of one researcheer (or one team of two researchers), but we can't then go ahead and apply it to the SMT research across the board. That is where the WP:SYN violation happens. That said, I maintain that we should remove all studies which are about SMT in general and do not make distinct conclusions about chiropractic specifically. These general SMT studies would be perfect for the spinal manipulation article. -- Levine2112 ^discuss 16:09, 13 May 2008 (UTC)

Spinal manipulation is inherent to chiropractic as its most commonly performed modality and we should not second-geuss the reviewers. QuackGuru 18:06, 13 May 2008 (UTC)

(outdent) I strongly disagree that generic SMT research should be excluded from Chiropractic. It's standard practice in high-quality chiropractic sources to include such research, we have a high-quality chiropractic source saying that there's no significant difference between chiropractic and non-chiropractic research data in SMT, and we have no high-quality sources disagreeing. However, to help move the discussion ahead I propose a new version #Scientific investigation 3C below, which excludes generic SMT research. That is, all the sources #Scientific investigation 3C talk explicitly about chiropractic care, not just about SMT (or mobilization or whatever) in general. Eubulides (talk) 19:59, 13 May 2008 (UTC)

Researchers commonly apply regular SMT research and sources indicate there is no sigificant difference among the high quality studies. This version is a bit short and could use a slight expansion. QuackGuru 11:50, 14 May 2008 (UTC)

Here is what the scientific investigation (now renamed scientific research) section of the article was at the beginning of year. The current version includes newer peer-reviewed references and is very concise. QuackGuru 13:11, 14 May 2008 (UTC)

Proposal for fix 3C

I view this "3C" draft as being far inferior to #Scientific investigation 3 due to 3C's weaker sourcing, but 3C is still much better than what's in Chiropractic now. I offer 3C as an attempt to fix Chiropractic's obvious datedness and POV problems now, and to continue the discussion here about what to do about the generic SMT studies.

The revised proposed fix is to replace the sections Chiropractic #The Manga Report through Chiropractic #Scientific investigation with the following text (between the horizontal lines), to keep Chiropractic #Safety unchanged, and to replace the "===Vaccination===" with "==Vaccination==" (as that section has nothing to do with scientific investigation).

(Please place further comments below.) Eubulides (talk) 19:59, 13 May 2008 (UTC)

Scientific investigation 3C

In the current healthcare environment, The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which treatments are legitimate and perhaps reimbursable under managed care. Chiropractic treatments are evaluated using those same standards. Evidence-based guidelines are supported by many chiropractors while others remain pseudoscientific and antiscientific and make unsubstantiated claims. Research has focused specifically on spinal manipulation therapy (SMT) rather than on the whole chiropractic visit and all that is involved in the patient encounter, some of which may be the result, as with all healthcare encounters, of the placebo effect, The distinction is not significant regarding who performs SMT for musculoskelatal conditions.

Effectiveness 3C

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective. As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective. Chiropractic care, like all medical treatment, benefits from the placebo response. Few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality. The efficacy and cost-effectiveness of maintenance care in chiropractic is unknown.

Research has focused on spinal manipulation therapy (SMT) in general, rather than specifically on chiropractic SMT. There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks. A 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition.

Available evidence covers the following conditions:

• Low back pain. A 2007 literature synthesis found good evidence supporting SMT 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. A 2008 critical review found that chiropractic SMT is possibly effective for back pain, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference.

• Other musculoskeletal conditions. A 2005 review found little investigative research into chiropractic manipulative therapy for acute neck pain. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, and a lack of higher-quality publications supporting chiropractic management of leg conditions. A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine).

• Nonmusculoskeletal conditions. A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine. A 2007 systematic review found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions. Other reviews have found no evidence of benefit for baby colic, bedwetting, or fibromyalgia.

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(End of proposed replacement text.)

(Please place further comments below.) Eubulides (talk) 19:59, 13 May 2008 (UTC)

Comments on Scientific investigation 3C

(Please put comments here.)

I agree that if the premier chiropractic researchers use generic SMT studies in their reviews, we should be able to use them too. However, Sci Inv 3C is far better than what's in the article now, so let's replace Manga and Worker's Comp with it.--—CynRN ^(Talk) 04:41, 14 May 2008 (UTC)

This extremely short version runs afowl with NPOV. More importantly, the reader deserves to read a comprehensive version. A comprehensive version is more imformative for the reader. This lack of information version is not it. It is way to short and is below Wikipedia's standard. QuackGuru 11:45, 14 May 2008 (UTC)

Where does it run afowl with NPOV?DigitalC (talk) 23:43, 14 May 2008 (UTC)

I am happy with 3C.DigitalC (talk) 06:08, 15 May 2008 (UTC)

I'm guessing maybe QuackGuru means that by being too short, it's not giving due weight to effectiveness of SMT to reflect how much that's discussed in the sources. I apologize in advance if I got that wrong, QuackGuru. ☺ Coppertwig (talk) 02:57, 16 May 2008 (UTC)

I think this version gives far too much wait to this opinion: "A 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition." This comes from a major chiropractic critic often accused of bias and not necessarily a neutral researcher. As such it should be balanced or removed. That said, I am all for keeping this section brief if we have it at all. This is an article about Chiropractic and not about SMT. All of the details about every study ever conducted about SMT should be saved for spinal manipulation. -- Levine2112 ^discuss 03:10, 16 May 2008 (UTC)

A major chiropractic critic often accused of bias and not necessarily a neutral researcher? Please provide your evidence. Ernst is peer-reviewed and meets the inclusion criteria for this article. We should edit based on NPOV and exclude any personal opinion. Thus, we can include Ernst. QuackGuru 03:20, 16 May 2008 (UTC)

Yes, but this version gives his opinion far too much prominence. -- Levine2112 ^discuss 03:26, 16 May 2008 (UTC)

That's your opinion. Please provide evidence of any bias by Ernst. QuackGuru 03:33, 16 May 2008 (UTC)

Not even mainstream medicine listens to Ernst re: his views on the safety and effectiveness of spinal manipulation for back pain. His view is fringe. It can be proved. To repeat: Ernsts (MD) views on spinal manipulation is the FRINGE viewpoint within respect to mainstream medicine. It will be weighed as such. He is not an expert on SMT nor chiropractic, but is simply a vocal critic who is coming off as increasingly righteous and pig-headed despite the mounting evidence which negates his POV. CorticoSpinal (talk) 05:33, 16 May 2008 (UTC)

Ernst is not fringe. His works are often cited by his peers. I just now visited Google Scholar and typed the query "chiropractic Ernst". This returned about 2390 citations. In the first page, one source by Ernst (the 2001 desktop guide) was cited 280 times. Another by Ernst (the 2000 BBC survey) was cited 170 times. All of these numbers beat the query "chiropractic Haldeman" (1230 citations, top two sources on the 1st page cited 107 and 97 times). By this measure, or any other reasonably neutral measure, Ernst is one of the top current sources in the area. Eubulides (talk) 07:35, 19 May 2008 (UTC)

Citations does not necessarily translate into positive remarks on his work. It has also generated significant controversy and those same papers would have to cite his work in order to talk about it. Since it is the most vocal anti-SMT voice, both chiropractic researchers and healthcare researchers reference it as the most extreme, which I would assume would be considered the "fringe" of science.. but you know what assuming does. But, regardless, we can't just assume that citations translates into quality or mainstream. -- Dēmatt (chat) 11:51, 19 May 2008 (UTC)

I tested the theory that citations to Ernst are to cover the controversy by taking the most-cited work of Ernst mentioned above (the desktop guide), going to Google Scholar, finding which works cite it, looking at the first page of results, and reading each of the papers that cite it. I skipped the papers cowritten by Ernst himself for obvious reasons. None of the citations mentioned any controversy; they all simply cited Ernst as an authority. The papers I examined were Marty 2002 {{doi:10.1089/107555302317371523}}, Mason et al. 2002 (PMID 12376448), Bair et al. 2002 (PMID 12406817), Cohen & Eisenberg 2002 (PMID 11955028), and Cherkin et al. 2003 (PMID 12779300). These papers are all highly-cited (all have at least 45 citations). Of course this is just a spot-check, but it suggests that Ernst is not considered to be fringe by mainstream researchers. Eubulides (talk) 20:47, 19 May 2008 (UTC)

Evidence of bias by Ernst:

• Evans, W. (2003). "Chiropractic Care: Attempting A Risk-benefit Analysis". American Journal of Public Health. 93 (4): 522. Retrieved 2008-05-20.
• Bronfort, G. (2006). "Review conclusions by Ernst and Canter regarding spinal manipulation refuted". Chiropractic & Osteopathy. 14 (1): 14. doi:10.1186/1746-1340-14-14. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)CS1 maint: unflagged free DOI (link)
• Hurwitz, E.L. (2002). "Chiropractic care: a flawed risk-benefit analysis?". Am J Public Health. 92 (10): 1603–4. Retrieved 2008-05-20. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
• Morley, J. (2001). "Ernst Fails to Address Key Charges". The Journal of Alternative & Complementary Medicine. 7 (2): 127–128. doi:10.1089/107555301750164145. {{cite journal}}: Unknown parameter |coauthors= ignored (|author= suggested) (help)
• "Profession Responds Quickly to Negative U.K. Study on Spinal Manipulation". Retrieved 2008-05-20.
• SPINAL MANIPULATION DOES WORK: THE FACTS FROM THE BCA
• A balanced review of evidence?

DigitalC (talk) 06:40, 20 May 2008 (UTC)

Yes, Ernst is strongly opposed by many in the chiropractic profession, and those citations illustrate this opposition. However, this does not undercut the claim that citations to Ernst by high-quality mainstream publications are, by and large, positive. Eubulides (talk) 07:20, 20 May 2008 (UTC)

Being opposed by many in the chiropractic profession doesn't have anything to do with research. Research doesn't oppose anything, it is what it is; it either supports or it doesn't. DigitalC's information does show that at least some of those 2390 citations are not positive, which, of course, was my point above. I would suggest that no-one has disagreed with Haldeman's research because he is a neurologist/chiropractor. Maybe that is why he has only half the citations :-) Anyway, I think this shows that Ernst is Ernst and we use his information just as we would Haldemans's or anyone else's. -- Dēmatt (chat) 13:23, 20 May 2008 (UTC)

Obviously some of the citations are negative. But my spot-check from Google Scholar suggests that most of them are positive. (It doesn't prove this, of course; it was only a spot-check.) And it is not true that nobody has disagreed with Haldeman; I can easily cite sources strongly criticizing Haldeman's work. I agree that we should cite Haldeman as well as Ernst; both are leading and reliable sources. Eubulides (talk) 22:16, 20 May 2008 (UTC)

If most of them are positive, then why is more weight being given to the negative ones in the version above? Featuring this - "chiropractic SMT has not been shown to be effective for any medical condition" - so prominently in the lead of this section seems to violate WP:WEIGHT - especially in the context given. I believe enough concern has been raised about Ernst's lack of objectivity, that giving his opinions so much weight seem unjust to the article. -- Levine2112 ^discuss 22:38, 20 May 2008 (UTC)

That quote is preceded by "Although a 2008 critical review found that with the possible exception of back pain" so it is not as strong as that out-of-context snipped would make it appear. Furthermore, the sentence containing quote also says "a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments" (citing Bronfort et al. 2008, PMID 18164469). This is a strong criticism that immediately undercuts Ernst's claims. If anything, this is being unfair to Ernst; it's not the sort of treatment that any other source is being given here. Given all this context, it's not out of line to let Ernst briefly have his say. Eubulides (talk) 02:16, 21 May 2008 (UTC)

A mischaracterization of what was posted above. In some of the papers there is no way to know what degrees/professions the authors have. For example, in the Bronfort et al. paper, we get these associated groups, but no degrees. (Chalmers Research Group, Evidence-based Practice Center, Departments of Pediatrics, Epidemiology and Community Medicine, University of Ottawa, 401 Smyth, Ottawa ON, K1H8L1, Canada; 4Institute for Research in Extramural Medicine, Vrije Universiteit Medical Centre, The Netherlands; 5Texas Back Institute, 6300 W. Parker Road, Plano Texas 75093, USA; 6Department of General Practice and Nursing Home Medicine, LUMC Medical Centre, Leiden, The Netherlands). In addition, one of the Authors, Assendelft, is a prior co-author with Ernst, and an MD, NOT a Chiropractor. He's also writes cochrane reviews, so he probably knows how to assess evidence.DigitalC (talk) 07:56, 20 May 2008 (UTC)

It is not a mischaracterization. The Bronfort et al. paper has 10 authors, of which 5 have DCs (including Bronfort, the lead author) and 1 (Assendelft) has an MD. So it's strongly dominated by chiropractors. The other sources are even more strongly dominated by chiropractors. Ernst has cowritten more than a dozen Cochrane reviews so I daresay he knows how to assess evidence as well. What we have here is a difference of opinion among experts, a difference that should be reported fairly and neutrally; Ernst is not at all on the fringe here. Eubulides (talk) 09:17, 20 May 2008 (UTC)

It IS a misrepresentation of the sources to state as a summy that "Ernst is strongly opposed by many in the chiropractic profession", when the sources are not solely Chiropractors.DigitalC (talk) 11:20, 20 May 2008 (UTC)

It is not a misrepresentation. The sources given were:

• A letter by a DC (Evans).
• A paper with 5 DC and 1 MD coauthors, the lead being a DC (Bronfort et al.; 4 coauthors were neither DCs nor MDs)
• A letter signed by 3 DCs and zero MDs (Hurwitz et al.).
• A letter signed by 2 DCs and zero MDs (Morley et al.; 1 coauthor was neither DC nor MD).
• An article about chiropractors lobbying against Ernst (Dynamic Chiropractic).
• A position paper by the British Chiropractic Association.
• A letter signed by 2 DCs and zero MDs (Breen et al.; 3 coauthors were neither DC nor MD).

It's true that there are some non-chiropractors there, but these sources are heavily dominated by chiropractors. They may represent the mainstream of opinion within chiropractic, but they do not represent mainstream opinion generally. They do not at all demonstrate that Ernst is a fringe researcher. Eubulides (talk) 22:16, 20 May 2008 (UTC)

I was responding to QG's request for evidence of claims of bias towards Ernst. That is what I provided.

Ernst's conclusions are fringe and so are his opinions on the subject. His work on SMT and Chiropractic care has been terrible. He's represents the extreme on one end; the WCA represents the fringe on the other end. Both views should be discarded because they are just that, extremist. Ernst has been used to 'bomb' CAM related articles with his 'reviews' which he essentially reviews himself. CorticoSpinal (talk) 12:50, 21 May 2008 (UTC)

We appreciate that's your belief, but just restating it isn't convincing. If an author is heavily cited then it's pretty clear that people are listening to him. Regardless of ones personal beliefs on his work that makes him a notable party. Jefffire (talk) 13:00, 21 May 2008 (UTC)

(Undent) Here is the rift here. If we were to accept that chiropractic researchers are biased, then that acknowledges that medical research is biased. I personally think they are equally biased, but that is just my experience. Therefore, we have two choices, use them both as equal, or consider them POV and attribute the findings to the different sources. One method requires a littel more writing, but either can be productive and get toward the end product. -- Dēmatt (chat) 13:01, 20 May 2008 (UTC)

Once again Dematt comes up with the Solomonic solution - inclusion of all POV using good sources. I also agree with most of his comments. We are all biased, controversies occur, and those biases and controversies need to be documented here. We just need to do it properly. -- Fyslee / talk 14:38, 20 May 2008 (UTC)

That is the goal of #Scientific investigation 3. It includes both supportive and critical sources and cites them appropriately, with due weight given to all sides. Eubulides (talk) 22:16, 20 May 2008 (UTC)

Unfortunately it does not seem like your interpretation of Scientific Investigation 3 is shared by the majority of editors nor does it generally represent the conclusions of the scientific community (due to cherry picking of sources). CorticoSpinal (talk) 12:50, 21 May 2008 (UTC)

Looks quite sound to me. Could you give specific advice for how to improve it, rather than baseless sniping, thanks. Jefffire (talk) 13:00, 21 May 2008 (UTC)

Is there a reason that effectiveness 3C has been struck out entirely, and that multiple editors comments are struck out as well? I seem to have missed something. DigitalC (talk) 06:42, 31 May 2008 (UTC)

The talk page is now archived automatically by a bot. Sections that haven't been changed for 14 days get archived. If you want the section back, you can resurrect it by hand from the archive. Eubulides (talk) 07:56, 31 May 2008 (UTC)

Effectiveness 3C has not been archived, it has been struckout struck out. As have comments of more than one editor in relation to it. DigitalC (talk) 07:58, 1 June 2008 (UTC)

Sorry, I misunderstood, and I don't know who struck it out or why or when. I assume the history could tell you? Eubulides (talk) 08:39, 2 June 2008 (UTC)

I assume the history COULD tell me, however the functionality of the history is subpar, IMHO, and it would take hours to try and sift through and find the diff. Since you drafted the section, and didn't strike it out yourself, and since CynRN didn't chime in to say she struckout her comment (which has since mysteriously been unstruck, as has QGs), I will unstrike the entire section.

Continued discussion of Scientific investigation 3C

Okay, back to work on SCI 3C. I've sticken through:

• Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims.

Evidence based medicine does not care what your philosophy is, if it works it works. It doesn't matter which side of any arbitrary line you are on. This just seems like an opportunity to use the word pseudoscience, but it doesn't really fit. -- Dēmatt (chat) 13:55, 21 May 2008 (UTC)

It's true that evidence-based medicine is independent of philosophy. However, the point is that some chiropractors accept the principles of evidence-based medicine, and others don't. This is quite relevant to the subject of scientific investigation, because the entire philosophical basis of scientific investigation is questioned by a significant minority of chiropractors. For the purpose of this section, I agree "pseudoscience" isn't needed so I struck that instead. Eubulides (talk) 16:43, 21 May 2008 (UTC)

I'm not sure I'm buying that one, Eubilides. Let's put the groups scientific orientation in the sections that address their scope and leave this for the science - which doesn't care what race, creed, or color you are. -- Dēmatt (chat) 19:36, 21 May 2008 (UTC)

Other sections (notably Chiropractic#Philosophy already discuss this issue at some length. However, it's useful to put in a brief mention of the problem here. We can't expect every reader of this section to have read the whole article. Eubulides (talk) 20:13, 21 May 2008 (UTC)

Absence of adherence to EBM does not automatically imply pseudoscience. I wouldn't even go that far characterizing the straight wing. As on the Physical therapy page, a significant chunk of PTs don't use the evidence (thus far) but I would not call them pseudoscientific. Even the MDs who use outdated methods (antibiotics for sinus infections) for the last 40 years which was found to be of 0 benefit. I'm actually beginning to see some quality research designs by straight-leaning chiropractic schools in the US. I think they're getting it. Publish or perish (or lose market share to professions who will fill the gap). CorticoSpinal (talk) 18:06, 21 May 2008 (UTC)

The current 3C draft omits "pseudoscience", which should address the concerns mentioned here. Eubulides (talk) 20:13, 21 May 2008 (UTC)

because the entire philosophical basis of scientific investigation is questioned by a significant minority of chiropractors - Then what we would have to do is explain why, i.e. this is where Keating ref would come in with antiscience - it's not that they don't believe science or rational thinking, it is not trusting the scientist that is doing the research, i.e. drug companies performing the research on drugs, MDs evaluating chiropractic methods. It is more a distrust than a true antiscience. -- Dēmatt (chat) 18:29, 21 May 2008 (UTC)

It might be helpful to add a discussion of this point. However, the source (Keating 1997) does not address the trust issue, so we'd need a reliable source to justify the discussion. Eubulides (talk) 20:13, 21 May 2008 (UTC)

This statement does not match the source. I changed it as shown, it still needs work, but just to get it on paper disk.

• Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective. As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective.

-- Dēmatt (chat) 14:37, 21 May 2008 (UTC)

• • It does match the source. The source says "Nevertheless, there are different views concerning the efficacy of chiropractic treatment, which is not surprising. Unfortunately, it is difficult to establish definitive, unarguable, and conclusive findings regarding much in the healing arts despite the millions of papers that have been written about presumably scientifically sound studies. Because of this difficulty, numerous medical procedures have not been rigorously proven to be effective either." The sentence in question is an abridged version of this quote. The stuff about "as of 2002" is obsolete and should not appear here. Also, in general it's not a good idea merely to quote the source; we should use the ideas and not degenerate into a list of quotes. Eubulides (talk) 16:43, 21 May 2008 (UTC)
    • While attempting to be constructive, Eubulides, the tone of your message to Dematt comes off rather condescending and paternalistic to a highly respected editor. I'm sure that was not the intent, but I had mentioned this concern before and hope you realize that Dematt's editorial skills are appreciated by both proponents and skeptics. CorticoSpinal (talk) 18:06, 21 May 2008 (UTC) I can tell he was smiling when he said that ;-) It's okay, really, down doggie, down :-)

I'm reading the Pubmed version and don't see your sentence there. The doi link is not working for me. -- Dēmatt (chat) 18:42, 21 May 2008 (UTC)

The source is copyrighted and only the abstract is freely readable. The above quote is from the "Efficacy and Patient Satisfaction" section of the source. Eubulides (talk) 20:13, 21 May 2008 (UTC)

Nevertheless, I think we can write it more neutrally and fit the source better if we say it this way:

• Because it is difficult to establish definitive, unarguable, and conclusive findings regarding much in the healing arts, most medical procedures have not been rigorously proven to be effective. Chiropractic fits this category as well.

-- Dēmatt (chat) 19:31, 21 May 2008 (UTC)

That's less neutral than the current summary, because the cited source does not say "most medical procedures"; it merely says "numerous". Also, I don't see how adding all that other verbiage makes the summary more neutral. What's not neutral about the much-shorter "Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective."? Eubulides (talk) 20:13, 21 May 2008 (UTC)

I merged the second sentence to make it shorter, but don't want to lose the qualifying section of the sentence that explains to our readers who have no idea what 'rigorously proven' means. They need something to compare it to. All the reader sees is, "chiropractic treatment has not been proven to be effective" and of course that is not NPOV. We have to qualify it and still keep it along the lines of what the author was intending to say (which in the abstract was actually positive towards chiropractic), otherwise we are creating and SYN error, or OR. The other option is number three, where we use the information from the abstract itself:

• "Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective."?

• "Because it is difficult to establish definitive, unarguable, and conclusive findings regarding much in the healing arts; numerous medical procedures, including chiropractic care, have not been rigorously proven to be effective."

-- Dēmatt (chat) 20:50, 21 May 2008 (UTC)

It's not the case that 'All the reader sees is, "chiropractic treatment has not been proven to be effective"'. The reader also sees "Like many other medical procedures" at the start of the sentence. This places the claim in context. The wording also uses the word "rigorously" to make it clear that we're talking about proofs with a high degree of confidence. The quote from the source is wordy and the extra verbiage adds little; plus, we shouldn't just be stringing together quotes. I take it that the objection is that the summary does not mention the point that it's hard to establish definitive findings? Then how about rewording it to "It is hard to make definitive findings about much of medicine, and like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective." Eubulides (talk) 08:35, 22 May 2008 (UTC)

The placebo source is excellent, but the sentence is misplaced. I just struck it out for now.

• Chiropractic care, like all medical treatment, benefits from the placebo response.

-- Dēmatt (chat) 14:58, 21 May 2008 (UTC)

Thanks. But let's find a better home for it rather than just removing it. I unstruck it for now. Eubulides (talk) 16:43, 21 May 2008 (UTC)

I found one!, but you know that, it is below. I won't delete the other one until we're all happy with the new placement. -- Dēmatt (chat) 19:16, 21 May 2008 (UTC)

This sentence has problems with the source, too. It's about chiropractic care with Type O problems. It's giving suggestions about how to improve studies. It's not making any judgements about 'low quality"?

• Many studies of chiropractic care are available, but they are typically of low quality.

-- Dēmatt (chat) 15:30, 21 May 2008 (UTC) Thanks for catching that. The source says "the number of studies on chiropractic care and/or SMT and other manual therapies for patients with nonmusculoskeletal conditions is relatively small, and the quality of the studies is generally not high.". I think there was a similar source for MS that said "many studies" that got removed by later editing; I'll take a look for it but for now I reworded the claim. Eubulides (talk) 16:43, 21 May 2008 (UTC)

Again, I hope thatis the source that is not listed, or am I missing something with the doi ref? -- Dēmatt (chat) 19:19, 21 May 2008 (UTC)

Sorry, I don't follow. Many of the sources for Chiropractic are not free; Hawk et al. is one of them. That's life in the big research city, I'm afraid. All other things being equal we prefer free sources, but high-quality nonfree sources are fine when equal-quality free sources are not available. Eubulides (talk) 20:13, 21 May 2008 (UTC)

I'll take a break now. I feel like this version (3C) so far still does not follow the sources well enough to represent what they are saying. I think we might be trying to fit things into our "Efficacy", but we're having to use sources that aren't really addressing that. We're still not there. We may have to go to some primary sources as well. Perhaps a combination of this and that other version that CS brought us and call it something different. -- Dēmatt (chat) 15:37, 21 May 2008 (UTC)

Okay, so much for the break, but I saw SC investigation 3 above and saw this sentence:

• Research has focused on spinal manipulation therapy (SMT) rather than specifically on chiropractic SMT, but the distinction is not significant: chiropractors use all forms of SMT, more than 90% of SMT in the U.S. is done by chiropractors, and SMT research is equally of value regardless of practitioner type.

We could add the placebo reference here, like this:

• Research has focused specifically on spinal manipulation therapy (SMT) rather than on the whole chiropractic visit and all that is involved in the patient encounter, some of which may be the result, as with all healthcare encounters, of the placebo effect, The distinction is not significant regarding who performs SMT for musculoskelatal conditions.

Still needs work, but you get the idea. -- Dēmatt (chat) 16:10, 21 May 2008 (UTC)

I don't see why we'd want to move the placebo sentence from the generic paragraph to the SMT paragraph. The placebo effect applies to all treatments, not just to SMT. Eubulides (talk) 16:43, 21 May 2008 (UTC)

If placebo applies equally to all Tx (which it does) why redundantly mention it? CorticoSpinal (talk) 18:06, 21 May 2008 (UTC)

I'm okay with putting it in the generic paragraph, I'll do it now to see what it looks like. -- Dēmatt (chat) 18:48, 21 May 2008 (UTC)

By "generic" I meant "generic to effectiveness", not "generic to all research". Safety studies generally don't use placebos. How about moving it back to where it was, which was in the generic-to-effectiveness paragraph? Eubulides (talk) 20:13, 21 May 2008 (UTC)

I see that more material was added here, but I confess I don't see the point. I thought that the idea behind the 3C draft was to avoid all mention of sources unless they specifically talk about chiropractic care. And yet now a lot of material has been added that talks about SMT irrespective of chiropractic. But that's what Chiropractic#Effectiveness does. Why not start with that version, rather than the old 3C version whose goal in excluding all but specifically chiropractic sources was different (and by the way, was a goal I didn't agree with)? Eubulides (talk) 08:35, 22 May 2008 (UTC)

"Rigorously proven"

I agree with Dematt that the bit about "rigourously proven" is not a good abridgement of that source: it strikes me as implying much more strongly than the source does that chiropractic is unproven. I think a better abridgement of that source is the following direct quote from the source: "There are different views concerning the efficacy of chiropractic treatment." ☺ Coppertwig (talk) 00:10, 26 May 2008 (UTC)

And actually, I agree with Dematt that the quote about 30 of 43 studies is better. Eubulides, the quote you give from the source above does not actually state that the efficacy of chiropractic has not been rigorously proven. It leaves open the possibility, for example, that some people believe it to have been rigorously proven while others do not. Perhaps it implies that it has been rigorously proven and perhaps it does not, but it doesn't state it, so we shouldn't state it right out either based on that source. ☺ Coppertwig (talk) 01:31, 27 May 2008 (UTC)

• Sorry, I don't know what you mean by "the quote about 30 of 43 studies"; there's no string "30 of 43" anywhere else on this talk page.
• I don't see how to read the source in the way that you say. Nobody seriously argues that the efficacy of chiropractic care has been rigorously proven.
• That quote is there because of a common theme in many sources that although chiropractic care has not been rigorously proven, in this respect it's in the same boat as many other forms of medical treatment. That's an important point, which should be made. All too often, chiropractic critics say "the science isn't there" without noting that the science isn't there for many other forms of medical treatment, too. Perhaps DeVocht is not the ideal source to make this point, but it will do until we find a better one.
• We don't need DeVocht to support the claim that there are differing views of the subject; that claim is already stated elsewhere in the section, and is well-supported already (by better sources than DeVocht).

Eubulides (talk) 08:08, 27 May 2008 (UTC)

Thanks for your reply, Eubulides. Sorry I wasn't clearer. By "30 of 43" I meant "As of 2002, 43 randomized trials of spinal manipulation for low back pain had been published with 30 showing more improvement than with the comparison treatment, and none showing it to be less effective." However, as you point out, this would leave out the point about comparing with the situation with medical treatments.

I dispute whether the source supports the claim that "chiropractic treatment has not been rigorously proven to be effective". You said this was an abridgement of a paragraph you quoted above. I don't see how to read that paragraph the way you do. One possibility might be changing the footnote to a source which clearly makes this claim, if one can be found.

May I suggest another alternative wording: "It is difficult to establish conclusive findings regarding either chiropractic treatment or numerous medical procedures." Would you agree that that's a reasonable abridgement of the paragraph quoted?

I'll assume what you say is true, that "nobody seriously argues that the efficacy of chiropractic care has been rigorously proven." However, based only on this, it would be Original Research for Wikipedia to state that the efficacy of chiropractic care has not been rigorously proven. To state that, we would need a source which claims that the efficacy of chiropractic care has not been rigorously proven. Regards, ☺ Coppertwig (talk) 00:29, 2 June 2008 (UTC)

• That "30 of 43" comment is not worth mentioning here. Chiropractic#Effectiveness already cites far more-systematic (and more recent) reviews talking about SMT for low back pain, reviews that (like DeVocht) are favorable to chiropractic (e.g., Bronfort et al. 2008, PMID 18164469; or Meeker et al. 2007, no PMID), and DeVocht's opinion piece isn't close to being in their league. DeVocht is a reasonable source for supporting the argument that chiropractic care is like many other forms of medical treatment in that it hasn't been rigorously proven, but this is true mainly because the more-reliable sources don't address the point.
• I don't see how the proposed alternate wording solves the (to my mind hypothetical) problem. DeVocht nowhere says in one brief quote that it is difficult to establish conclusive findings regarding "chiropractic treatment". The proposed alternate wording relies on the fact that DeVocht is obviously including chiropractic treatment as being part of "much of the healing arts". But if there is some reluctance to say what DeVocht is obviously saying (namely that chiropractic care, like many other medical treatments, is hard to test and has not been rigorously proven), then this (to my mind hypothetical) objection applies with equal force to the proposed alternate wording. In that case, why change the wording to something that is longer and more confusing?

Eubulides (talk) 08:39, 2 June 2008 (UTC)

Thank you for your reply, Eubulides.

Perhaps I see a distinction that you don't – in which case it should perhaps be easy to find wording we can both agree on.

The paragraph quoted from the source implies that chiropractic care has not been rigorously proven to be effective. However, as I see it, it does not state that. I believe the author deliberately refrained from stating that, because it would be a statement which would be hard to prove and which could go out-of-date if new studies are published. Regardless of the reason why it doesn't state it, since (IMO) it doesn't, we shouldn't (IMO) state it either.

To my mind, the source also leaves open the possible alternative interpretations of "Numerous chiropractic treatments, like numerous medical procedures, have not been rigorously proven to be effective" or, along with the previous sentence, "Much of chiropractic is difficult to prove effective ... numerous medical procedures have not been proven effective either." If I understand what you're saying, Eubulides, you mean that it's not completely clear whether all of chiropractic is intended to be included in "much of the healing arts".

To me, there is an important distinction between "it is difficult to establish conclusive findings," which implies but does not state that there is no rigorous proof, and "has not been rigorously proven," which states it outright and is a very strong, probably impossible-to-prove and therefore perhaps unscientific statement when applied to all of chiropractic care as opposed to being applied to an unspecified and therefore flexible set of medical procedures. A scientist can state that they have not seen proof of something and we can all conclude from that that there probably isn't proof, since the scientist probably keeps up with the literature; but a scientist is less likely to state confidently that no proof exists anywhere.

Just making a sentence a little longer and more confusing is a minor problem, to my mind, in comparison to the importance of adhering to WP:V and avoiding stating something which is not (IMO) stated in the source (as represented in that paragraph), and which you seem to be saying is not stated in the other, more reliable, sources either. However, the first three of the suggested alternative wordings below are shorter and arguably simpler than the current wording:

• "Like many other medical procedures, chiropractic treatment is difficult to test." (short and simple.)
• "As with numerous medical procedures, the effectiveness of chiropractic treatment is difficult to test."
• "Like many other medical procedures, chiropractic treatment is difficult to rigorously prove effective."
• "There are difficulties in trying to rigorously prove effectiveness for many health care treatments, including chiropractic treatment as well as numerous medical procedures."
• "Numerous medical procedures have not been rigorously proven effective; this is also true of chiropractic treatments." (deliberately ambiguous – perhaps we shouldn't do that, though)
• "Numerous medical procedures and chiropractic treatments have not been rigorously proven to be effective." (also deliberately ambiguous: does "numerous" apply to "chiropractic treatments"?)

Regards, ☺ Coppertwig (talk) 19:42, 3 June 2008 (UTC)

(outdent)

• "Has not been rigorously proven," is a scientific statement and is quite common in scientific papers. Here are some examples of its use in high-quality scientific sources:

• "Hyperglycemia has a key role in oxidative stress in diabetic nerve, whereas the contribution of other factors, such as endoneurial hypoxia, transition metal imbalance, and hyperlipidemia, has not been rigorously proven." (Obrosova 2002, PMID 12198815)
• "The accuracy of the definition of the bottom of the nerve fiber ayer measurement has not been rigorously proven." (Jaffe & Caprioli 2004, PMID 14700659)
• "Although it has been frequently proposed that AICD is a signalling molecule similar to the Notch intracellular domain, this has not been rigorously proven." (De Strooper 2007, PMID 17268505)

• The source in question (DeVocht 2006, PMID 16523145) is two years old. It's fairly high level; I don't think it's much more out-of-date now than it was when it was published.
• The source talks about "chiropractic treatment", not "chiropractic treatments". That is, it is not talking about particular treatments, but about chiropractic treatment as a whole.
• The previous paragraph in the source says this about chronic headache: "Although not rigorously documented in large-scale, well-designed randomized control trials, as of 2001, there had been at least nine trials of various degrees of quality and size involving 683 patients with chronic headaches with reported clinical improvement." The source is saying that the literature on the effectiveness of chiropractic treatment (here, for chronic headache) has not rigorously documented effectiveness. This is what builds up to the "has not been rigorously proven" (for all chiropractic treatment) in the next paragraph.
• How about this rewrite? It's derived by combining the 2nd and 5th of your proposals, along with changing the word "test" to the source's word "establish":

"As with many other medical procedures, the effectiveness of chiropractic treatment is difficult to establish and has not been rigorously proven."

Eubulides (talk) 21:04, 3 June 2008 (UTC)

I acknowledge that some scientific articles state that some things are not rigorously proven. However, in this discussion we don't have any article that states (IMO) that the effectiveness of chiropractic treatment in general has not been rigorously proven. It says something about rigorous documentation with regard to treatment of headaches in particular; and it says it in an "although" clause. If we need to reach down into "although" clauses of less-reliable sources, maybe the statement is getting undue weight. I oppose the sentence you propose, which states that the effectiveness of chiropractic treatment has not been rigorously proven. I suggest: "As with many other medical procedures, the effectiveness of chiropractic treatment is difficult to establish." Or, how about saying something more similar to what the source says: "The effectiveness of chiropractic treatment is difficult to establish; many medical procedures also lack rigorous proof of effectiveness." (I posted the preceding at 22:28, 3 June 2008. ☺ Coppertwig (talk) 00:33, 4 June 2008 (UTC))

• These two suggested paraphrases suffer from the same issue (which I still don't see as being an important one) as the paraphase that is currently in Chiropractic. Neither suggested paraphrase logically follows from what the source formally states (even though they are both obvious paraphrases of what the source is saying). For example, both paraphrases say "The effectiveness of chiropractic treatment is difficult to establish", which is obviously supported by the source; but this is not a logical implication of what the source formally says. If the problem is that an obvious paraphase uses deduction that is formally unwarranted, then what makes these paraphrases acceptable but the paraphrase in Chiropractic unacceptable?
• Let's put it a different way. The source says "numerous medical procedures have not been rigorously proven to be effective either". The only plausible way I can see to interpret that either is as follows: although chiropractic treatment has not been proven to be effective, numerous medical procedures have not been rigorously proven to be effective either. Is there any other plausible way to interpret that either? If not, then Chiropractic's current paraphrase is fine, no?

Eubulides (talk) 07:24, 4 June 2008 (UTC)

Good point, Eubulides, about my suggestions also being mere paraphrases. One answer to that is: if you see them as equally bad but I see the current sentence as worse, then why not just go with one of my suggestions? Another answer is: the paraphrases I suggest seem to me to be innocuous paraphrases, while the statement that there is no rigorous proof of effectiveness is a very strong statement which would require very careful sourcing.

Yes, I see plausible alternative interpretations of the "either" statement in the source. The best one seems to me to be this: "Opinions differ about the effectiveness of chiropractic treatment. Many people believe that the effectiveness of chiropractic treatment has not been rigorously proven; however, the effectiveness of many medical procedures has not been rigorously proven, either."

I suggest the following, which I think follows the source more closely: "As with some medical procedures, many of which also lack rigorous proof of efficacy, opinions differ as to the efficacy of chiropractic treatment." ☺ Coppertwig (talk) 10:06, 10 June 2008 (UTC)

I see your point, and your suggestion has merit, but it also has problems that mean it's a bit worse than what is in there now.

• Most important, the source says "opinions differ" first, and then follows up with lack of rigorous proof as being a problem in settling the difference of opinion. But the suggested wording puts it the other way: it says there is a lack of rigorous proof, and therefore that opinions differ about efficacy, with the implication that this is the same as many other medical arts. But that is not what the source is saying. The source is saying that opinions about chiropractic treatment differ for whatever reason (philosophy, or turf-war, or whatever), and the difficulty of finding solid evidence hinders us from resolving the dispute.
• I don't follow your interpretation of the word "either" in the source. The source does not say or imply that "Many people believe that the effectiveness of chiropractic treatment has not been rigorously proven". It says flatly "numerous medical procedures have not been rigorously proven to be effective" (followed by the word "either", which means chiropractic treatment is in the same boat). There is no implication that there's serious doubt about this flat claim. The "different views" the source mentions are different views about whether the treatment is efficacious (where there is not a consensus among experts), not about whether the the treatment's effectiveness has been rigorously proved (where the consensus is clear: it hasn't been rigorously proved).
• The source talks about "much in the healing arts" and "numerous medical procedures", which clashes with the suggestion's "some medical procedures".
• The source says "rigorously proven to be effective", which clashes slightly with the suggestion's "rigorous proof of efficacy". Effectiveness is not the same as efficacy, though they are related.
• Given the continuing conflict we're having here, perhaps the simplest thing is to remove the sentence in question from Chiropractic. That's too bad, as I think it's important to mention that chiropractic treatment is in the same boat as many other medical procedures with respect to evidence. I'm confident DeVocht is making this point, but if the consensus is that he's not, then let's just remove the sentence entirely (until and unless we find some other source that is making the point).

Eubulides (talk) 19:43, 10 June 2008 (UTC)

I think this version addresses all of the points you raise above: "Opinions differ as to the effectiveness of chiropractic treatment; many medical procedures also lack rigorous proof of effectiveness." I thought you had said that several sources had made the point that medical procedures are in the same boat; I also think it's important to include this point. However, I'd rather just remove the sentence than leave it as is.

The source doesn't say that many people believe that effectiveness of chiropractic treatment has not been rigourously proven. It also doesn't say that everybody believes that. It just doesn't say explicitly anything about it. The word "either" is obviously alluding to something unstated: it could as easily be the unstated thing I suggest as the unstated thing currently in this article. I think the author refrained from stating that the effectiveness of chiropractic treatment has not been rigourously proven in order to avoid being challenged by people who believe that it has been, as well as to cover himself in case proof of effectiveness was just being published around the same time as that paper or would be published within a few years. ☺ Coppertwig (talk) 22:35, 10 June 2008 (UTC)

The source does not say that many people believe or disbelieve anything about rigor. It just says that many medical procedures haven't been rigorously proven (there's nothing about belief in that statement). I disagree that the "either" could just as easily cause us to interpret DeVocht as saying merely "Many people believe that the effectiveness of chiropractic treatment has not been rigorously proven"; he is saying that the effectiveness has not been rigorously proven, period. However, all that being said, the latest wording you proposed is adequate so I put it in after replacing an "effectiveness" with an "efficacy" (to match the source better) and adding an "other" (to avoid making the implication that chiropractic treatments are somehow not medical). Eubulides (talk) 23:25, 10 June 2008 (UTC)

That sentence that was just put in is still not worthy. The cited source doesn't back it's inclusion. It won't pass WP:SYN. This is what the source says. You can pick out the part that we have chosen to use:

• "Although by far most chiropractic treatment is given for back pain, it seems able to affect a broader range of conditions as shown in the following few examples. Second to back pain, chiropractors probably are best known for treatment of chronic headaches. Although not rigorously documented in large-scale, well-designed randomized control trials, as of 2001, there had been at least nine trials of various degrees of quality and size involving 683 patients with chronic headaches with reported clinical improvement.2 In one study, subjects with chronic mechanical neck pain syndromes receiving spinal manipulation had an average increase in pressure pain threshold of 45% whereas a control group showed no change.48 There is some indication that chiropractic treatment may be helpful for some cases of temporomandibular disorders based on positive case reports 13,19,38 and the improvement of all nine patients in a small prospective case series.11 The edge light pupil cycle time, a reflex of the eye that is mediated through the autonomic nervous system, is influenced by high-velocity manipulation to the upper cervical spine.18 Mechanical stimulation of the spine of rats has an effect on blood pressure, heart rate, and the activity of sympathetic nerves.39 Some chiropractors report having successful treatment of otitis media such as in a case report by Saunders 40 that also includes reviews of a retrospective study of 46 children,16 a pilot study of 22 children,41 and two case series of five and 322 children.14,17

Nevertheless, there are different views concerning the efficacy of chiropractic treatment, which is not surprising. Unfortunately, it is difficult to establish definitive, unarguable, and conclusive findings regarding much in the healing arts despite the millions of papers that have been written about presumably scientifically sound studies. Because of this difficulty, numerous medical procedures have not been rigorously proven to be effective either.24,44 Expert opinions vary on virtually every aspect of health care...."

IOWs, the author prefaces his statement about "rigorously proven" with a long diatribe about the research that supports chiropractic and then argues that people still don't believe it. So he states the obvious 'that it is difficult to establish definitive, unarguable, and conclusive findings for "anything"'. And nothing in medicine is rigorously proven because of this. His point is that we have to loosen up and realize that there is value there. If we don't represent this sentence in this fashion, then we are misrepresenting the author's intention. We are using the sentence to represent chiropractic treatment negatively, which is not the intention of the author. It would be like us saying that Ernst says "chiropractic care adds quality of life". -- Dēmatt (chat) 02:32, 11 June 2008 (UTC)

• It would be quite reasonable to quote Ernst on the strengths of chiropractic. Indeed, #Cost-effectiveness 2 cites Ernst to support the claim "A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain...".
• More generally, it's a good thing, not a bad thing, to quote chiropractic critics on strengths of chiropractic, and to quote chiropractic supporters on weaknesses. A strength that is admitted even by critics is quite well supported, and conversely by weaknesses admitted even by supporters.
• Research that supports chiropractic is already summarized in Chiropractic at length, supported by more-recent and far more-reliable sources than DeVocht. There is no point saying again here (simply because DeVocht says so) that research support exists for chiropractic treatment. The only reason to cite DeVocht here is because he makes the valid and important point (which the more-recent and far more-reliable sources do not) that it's hard to rigorously prove large chunks of medicine.

Eubulides (talk) 17:58, 11 June 2008 (UTC)

Thank you very much for making that change, Eubulides. I really appreciate it and think it's a big improvement. That paragraph now no longer seems to me to be a WP:V violation.

I agree with Eubulides that, when feasible, quoting critics on the strengths and supporters on the weaknesses is a good way to ensure that we're reporting solid facts.

In response to Dematt's point: I now notice that the first paragraph of "effectiveness" all seems rather negative: Since the first paragraph should serve as an introduction to the whole section, I think the paragraph could be improved by adding a few words meaning that there is in fact some evidence supporting the effectiveness of chiropractic treatment. For example, adding "Chiropractic treatment seems able to affect a broader range of conditions than back pain", based on the paragraph quoted by Dematt above. I'm trying to figure out where this could fit into the paragraph smoothly: I suggest putting it just before the last sentence, and joining it to the last sentence by inserting "but".☺ Coppertwig (talk) 23:42, 13 June 2008 (UTC)

• The first paragraph of Chiropractic#Effectiveness is not all negative.

• Its 1st sentence is neutral: "The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment."
• Its 2nd sentence defends chiropractic: "Opinions differ as to the efficacy of chiropractic treatment; many other medical procedures also lack rigorous proof of effectiveness."
• Its 3rd sentence is both negative (it says chiropractic benefits from the placebo response) and positive (it defends chiropractic by saying all medical treatment does). Here's the sentence: "Chiropractic care, like all medical treatment, benefits from the placebo response."
• Its 4th sentence states something negative about our knowledge, not about chiropractic: "The efficacy of maintenance care in chiropractic is unknown."

The proposed text "Chiropractic treatment seems able to affect a broader range of conditions than back pain" is not a good idea. That text is controversial and comes from a source (DeVocht 2006, PMID 16523145) that was partisan by design. That source was one side of a debate between two chiropractors: the other side of the debate was Homola 2006 (PMID 16446588). The two articles were published adjacently in the same volume of Clinical orthopaedics and related research. Both sides of this debate were chiropractors (so this was not a debate that covered the mainstream spectrum), but DeVocht was more pro-chiropractic than Homola was. In his debate piece, DeVocht does not attempt to be balanced. For example, his above-quoted discussion of chronic headache, otitis media (middle ear infection), and temporomandibular disorders gives only pro-chiropractic sources (and dated sources to boot) and does not at all reflect mainstream consensus. Eubulides (talk) 09:23, 14 June 2008 (UTC)

Improved version RfC

It is my opinion that this change was for the better. Please give your opinion on the matter. ScienceApologist (talk) 15:01, 14 May 2008 (UTC)

The majority of these edits were contentious, still being discussed on this page, and still lack consensus. Accordingly, I have reverted. There were some decent housekeeping edits in the mix, but the bad outweighed the good in my opinion. -- Levine2112 ^discuss 17:45, 14 May 2008 (UTC)

I would not have made these edits at this time. That being said, the discussion in #Comments on Scientific investigation 3 seems to have petered out, with questions remaining for the dissenting editors but no replies from them recently. The edits that were already discussed are a big improvement over what was in Chiropractic. Surely they can be further improved, and we can discuss that here. Many edits were not previously discussed, though, and they are more problematic; please see #Several important changes were never discussed below for more about them. Eubulides (talk) 23:44, 14 May 2008 (UTC)

It has been discussed on this talk page previously that any contentious edits should be discussed on the page before being implented. In addition, rather than grouping large housekeeping edits and reference formatting with contentious edits, it is better to make a larger number of smaller changes.DigitalC (talk) 23:53, 14 May 2008 (UTC)

We are not bound by what has happened on this page in the past (see e.g. WP:BOLD, WP:IAR). The question is whether the edits were good. There is consensus that they are. ScienceApologist (talk) 19:34, 19 May 2008 (UTC)

• It is true that we are not bound; still, standard practice, as noted at the top of this talk page, is to discuss controversial changes before making them, which was (alas) not done here.
• Even if there was consensus that the big edit improved the article overall, that would not imply that consensus for each part of the big edit. None of the commenters backing the consensus have commented on detailed criticisms of the previously-undiscussed parts of the big edit. (These criticisms were not available to the commenters, precisely because the big edit was sprung on the regular editors without discussion.) So there is no real evidence for consensus for the previously-undiscussed parts of the big edit that have been criticized after the big edit was made.

Eubulides (talk) 20:47, 19 May 2008 (UTC)

• Agree with ScienceApologist: Surveying these changes, they appear to be quite reasonable and backed by reliable sources. I agree with SA that these changes constitute an excellent start at reform of this page, which is sorely needed to create something encyclopedic that conforms to WP:NPOV.--Filll (talk) 18:04, 14 May 2008 (UTC)

• It looks good, adds balance, especially to the section on the Manga report. The additions appear to be well-supported. Guettarda (talk) 18:26, 14 May 2008 (UTC)

• I think it's better, more NPOV. I'm not sure that adding back practice styles is worthwhile (this article is way long already!) and I believe it's hard to pigeon-hole any individual chiropractor, but I approve of most changes, esp. re. Manga and worker's comp studies.--—CynRN ^(Talk) 19:07, 14 May 2008 (UTC)

• I will take a look at the edits one by one and add the ones that haven't been disputed; I'll then come back here and summarize what's remaining. Eubulides (talk) 19:32, 14 May 2008 (UTC)

• After I wrote the above comment, someone else added all the edits. So now I'm looking at them one by one and plan to take out the ones with the most problems. (If someone else doesn't revert again first.…). So far I've found mostly just citation problems, but I haven't got to the controversial stuff yet. Eubulides (talk) 20:13, 14 May 2008 (UTC)

• I found a serious problem with the edits: many of them have never been discussed on this page, even though they are potentially controversial. For now I have reverted them; please see [[#[edit] Several important changes were never discussed]] below. Eubulides (talk) 23:44, 14 May 2008 (UTC)

• I agree that the changes meet NPOV, are well sourced and helps the article to be able to go forward. My comment is from an outside opinion who watches the article and the talk page. --CrohnieGal^Talk 19:39, 14 May 2008 (UTC)

• There is growing consensus for the recent changes that are being discussed in this RFC. However, a couple of edits deleted some information that was part of the recent changes discussed in this RFC. Any minor tweaks can be made in mainspace. QuackGuru 01:07, 15 May 2008 (UTC)

• This severely controversial change went against broad consensus. QuackGuru 01:12, 15 May 2008 (UTC)

• I've restored the content under discussion. It appears fairly well-sourced. It deserves to be discussed rather than removed on a whim without properly addressing the quality of the references and their use. Let's all follow WP:TALK and WP:CON here. Thanks. --Ronz (talk) 01:42, 15 May 2008 (UTC)

There are serious problems with many parts of the edit. This should have been discussed before insertion, as per consensus above that any contentious edit would be previewed on the talk page before being taken to mainspace.DigitalC (talk) 04:16, 15 May 2008 (UTC)

I do not see any serious problems. I see a very thoughtfully written improved version. My recent edits were discussed in this RFC. Please respect the external advise. QuackGuru 04:38, 15 May 2008 (UTC)

There is broad consensus among external observers in this new RFC discussing the recent changes I made. These edits went against the advise from external third-party input of this RFC. QuackGuru 04:38, 15 May 2008 (UTC)

That edit had two parts. First, it installed the changes proposed in #Scientific investigation 3 and discussed extensively earlier. Second, as mentioned below, that edit installed several changes that were never discussed before installation. None of the external observers have commented specifically on the second (previously-undiscussed) class of changes. It is not clear that they approve of the previously-undiscussed changes. It is not even clear that the observers even noticed the previously-undiscussed changes. I didn't notice them without doing a line-by-line analysis of the edit, which took quite some time. Eubulides (talk) 06:09, 15 May 2008 (UTC)

The external observers are commenting at this RFC about this recent change. QuackGuru 06:25, 15 May 2008 (UTC)

The discussion here has been fruitful in this RFC for this recent change but this edit went against established third-party consensus. QuackGuru 06:39, 15 May 2008 (UTC)

I will follow up at #Several important changes were never discussed below. Eubulides (talk) 06:48, 15 May 2008 (UTC)

I saw this dispute while reading Vassayana's talk page. I don't know the subject, but I can see two things: first, probably many of the changes are good. Second, that while bold edits are good, they were subsequently edit warred in, [11](these for example) which is against the processes of WP. Therefore, there is a need for obtaining consensus on the changes before they are considered more than suggestions. ——Martin^phi ☎ Ψ Φ—— 02:07, 16 May 2008 (UTC)

There was growing consensus for the recent changes but it appeared a certain editor attempted to flout consensus by edit warring.[12][13][14][15] QuackGuru 22:19, 19 May 2008 (UTC)

Or rather that certain editor was flouting the lack of consensus despite another certain editor touting that there was one. -- Levine2112 ^discuss 22:32, 20 May 2008 (UTC)

Martin, do you believe that the agreement seen by so many outside reviewers of the RfC that the content is good is not enough to establish that the content should be added? ScienceApologist (talk) 19:34, 19 May 2008 (UTC)

• Concerned Comment The biggest problem I have with this version is that it is being billed as a consensus from the community, but they have not shared in the conversation or the work that has been put in to improve upon the very version they are looking at. There is more work to do, but if you call this a consensus version, it will be virtually impossible to make any more edits - even minor ones - as a particularly eccentric editor will likely take it as his duty to defend the "consensus view from outside editors". So while I can work with anything, nobody can work with the constant reversions to "the RfC version that many outside members have agreed to". So, unless you really like this version, I would rather you suggest that we continue to work together in the manner that WP was meant to work - where anyone can edit anytime and collaboration is the preferred method to accomplish consensus. Let the ones that are working this article decide what the 'best version' is. -- Dēmatt (chat) 00:58, 20 May 2008 (UTC)
  • Again, well said. -- Levine2112 ^discuss 22:32, 20 May 2008 (UTC)
    • I agree. The "consensus version" has real flaws and can use further improvement. Eubulides (talk) 02:16, 21 May 2008 (UTC)
      • I have made further improvements. Please review. QuackGuru 15:31, 23 May 2008 (UTC)

Objective straights and reforms

Part of the change added material about objective straight and reform chiropractors, two groups which it's not clear still exist (we don't have good evidence that they exist, and we have weak evidence that they don't). As I recall this was last discussed at the end of the long section Talk:Chiropractic/Archive 18 #Problems with current Effectiveness draft, without a consensus about including the material in Chiropractic#Schools of thought and practice styles. I suggest moving this material to Chiropractic history or perhaps Chiropractic #History; I don't think it'd be controversial there. I removed this material for now, pending further discussion. Eubulides (talk) 20:54, 14 May 2008 (UTC)

I don't think the article needs the material about reform and objective straights, maybe not even in history. I don't think it's very notable.--—CynRN ^(Talk) 21:20, 14 May 2008 (UTC)

I'm not sure that removing the material was altogether appropriate. I agree that the issue may be one of historical relevance rather than modern day relevance, but I found the material to be informative, interesting, and well-sourced. ScienceApologist (talk) 22:09, 14 May 2008 (UTC)

I don't feel strongly either way. The subject of the reform group especially got discussed ad nauseum on the talk pages a few months ago with no real consensus. History would be the place if it is to be included.--—CynRN ^(Talk) 22:16, 14 May 2008 (UTC)

OK, for now I moved it to Chiropractic #History. Eubulides (talk) 22:25, 14 May 2008 (UTC)

I prefer the information under Internal conflicts be put at the end of the Schools of thought and practice styles section. QuackGuru 01:07, 15 May 2008 (UTC)

The internal conflicts section is relevant to the schools of thought and practice styles section. The internal conflicts has discussion about the varying thoughts, practices, and beliefs. QuackGuru 08:12, 15 May 2008 (UTC)

Sure, but almost everything in Chiropractic #History is relevant to some other section, and could be moved there. The point is that Chiropractic, by and large, is a discussion of chiropractic as it is today. Stuff that's no longer relevant should be put in Chiropractic #History to avoid cluttering up the rest of the sections with material that used to be true but is no longer true. That's how other historical material is treated, and this particular historical material should be no exception. Eubulides (talk) 02:06, May 15, 2008 (UTC)

I fear that statement reveals a misunderstanding (at least on this point) of Wikipedia. While I agree that purely historical and dated events (IOW no longer, unquestionably, and impossibly current in any manner) should be placed in the history section IF our sources also do so, this happens to be a different matter. Wikipedia articles should NOT limit themselves to the present picture of the subject. It would take alot of OR to achieve this with some things about chiropractic, since many DCs in practice TODAY believe, think, and act as described by what you term "historical" or what CorticoSpinal terms "progressive". Chiropractic today is a very broad spectrum of beliefs and practices, and we shouldn't limit mention of something we believe (or wish) is purely historical to the history section, since it is ALL current practice and belief many places. Ultra straight subluxationism and anti-subluxationism are all very current within the profession. They are all part of "progressive" chiropractic, depending upon one's own personal POV. The struggle for domination is far from over.

There is also a straw man at work here, which you (Eubulides) many not be aware of. Straw men can effectively be used to shoot down unpopular ideas. When this section was first written and later being developed further, the strawman of existence or nonexistence of groups and organizations was constantly being brought up as if it was an issue to this section. It is NOT an issue in this section. This section is about "schools of thought and practice styles". Let me illustrate. Luther is long since dead, but his "school of thought" still exists and is present in Protestantism, and we mention him, his thoughts, and the work of various protestant groups and denominations. Just so here. Even if the only organization that has been officially reform (the NACM) were to cease to exist (it happens to live a quiet existence, as always), it's school of thought is expressed by many chiropractors whose utterances reveal that they share "reform" thoughts and their practices as well. In this context it is OR to engage in speculations about the existence of an organization which is so unlike ordinary organizations that it has usually been relatively quiet and whose membership has been relatively secret. That question is totally irrelevant to this section.

What we need to focus on is: (1) Did that school of thought exist and (2) was it officially the position of one organization? Yes. Unquestionably. (3) Does that school of thought still exist? Unquestionably. That's all we need to know to include mention of the organization, its school of thought, and its role in the profession, past and present. In fact, a substantial portion of the proof of its influence and notability has been provided by its opposition. Notoriety is a pretty powerful form of notability which Wikipedia recognizes. If you want the strongest proof of something, get its enemies to provide it. The testimony of friends can't always be trusted, but the opposition of enemies can certainly be used as evidence. FYI, chiropractors wouldn't have access to VA hospitals today if it hadn't been for the influence of the representative of the NACM on the work committee where access was granted. That's a pretty powerful influence exerted by one little, minority, relatively secret, organization that has been very notably and vocally opposed by the whole profession. [16][17] Although that representative was initially attacked[18] quite viciously, that representative was actually thanked later for his role. Ultra straight organizations had actually opposed the idea. -- Fyslee / talk 04:38, 22 May 2008 (UTC)

Luther is dead, but the Lutheran church is very much alive: I can still call up the Lutheran church and someone will answer the phone. This is not the case for the NACM, by all reports. Let me take that analogy and run with it: Lutheranism only briefly mentions Pietism (in Lutheranism#See also), and this is appropriate. Pietism was formerly a very active branch of Lutheranism, but it's now dead as an organized group: you can't call any Pietist churches on the phone (the Pietists have an indisputable effect on current teachings of some Lutherans, but they're no longer active). In contrast, Lutheranism does mention the differences between reformism and confessionalism, an important and active distinction among Lutherans: one can currently call up the reformists and someone will answer the phone, and likewise for the confessionalists, and it's entirely appropriate to cover that as a current issue.

In that sense, I don't see any reliable evidence cited showing that reformers are still active. Their work may have influenced current thought (just as Pietists influenced current Lutheran thought), but outside the History section Chiropractic should cover current thought, not the historical influences. Eubulides (talk) 08:35, 22 May 2008 (UTC)

You're missing the point, which is that it doesn't make any difference if the organization is active or not. The school of thought and practice style (anti-subluxation) is very much alive. Those who express such views are reform chiropractors. -- Fyslee / talk 14:16, 22 May 2008 (UTC)

I agree with this. -- Dēmatt (chat) 13:10, 23 May 2008 (UTC)

If we can find reliable sources showing that anti-subluxation is very much alive now, then I agree that should be included in the school-of-thought section. But it should be called "anti-subluxation", not "reform", no? Eubulides (talk) 16:58, 22 May 2008 (UTC)

It's not anti-subluxation per se, but pro-mainstreaming (which means they think chiropractors must drop their garb). -- Dēmatt (chat) 13:12, 23 May 2008 (UTC)

OMG is "garb" not just the perfect word for it! We should write for living! -- Dēmatt (chat) 13:16, 23 May 2008 (UTC)

Unless something has changed since previous consensus existed that there was not sources to believe these groups still exist, they should ONLY be placed in the history section. I for one believe that reform chiropractors DO exist, they just don't use the name "reform chiropractors" - but alas, without the name, it is hard to find sources that back that up. In that sense, I guess they are just at the end of the ideological spectrum of mixers.DigitalC (talk) 00:21, 16 May 2008 (UTC)

Effectiveness and Cost-benefit sections

Both of these section were added without a consensus. They are still a lot of discussion about the wording and even about whether or not to add these sections at all. To me, this (and the addition of the Objective straight and Reform) were the most egregious of the mass edits and most in need of being removed. -- Levine2112 ^discuss 21:42, 14 May 2008 (UTC)

There's an RfC currently in the works. Most of the people commenting seem to think that the edits including these bits were good. You are free to explain exactly what your objections are, but I don't think removal at this time is appropriate. ScienceApologist (talk) 22:10, 14 May 2008 (UTC)

The RfC was about effectiveness, not about cost-benefit. The cost-benefit section was added without any discussion, which is not a good idea for a controversial article like this. Also, the effectiveness section that was added was not the effectiveness section that was proposed. For now, I reverted to what was proposed and copied the undiscussed stuff to the next subsection. Eubulides (talk) 23:44, 14 May 2008 (UTC)

The new RFC was linked to the recent edits. I see growing consensus to include the information from the comments in the new RFC. QuackGuru 01:07, 15 May 2008 (UTC)

Calling a consensus again when there is no such consensus?DigitalC (talk) 04:18, 15 May 2008 (UTC)

There is broad consensus among external observers in the new RFC which is to be respected. QuackGuru 04:26, 15 May 2008 (UTC)

Again, I disagree that the external observers have a consensus about (or even noticed) the previously-undiscussed changes in that edit. Eubulides (talk) 06:09, 15 May 2008 (UTC)

Several important changes were never discussed

The edit contains several important changes that were never discussed on the talk page. Some of them are quite likely controversial. Please discuss changes like these before putting them in. For now I removed the undiscussed changes and list them below for further comment. Eubulides (talk) 23:33, 14 May 2008 (UTC)

• The following text was added to the discussion of the British Medical Association:

'In 1997, the BMA has identified chiropractic health care that can be regarded as "discrete clinical disciplines" because it has "established foundations of training and have the potential for greatest use alongside orthodox medical care."'

• The version of Scientific investigation that was installed had serious discrepancies from what was proposed in #Scientific investigation 3. It appears to be some mixture of #Scientific investigation 3 and the older Talk:Chiropractic/Archive 18 #Scientific investigation 2. For now, I have changed it to the #Scientific investigation 3, as that seemed to have more consensus. Further edits will no doubt be needed, but this sort of thing should be discussed first.

• The new Cost-benefit section was never discussed. I enclose it below, for further discussion. Please put comments in #Comments on Cost-benefit 1 below.

Eubulides (talk) 23:33, 14 May 2008 (UTC)

The RFC was about all of my recent edits. QuackGuru 01:07, 15 May 2008 (UTC)

The external observers commented about the overall edit, most of which had been discussed earlier. There's no evidence that the observers noticed, much less approved of, the changes that were slipped into that edit without any previous discussion. The only comments they made were about the changes that had been discussed earlier. It is contrary to common practice on this page to install major, potentially-controversial changes without any discussion on the talk page. Please discuss these changes in the relevant sections of this talk page, now that the sections have been created. Eubulides (talk) 06:48, 15 May 2008 (UTC)

The external observers were commenting on this recent change. We have discussion from third-party input. Uninvolved Wikipedians did discuss my recent change in the new RFC. QuackGuru 07:08, 15 May 2008 (UTC)

Most of what you are calling "my recent change" consisted of material that had been previously discussed. The uninvolved Wikipedians commented on the entire edit, and could easily have been fooled (by the way earlier discussion occurred) into thinking that the edit was installing what had been discussed. None of the comments by the uninvolved Wikipedians indicate that they read, understood, or agreed with the not-previously-discussed part of the change. It is poor practice to take a proposed edit which has had a lot of discussion, to make unannounced and important changes to it, and to install the changed edit without bothering to notify people that the edit involves undiscussed changes. I cannot emphasize this enough. Major changes need to be discussed first, before installing them; that is the standard procedure on this page, and it's standard procedure for good reason. Eubulides (talk) 09:15, 15 May 2008 (UTC)

There is absolutely NO indication that any of the RfC respondents were fooled. This is pure obstructionism. I will assume good faith and simply ask you to abide by the new consensus that the additions are good and needed in the article. There is no policy or guideline that says someone has to discuss first. One can discuss after the changes are made. That is being done here. The current consensus is to keep the changes. Please also stop making up rules for editing. Your cooperation is appreciated. Thanks. ScienceApologist (talk) 14:39, 15 May 2008 (UTC)

• There is no evidence that the RfC respondents read or understood the not-previously-discussed changes. None of the RfC respondents have responded to the substance of the subsequent criticism of the not-previously-discussed changes; this appears in many sections on the talk page, including #Comments on Cost-benefit 1, #Sorry to stop by in the middle of a POV war, and #Objective straights and reforms.
• So it is not true that "the current consensus is to keep the changes"; there may have been a consensus at the point the previously-undiscussed changes were made, but now that problems have been pointed out with those changes, the consensus, if there was one, is no longer present.
• Your revert to an old state ignored discussion that occurred after the "new consensus" (see, for example, #Sorry to stop by in the middle of a POV war). This discussion resulted in several improvements in wording in citation to the material, improvements that have not been disputed, and thus your revert lost this useful information. Please do not ignore later discussion, and please do not blindly revert and inadvertently remove later improvements.

Eubulides (talk) 16:14, 15 May 2008 (UTC)

• One other thing: I am not "making up rules for editing". The top of this talk page says "This is a controversial topic that may be under dispute. Please read this page and discuss substantial changes here before making them." This is a good rule, and should in general be followed. It was not followed for the previously-undiscussed changes. It is bad procedure to install changes into a controversial article without discussing them first. Eubulides (talk) 16:17, 15 May 2008 (UTC)

One thing is for sure, there is clearly no consensus to add these edits. It is truly a mystery why these editors are claiming that there is a consensus when so many editors disagree with these edits. -- Levine2112 ^discuss 19:32, 15 May 2008 (UTC)

Consensus is established above. ScienceApologist (talk) 17:11, 18 May 2008 (UTC)

I don't think so, SA. The question of validity still has not been addressed; i.e. why are Eubulides et QuackGuru trying to push an WP:SYN of SMT and pass it off as effectiveness of chiropractic. What is the effectiveness of medicine, dentistry and maybe more appropriately, physical therapy? If you can provide a sound rationale that would be helpful. CorticoSpinal (talk) 19:21, 18 May 2008 (UTC)

You are confused about what consensus is. Please read up on Wikipedia policies and guidelines. ScienceApologist (talk) 19:25, 19 May 2008 (UTC)

• Concerned Comment The biggest problem I have with this version is that it is being billed as a consensus from the community, but they have not shared in the conversation or the work that has been put in to improve upon the very version they are looking at. There is more work to do, but if you call this a consensus version, it will be virtually impossible to make any more edits - even minor ones - as a particularly eccentric editor will likely take it as his duty to defend the "consensus view from outside editors". So while I can work with anything, nobody can work with the constant reversions to "the RfC version that many outside members have agreed to". So, unless you really like that version, I would rather you suggest that we continue to work together in the manner that WP was meant to work - where anyone can edit anytime and collaboration is the preferred method to accomplish consensus. Let the ones that are working this article decide what the 'best version' is. -- Dēmatt (chat) 00:58, 20 May 2008 (UTC)
  • Here, here. Well said. -- Levine2112 ^discuss 22:29, 20 May 2008 (UTC)

Cost-benefit 1

The benefits of chiropractic care seem to outweigh the involved risk. The cost-effectiveness of SMT has not been demonstrated beyond a reasonable doubt. However, spinal manipulation for the lower back appears to be relatively cost-effective. Of the various interventions available, the most cost-effectiveness treatment for lower back pain could not be determined from the limited research available. The data indicates that SM therapy typically represents an additional cost to conventional treatment. Due to SM's popularity, higher quality research into the risk-benefit is recommended. Preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care after an initial therapy. When compared with treatment options such as physiotherapeutic exercise, the risk-benefit balance does not favor SM. The small risk associated with manipulation of the cervical spine could be avoided with the use of nonthrust passive mobilization movements. There is no evidence that SM is superior to other treatment options available for patients with low back pain. In occupational low back pain, shorter chiropractor care had a benefit for reducing work-disability recurrence and longer chiropractic care did not show a benefit for preventing work-disability recurrence when analyzing tha data from workers' compensation claims data. SM helps to reduce time lost due to workplace back pain, and thus employer savings.

Comments on Cost-benefit 1

(Please put comments here.) Eubulides (talk) 23:33, 14 May 2008 (UTC)

• First comment is that any SM should be changed to SMT. I changed the first thinking it was a typo. This is going to run into similar problems as effectiveness, where the sources are talking about the cost-effectiveness of SMT, not the cost-effectiveness of chiropractic.DigitalC (talk) 00:02, 15 May 2008 (UTC)
• If There is no evidence that SM is superior to other treatment options available for patients with low back pain.is to be included, it should be changed to There is no evidence that SMT is either superior or inferior to other treatment options available for patients with low back pain. In accordance with the following quote from the conclusion of the article "Neither did we find evidence that these therapies are superior to spinal manipulative therapy.". However, this source is not EVEN on cost effectiveness of SMT, it is on effectiveness of SMT, and as such should not be in this section.
• after an initial therapy. is grammatically incorrect. After initial therapy, or after an intiial treatment would be grammatically correct.
• When compared with treatment options such as physiotherapeutic exercise, the risk-benefit balance does not favor SM. Again, this falls into the trap of assuming that this is Cost-benefit of SMT, and not Cost-benefit of Chiropractic. Chiropractors use physiotherapeutic exercise as a treatment.
• The small risk associated with manipulation of the cervical spine could be avoided with the use of nonthrust passive mobilization movements. This one is a POV statement, and I will have to search for a source the backs that it is POV. From my understanding the risk is the same for any grade of mobilization. DigitalC (talk) 00:49, 15 May 2008 (UTC)

Actually, the research suggests that manipulation and mobilization carry the same risk. In fact, the same risk as performing a cervical range of motion exam. So not only is it POV, it's not accurate. Is there a reference for it? -- Dēmatt (chat) 03:43, 15 May 2008 (UTC)

Yes, it is referenced, but I agree with you that research suggests that any movement of the cervical spine carries the same risk.DigitalC (talk) 04:10, 15 May 2008 (UTC)

I am pretty much against the majority of the content which Quackguru added. . . moreover I am petrubed by the manner in which it was added. Discussion about Reformers should be removed. . . along with the contentious efficacy and research section.TheDoctorIsIn (talk) 01:03, 15 May 2008 (UTC)

I feel there are severe limitation still in this version although there is undoubtedly some good to it too. We can work with this and make it much better and more relevant, however. The validity some of the information presented here is highly suspect and there are major omissions still. For example, scientific research into chiropractic has been done by chiropractors, believe it or not, since the 1920's. I thought we are supposed to be discussing scientific investigation of chiropractic care, not SMT. They're not the same. What about the NIH study? That was a landmark one in 1976. The New Zealand study in 1979? The Meade study, the Rand study, etc? These are all SPECIFIC to CHIROPRACTIC CARE. Just because they're old doesn't mean that their invalid. The Crick and Watson paper (1955) after all, is holding up well. Also, there has been some pretty bad cherry picking that is either a violation of WP:POINT or WP:COATRACK. If our allopathic editors want to play that game, we can have a tit for tat war with inserting trivial facts that present the OTHER POV. For example, the addition of the "Canadian DCs don't know how to research" is a bit over the top. This study was done in the province of ALBERTA representing less than 15% of Cdn DCs most of whom graduated when the EBM era hadn't arrived. There are more examples, but I must go back to work. Too bad these edits had been railroaded in, and supported blindly by the usual suspects. Also, Fill -- your comment was in poor taste. If you think the Citizendium article with it's lead (with a direct quote taken from 1966) applies here, you're not up with the times. Also, the medical community here is editing against the evidence which I find distressing. Lastly, Ernst is being used throughout this article to negate, trump or override the sound opinion of EXPERTS in SMT and EFFECTIVE and CHIROPRACTIC CARE. This practice must stop. CorticoSpinal (talk) 16:58, 15 May 2008 (UTC)

• The current version emphasizes scientific investigation of chiropractic care. This inevitably means heavy coverage of SMT, since SMT is a core component of that care.
• If an old study is truly landmark it can be expected to affect current reviews. If not, then we shouldn't be mentioning it ourselves. We should rely on expert opinion as to what is important and what is not. We should not be making those calls ourselves, when the expert opinion is already available.

• No, and SmithBlue told you this already. If the purpose of the review is not congruent with the given topic, the review is not valid and should not be used. DCs would consider Manga to be landmark, MDs not so much. So we are to rely on MD reviews? CorticoSpinal (talk) 22:18, 16 May 2008 (UTC)

• SmithBlue's argument, while valid, is not a get-out-of-jail-free card that will let an editor ignore a review whenever they please. It requires a good reason that the review is not congruent with the given topic. No reason has been advanced for any of the reviews cited in Chiropractic, so in no case has there been any justification for ignoring expert reviews and reaching down into the reviewed sources. Eubulides (talk) 07:35, 19 May 2008 (UTC)

• I agree that reaching down and inserting trivial facts from primary studies is not the way to go. If that exists in Chiropractic now, we should fix it.
• The "Canadian DCs" stuff has been removed (for now; until someone reverts it again, I suppose). That stuff is contentious and was not discussed before inserting. I agree that it is potentially controversial and deserves careful review first.

• It was an attribution problem; and the Grod citation should have been used to demonstrate the opposing POV to make it NPOV. CorticoSpinal (talk) 22:18, 16 May 2008 (UTC)

• Sorry, I don't follow this remark. Anyway, I don't see "Canadian DCs" in the current version, so perhaps this point is moot now? Eubulides (talk) 07:35, 19 May 2008 (UTC)

• Many (most?) cites to Ernst are not to things that override expert chiropractors. The exceptions are marked as such (e.g., "a critical review"). At least, that's the intent; if there are problems in this area then let's please discuss fixes.

19:18, 15 May 2008 (UTC)

• Ernst is pushed on every single CAM article and although his opinion is certainly notable (that's NEVER been debated) the weight, tone and influence of his words, especially in chiropractic has been a huge problem since he was pushed onto the scene in Feb 08. Mainstream doesn't even agree with his views on SMT, this is illustrated with the American College of Physicians recommending SMT for LBP whereas Ernst still says its "dangerous" with "no proven beyond a resonable doubt" and "adds costs". Essentially, all his statements are in direct conflict with bulk the mainstream literature. His star is fading as he continues his witch hunt and if he's reading this I think he's a massive douche bag and the quality of his papers re: chiropractic care are by far the most biased, unbalanced, unobjective and misleading ones out there. He should take a cue from Kaptchuk (1998) who can raise concerns but present both sides. CorticoSpinal (talk) 22:18, 16 May 2008 (UTC)

• There is certainly a difference of opinion in mainstream medicine about the effectiveness of SMT. The American College of Physicians does not "recommend" SMT for LBP; it lists it as a "likely effective" therapy, along with massage therapy, acupuncture, willow bark extract, and devil's claw.[19] There is substantial disagreement among low back pain guidelines, with some of them agreeing more with Ernst and some agreeing more with chiropractors (see Murphy et al. 2006, PMID 16949948). It is highly misleading to cite just one group in this area and to pretend that it is the final word, and Chiropractic should fairly represent all sides, including both the skeptics and the proponents of chiropractic. Eubulides (talk) 07:35, 19 May 2008 (UTC)

Manipulation of the cervical spine (MCS) is used in the treatment of people with neck pain and muscle-tension headache. The purposes of this article are to review previously reported cases in which injuries were attributed to MCS, to identify cases of injury involving treatment by physical therapists, and to describe the risks and benefits of MCS. One hundred seventy-seven published cases of injury reported in 116 articles were reviewed. The cases were published between 1925 and 1997. The most frequently reported injuries involved arterial dissection or spasm, and lesions of the brain stem. Death occurred in 32 (18%) of the cases. Physical therapists were involved in less than 2% of the cases, and no deaths have been attributed to MCS provided by physical therapists. Although the risk of injury associated with MCS appears to be small, this type of therapy has the potential to expose patients to vertebral artery damage that can be avoided with the use of mobilization (nonthrust passive movements). The literature does not demonstrate that the benefits of MCS outweigh the risks. Several recommendations for future studies and for the practice of MCS are discussed.

Here is the abstract from the Di Fabio RP ref. The risk can be avoided with the use of mobilization (nonthrust passive movements). Thanks. QuackGuru 04:23, 15 May 2008 (UTC)

As above, yes you have a source for it. However, it is POV, in that other sources state that the risk is the same for manipulation, mobilzation, range of motion examination, and shoulder-checking while driving.DigitalC (talk) 05:15, 15 May 2008 (UTC)

Please provide a list of other sources. QuackGuru 05:21, 15 May 2008 (UTC)

Please see Anderson-Peacock E, Blouin JS, Bryans R; et al. (2005). "Chiropractic clinical practice guideline: evidence-based treatment of adult neck pain not due to whiplash" (PDF). J Can Chiropr Assoc. 49 (3): 158–209. {{cite journal}}: Explicit use of et al. in: |author= (help)CS1 maint: multiple names: authors list (link)
 • we deem that where it is the mere movement of neck tissues that causes a risk factor to be an absolute contraindication to an HVLA thrust, manipulation that is not HVLA or mobilization are equally contraindicated by this factor, see also Rome P.L. “Perspectives: An Overview of Comparative Considerations of Cerebrovascular Accidents”, Chiropractic Journal of Australia 1999; 29(3): 87-102, as well as Terrett A.G. Current Concepts in Vertebrobasilar Complications following Spinal Manipulation. Des Moines, Iowa: National Chiropractic Mutual Insurance Company, 2001. DigitalC (talk) 05:38, 15 May 2008 (UTC)

The word however was added to a sentence. I do not see any reason for this. QuackGuru 07:52, 15 May 2008 (UTC)

"However" is a connecting adverb meaning "nevertheless, in spite of that, etc". "However" used correctly in a sentence will suggest that that sentence disagrees in sense somewhat with the preceeding sentence(s). In this case, it was used to tie two sentences together to improve flow, so that it wasn't so choppy.DigitalC (talk) 00:39, 19 May 2008 (UTC)

I have not yet had time for a detailed review of #Cost-benefit 1 (I've been tied up with the aftermath of the recent Effectiveness changes) but here is a quick first reaction:

• It's much improved from #Cost-benefit 0, but still needs quite a bit of work.
• It refers directly to many primary studies. It should focus instead on what recent reviews say, e.g., van der Roer et al. 2005 (PMID 15949783), Canter et al. 2006 (PMID 17173105), Cherkin et al. 2003 (PMID 12779300). Primary sources should be used only with good reason (e.g., if they're too new to be reviewed and are obviously important). Eubulides (talk) 09:00, 15 May 2008 (UTC)
• Isn't Assendelft et al. 2003 (PMID 12779297) superseded by Assendelft et al. 2004 (PMID 14973958). Why cite the obsolescent source?
• Let's stay away sources older than 5 years old. They're too dated. If a subject hasn't been reviewed in the past 5 years, then it's probably not worth summarizing here.

This makes no sense. Historically chiropractic care has been shown to be cost effective, why ignore the data? There's a reason why DCs SPECIFICALLY have been invited to participate in integrative models of care. Result? Less costs again. CorticoSpinal (talk) 17:03, 15 May 2008 (UTC)

Again, there is no intent to ignore old data. If old data is still important, it should appear in a recent review. If it doesn't appear, that's good evidence that it wasn't that important after all, at least according to published expert reviewers. Eubulides (talk) 19:18, 15 May 2008 (UTC)

Again, you are missing the point regarding the validity of some of the reviews. Let me paraphrase, again, what SmithBlue and myself have been telling you for quite some time now: if the purpose of the review is not congruent with the topic at hand, then it is not valid. There are severe logical flaws in your reasoning and you've used the same excuse for 4 months to keep out extremely reliable and valid "primary" studies that are far more valid and academically robust than some of the reviews supported by yourself. A refusal to include studies which meets WP:RS, WP:V and are from indexed peer-reviewed journals will forever prevent from making this article NPOV. CorticoSpinal (talk) 23:18, 16 May 2008 (UTC)

No argument has been put forth that the reviews in question are incongruent with the topic at hand. On the contrary, the reviews are quite congruent with the topic of effectiveness. There is no good reason to disregard reliable reviews and to substitute our own opinion about the the reviewed studies. Eubulides (talk) 07:35, 19 May 2008 (UTC)

• The text flows poorly. Contradictory sentences are run together without any explanation. The text needs to tell a consistent story and hang together; currently it doesn't do that well at all.

Eubulides (talk) 09:00, 15 May 2008 (UTC)

And yet, attempts to make it flow better are met with objection.DigitalC (talk) 00:02, 16 May 2008 (UTC)

• Minor grammatical point: "the most cost-effectiveness treatment" Please delete "ness" from end of word. ☺ Coppertwig (talk) 03:08, 16 May 2008 (UTC)

I have updated the cost-benefit section. It flows very well now. QuackGuru 15:43, 23 May 2008 (UTC)

Cost-Benefit of Chiropractic Care 2a: Work in Progress

The benefits of chiropractic care seem to outweigh the involved risk. A 2007 retrospective analysis of 70,274 member-months in a 7-year period within an IPA, comparing medical management to chiropractic management, demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance. This clearly demonstrates that chiropractic nonsurgical nonpharmaceutical approaches generates reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone. For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs . This effect was greater on a per-episode basis than on a per-patient basis. Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction. Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain. A 4-year retrospective claims data analysis comparing more than 700,000 health plan members within a managed care environment found that members had lower annual total health care expenditures, utilized x-rays and MRIs less, had less back surgeries, and for patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399). The authors concluded: "Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care." In occupational low back pain, shorter chiropractor care had a benefit for reducing work-disability recurrence and longer chiropractic care did not show a benefit for preventing work-disability recurrence when analyzing tha data from workers' compensation claims data. In 2004, Workmans Compensation evaluated the effectiveness and cost-effectiveness of chiropractic care for acute low back injuries and demonstrated that chiropractic care was superior to physical therapy in reducing pain, inproving perceived disability, and lost work time (9 days for chiropractic care in comparison to 20 days for physiotherapy). . This is in general agreement with previous Workmans Compensation analyses' which chiropractic care is equal or superior to standard medical care. A 1999 Medicare study revealed that "The results strongly suggest that chiropractic care significantly reduces per beneficiary costs to the Medicare program. The results also suggest that Chiropractic services could play a role in reducing costs of Medicare reform and/or a new prescription drug benefit." A demonstration project regarding an expansion of coverage of chiropractic services was launched in 2005. Under this demonstration project, chiropractors will be allowed to bill medical, radiology, clinical lab and certain therapy services related to the treatment of neuromusculoskeletal conditions.

Comments of Cost-effectiveness 2a

Before I get hounded, this is a very quick draft; it is by no means complete and I will integrate the best of QGs draft into when I have a bit more time. There are tons of workmans comp studies to include but the bulk of them say chiropractic care (for NMS disorders) is cost effective and patients prefer it to standard medical care (don't know if PT is included in this or not, we should find out so we don't lump in PT care with med if appropriate). The preliminary results of the just completed Chiropractic Medicare Demonstration project in the US shows this trend continues, but I'm willing to simply state there's been a cost-effectiveness and effectiveness project done by the DoD, Medicare and DVA in the US to determine the merits of integrating chiropractic care into managed, governmental programs. St-Mikes deserves a mention too; I think its the first hospital in North America to have permanent inclusion of DCs on staff who are fully integrated (i.e. full time employee status). I'm not quite sure of the situation in the US; although I do know there is a small, but increasing # of DCs who have hospital privileges. The trend is that this is increasing too. CorticoSpinal (talk) 22:53, 16 May 2008 (UTC)

This draft relies on primary studies when it should rely on reliable reviews. For cost-effectiveness we have enough high-quality reviews that there's no need to reach down into primary studies ourselves. Chiropractic's current cost-benefit section is bad enough, but at least it cites some reviews relatively fairly; this proposed 2a replacement is far worse in that regard. Eubulides (talk) 07:35, 19 May 2008 (UTC)

Well, it certainly appears thorough. I'll have to check the sources as Eubilides suggests, but it's a start. BTW, I haven't quite found my way around this talk page, so if there is something that is no longer of any use, how about archiving it so I don't strike up another conversation about something that is already settled. -- Dēmatt (chat) 19:41, 20 May 2008 (UTC)

• It's the "appears thorough" that worries me. By citing primary sources in addition to the secondary reviews, it's making the evidence appear stronger than it is, or it is arguing with the reviews (I don't know which, as I haven't had time to read all that stuff). Either way, it should be fixed, preferably by dropping citations to the primary sources (I don't see why they're needed, but again I haven't read the sources yet).
• Currently we're relying on auto-archiving; the page is getting a tad big to navigate through (or archive) by hand.

Eubulides (talk) 22:16, 20 May 2008 (UTC)

So, you haven't investigated the sources but object to them? Stop trying to omit valid studies that aren't covered by reviews. Geez, how many times in 4 months can you use the same argument, over and over again with many different editors disagreeing with the way you interpret MEDRS? CorticoSpinal (talk) 18:28, 21 May 2008 (UTC)

Has anybody actually read the sources? So far, I see no evidence that anybody has. As far as I can tell, this cost-effectiveness draft was generated by someone who read only the abstracts. Someone (and it will probably be me, sigh) will have to actually read the sources. I am skeptical that there will be any need to cite the primary sources, because I expect that review will cover the material in question. Eubulides (talk) 20:13, 21 May 2008 (UTC)

I've read the sources used in the draft. The claims are supported by the literature. Many of the papers are interdisciplinary collaboration, between DCs and MDs. So, a lot of bias goes out the window there. If we can find reviews that addresses all the points made above then obviously we can choose a review, however I doubt that one review will cover all the specific points. Tertiary sources such as governmental studies could be used as well. CorticoSpinal (talk) 23:23, 21 May 2008 (UTC)

By "reading the sources" I do not mean just reading the abstracts. I mean reading the entire papers. I still don't see any evidence that anybody has actually read the sources. Eubulides (talk) 08:35, 22 May 2008 (UTC)

I haven't read all the sources either, but I have now read the draft, and it is far inferior to what's in Chiropractic#Cost-benefit, a section that itself is not that strong. We'd be better off starting from the existing section than from this draft. Here are some specific comments. Some of these comments also apply to Chiropractic#Cost-benefit (as some of the text is in common).

• The most important complaint is that this section consists entirely of cites to primary studies. It should rely on reliable reviews where these are available. It should lead with the results from reviews, and should fill in with primary studies only when necessary. Currently it does just the opposite: it leads with primary studies, and emphasizes their results, and doesn't report reviews. This is backwards from what WP:MEDRS recommends, and means that there is all-too-great opportunity for our bias to leak into the text.

• "The benefits of chiropractic care seem to outweigh the involved risk." This is just a primary study, and should not be the lead sentence in the section. Also, the cited source does not talk about chiropractic care in general, just about chiropractic care for neck pain. Also, this relies on a single primary study and should say so. A better summary would be "A 2007 Dutch study found that the benefits of chiropractic care for neck pain seems to outweigh the involved risk." but this summary should not be used to lead the section. Eubulides (talk) 08:35, 22 May 2008 (UTC)
• "A 2007 retrospective analysis of 70,274 member-months in a 7-year period within an IPA, comparing medical management to chiropractic management, demonstrated decreases of 60.2% in-hospital admissions, 59.0% hospital days, 62.0% outpatient surgeries and procedures, and 85% pharmaceutical costs when compared with conventional medicine IPA performance. This clearly demonstrates that chiropractic nonsurgical nonpharmaceutical approaches generates reductions in both clinical and cost utilization when compared with PCPs using conventional medicine alone." Again, this is a primary study and should not be emphasized so strongly, at the start. The second "clearly demonstrates" sentence is POV and is not supported by the source. The source's conclusion makes it clear that these results are for one IPA and may or may not generalize to others. The first sentence is way too long, given that it's summarizing just one primary study. The study is just about costs, not cost-benefit, and as such is of limited use in this section. I suggest creating a new section Cost for material like this.
• "For the treatment of low back and neck pain, the inclusion of a chiropractic benefit resulted in a reduction in the rates of surgery, advanced imaging, inpatient care, and plain-film radiographs . This effect was greater on a per-episode basis than on a per-patient basis." Again, this is just one primary study. This is a direct and extended quote from the abstract, without quote marks, and as such is too close to being a copyright violation for comfort. The study is just about cost, not cost-benefit, so it'd be more appropriate for a Cost section.
• "Acute and chronic chiropractic patients experienced better outcomes in pain, functional disability, and patient satisfaction. Chiropractic care appeared relatively cost-effective for the treatment of chronic LBP. Chiropractic and medical care performed comparably for acute patients. Practice-based clinical outcomes were consistent with systematic reviews of spinal manipulation efficacy: manipulation-based therapy is at least as good as and, in some cases, better than other therapeusis. This evidence can guide physicians, payers, and policy makers in evaluating chiropractic as a treatment option for low back pain." Again, this is simply quoting the abstract from a single primary study; we can't do that. Somehow the quote managed to skip around the fact that this study found that chiropractic care costs were higher. This study is rarely cited elsewhere (I checked Google Scholar) and is suspect for that reason.
• "A 4-year retrospective claims data analysis comparing more than 700,000 health plan members within a managed care environment found that members had lower annual total health care expenditures, utilized x-rays and MRIs less, had less back surgeries, and for patients with chiropractic coverage, compared with those without coverage, also had lower average back pain episode-related costs ($289 vs $399). The authors concluded: "Access to managed chiropractic care may reduce overall health care expenditures through several effects, including (1) positive risk selection; (2) substitution of chiropractic for traditional medical care, particularly for spine conditions; (3) more conservative, less invasive treatment profiles; and (4) lower health service costs associated with managed chiropractic care." This is a higher-quality primary study, but there's way too much here for Chiropractic. Again, this is a copyright violation. Again, this is just a primary study; we should be focusing on the reviews.
• "In occupational low back pain, shorter chiropractor care had a benefit for reducing work-disability recurrence and longer chiropractic care did not show a benefit for preventing work-disability recurrence when analyzing tha data from workers' compensation claims data." Again, this is just citing a single primary study; here there is a bit more excuse for citing it (it's too recent to be reviewed) but the wording could be shortened quite a bit without harming this dicussion.
• The remaining text is supported by lower quality studies (some not peer-reviewed, some older) and I won't bother to review it here now.
• In short, this is a real step down in quality from what is in Chiropractic now. At least the current version cites three reviews and summarizes their results. This draft ignores the reviews. There is a great deal of possible bias inherent in going out and reviewing primary sources ourselves. We should resist that temptation by relying on reliable reviews whenever possible, as is largely the case here.

Eubulides (talk) 08:35, 22 May 2008 (UTC)

Your concerns of bias do not ring true. It is YOUR source, a secondary source nonetheless that has been demonstrated to be very biased and have severe design flaws. None of the primary studies cited have this deficiency. In other words, the review that is currently included is not valid and has been refuted but it being given a free ride despite the fact it's been rebutted. It's not a quality paper. You should resist the temptation of citing crap reviews that conform to your personal POV and goes against mainstream consensus. Yes, that's correct, Ernst's conclusions on SMT and chiropractic care goes against mainstream consensus. Which makes his opinion fringe. And his studies are flawed, so now we are citing flawed, fringe material as fact with 0 qualifiers. Is this the kind of "NPOVing" you want to bring to the article? CorticoSpinal (talk) 23:43, 26 May 2008 (UTC)

Wikipedia is not the place to conduct research reviews on our own, overriding reviews already published by experts in the field. Multiple reviews are cited in Chiropractic #Cost-benefit; they are not all by Ernst. Other reliable review sources are welcome, as per the usual WP:MEDRS guidelines. Reaching down into primary studies is dubious; Chiropractic #Cost-benefit already does way too much of this (and this should be fixed). Rewriting it to remove all mention of reviews, which is what is being proposed here, would be a step that is way, way in the wrong direction. Eubulides (talk) 08:08, 27 May 2008 (UTC)

Integration: Sources

http://www.pubmedcentral.nih.gov/articlerender.fcgi?artid=2384186 - CorticoSpinal 16:47, May 21, 2008

Education, licensing, and regulation drafts

Education, licensing, and regulation 1

This draft I wrote and now deleted is obsolete. QuackGuru 19:33, 2 June 2008 (UTC)

Education, Licensing, Regulation 2

The first school of chiropractic was opened in 1896 in Davenport, Iowa, USA.[20] Chiropractic education is unique in the United States that it is divided into straight or mixer (progressive) educational curriculums depending on the philosophy of the institution. In the United States, all but one of the chiropractic colleges are privately funded, but the colleges in Australia, South Africa, Denmark, one in Canada, and two in Great Britain are located in government-sponsored universities and colleges.. In 1971, National College of Chiropractic (now known as National University of Health Sciences) became the first federally recognized and accredited college by the United States Department of Education. This led the way to important grants in federal funding for research as well as grants and loans to chiropractic schools and prospective chiropractic students.

Most commonly, chiropractors obtain a first professional degree in Chiropractic medicine. In North America, typically a 3 year university undergraduate education is required to apply for the chiropractic degree. In general, there are 3 major educational paths involving full‐time chiropractic education across the globe:

• A four‐year full‐time programme within specifically designated colleges or universities, with suitable pre-requisite training in basic sciences at university level;
• A five‐year bachelor integrated chiropractic degree programme offered within a public or private university
• A two or three‐year pre‐professional Masters programme following the satisfactory completion of a specifically designed bachelor degree programme in chiropractic or a suitably adapted health science degree.

Regardless of the model of education utilized, prospective chiropractors without relevant prior health care education or experience, must spend no less than 4200 student/teacher contact hours (or the equivalent) in four years of full‐time education. This includes a minimum of 1000 hours of supervised clinical training. Health professionals with advanced clinical degrees, such as medical doctors, can can meet the educational and clinical requirements to practice as a chiropractor in 2200 hours, which is most commonly done in countries where the profession is in its infancy. Upon meeting all clinical and didactic requirements of chiropractic school, a degree in chiropractic medicine is granted. However, in order to legally practice, chiropractors, like all self regulated health care professionals, must be licensed.

Regulatory colleges are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency. Today, there are 15 accredited Doctor of Chiropractic programs in 18 locations in the USA and 2 in Canada, and an estimated 70,000 chiropractors in the USA, 6500 in Canada, 2500 in Australia, 2,381 in the UK, and smaller numbers in about 80 other countries.

Education, Licensing, Regulation 3

Chiropractors obtain a first-professional degree in the field of Chiropractic medicine. Canada and the U.S. require a minimum 90 semester hours of undergraduate education as a prerequisite for chiropractic school. Matriculation through an accredited chiropractic program includes no less than 4200 instructional hours (or the equivalent) of full‐time chiropractic education. Internationally, the World Health Organization (WHO) suggests 3 major educational paths involving full‐time chiropractic education:

• "A four‐year full‐time program within specifically designated colleges or universities, with a 1 - 4 year pre-requisite training in basic sciences at university level;
• " A five‐year bachelor integrated chiropractic degree programme offered within a public or private university;
• " A two or three‐year pre‐professional Masters programme following the satisfactory completion of a specifically designed bachelor degree programme in chiropractic or a suitably adapted health science degree."

The WHO also suggests that health care professionals with advanced clinical degrees can meet the educational and clinical requirements to practice as a chiropractor in 2200 hours that includes a minimum of 1000 hours of supervised clinical training. Once graduated, the chiropractor may then be required to pass national, state or provincial boards before being licensed to practice in a particular location. Depending on the location, continuing education may be required to renew these licenses.

In the United States, chiropractic schools are accredited through the Council on Chiropractic Education (CCE). The CCE-USA has joined with CCEs in Australia, Canada, and Europe forming CCE - International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally. Today, there are 18 accredited Doctor of Chiropractic programs in the USA, 2 in Canada, and 4 in Europe and the UK. All but one of the chiropractic colleges in the United States are privately funded, but in several other countries they are in government-sponsored universities and colleges.

Regulatory colleges and chiropractic boards in the U.S., Canada, Australia, Mexico and U.S. territories are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency. In 2006, there were approximately 53,000 chiropractors in the United States and over 6500 chiropractors licensed in Canada.

Comments on Education 3

• I prefer this draft to the others. However, I think that this line from Eubulides, "but in several other countries they are in government-sponsored universities and colleges" is better than "but the colleges in Australia, South Africa, Denmark, one in Canada, and two in Great Britain are located in government-sponsored universities and colleges". DigitalC (talk) 05:55, 30 May 2008 (UTC)
• I support this draft as well. I removed the strikeouts that QG inserted for the educational paths; his argument that its too much weight is unfounded; moreover, not all degrees conferred to chiropractors are the same. As the section suggests, some are 2-3 years MSc (chiro), some are 4 years BSc(chiro) and in North America, it's 4 years after a minimum of 3 (total of 7). The article needs to reflect this global perspective. The source is not in dispute, the source is not fringe so I don't know where the weight argument comes from. I think it's more WP:IDONTLIKEIT than anything else. CorticoSpinal (talk) 00:30, 31 May 2008 (UTC)
• This draft is still mutating so I hesitate to make comments on it, but on the offchance that people are taking it seriously I will say that the draft is disappointing, as it has essentially ignores many of the comments in #Education draft needed work. For example, I don't see anything in the cited source about the 2200 hours being "most commonly done in countries where the profession is in its infancy", and I am quite skeptical that that 2200-hour claim is true. This is just one example of a comment being ignored; there are others. Dematt, have you had a chance to read the bullets at the start of #Education draft needed work? (Just the top-level bullets; you can ignore all the to-and-fro underneath if you like....) Eubulides (talk) 01:08, 31 May 2008 (UTC)

I took out the infancy part. In my rewrite, I apparently inadvertently addressed some of the bullet points. It looks like I agreed with you on some and with others on others. I am hoping to equally satisfy/dissappoint everyone, yet remain true to the sources. Rather than me reading through all that above again, are there specific issues that you feel strongly enough about that you cannot support it? -- Dēmatt (chat) 02:25, 31 May 2008 (UTC)

Education 3 improvement suggestions

OK, I took the time to review the section completely. Here is the revised set of bullet points.

• "Most commonly, chiropractors obtain a first professional degree in Chiropractic medicine (DC or DCM)." The cited source does not say anything about "Most commonly". It says only that DC or DCM are the recognized first-professional degrees. The source is a U.S. source so this would be for the U.S., which should be stated in the text (or a better source should be found).
  • I agree that this is a problem sentence, mostly because I have never seen a DCM degree in the US, yet this is a US source. I could be very wrong, but I would feel better with a better source. I think we do need to say something about what the degree is (DC or DCM) if there is one somewhere. Also, this is the source that says the degree differentiates straight and progressive. I highly doubt that myself, but again could be wrong. I would like to see another source calling anyone progressive? However, because it is a verifiable and reliable source, I will put it in if that is what everyone decides. I'm just thinking we would be looking rather dated at the very least and quite possibly just wrong. -- Dēmatt (chat) 13:59, 31 May 2008 (UTC)
    • I see someone removed the "DC or DCM". But my objection was to the "Most commonly", not to the "DC or DCM". The sentence as written implies that chiropractors uncommonly do something other than get a first professional degree in chiropractic medicine. Is that really true? I'm skeptical. And the source doesn't say "most commonly". Or perhaps I'm misunderstanding the phrase "obtain a first professional degree"? In that case, the sentence needs to be clarified. Eubulides (talk) 08:39, 2 June 2008 (UTC)

• "In North America, a 3 year university undergraduate education (90 semester hours) is required before applying to chiropractic college," The 2nd citation (ccachiro) has nothing to do with the claim; it says nothing about prerequisites. It can be removed. The 1st citation (FPEH) is only about Canada, so the text should be changed from "North America" to "Canada" or better citations should be found. The claim is not true for all of North America (it's not true for Mexico). Neither source says anything about "90 semester hours", so that part should be removed from the text (or a better source found).

• "followed by no less than 4200 student/teacher contact hours (or the equivalent) in four years of full‐time education. This includes a minimum of 1000 hours of supervised clinical training." The citation is to the WHO guidelines, which are a guideline curriculum for the world, and do not place any requirements per se on Canada (or North America). And yet the text is worded as if the WHO was imposing curriculum rules on North America. The text needs to be reworded to make it clear that this is just a voluntary guideline, not a requirement.

• "Internationally, the World Health Organization (WHO) suggests 3 major educational paths involving full‐time chiropractic education:" This "suggests" bit could perhaps be moved in front of the "4200" bit, to make it clear that the "4200" is part of the suggestion.

• "
  • "A four‐year full‐time programme within specifically designated colleges or universities, with a 1 - 4 year pre-requisite training in basic sciences at university level;
  • " A five‐year bachelor integrated chiropractic degree programme offered within a public or private university;
  • " A two or three‐year pre‐professional Masters programme following the satisfactory completion of a specifically designed bachelor degree programme in chiropractic or a suitably adapted health science degree."

" It's tacky to have such an extensive quote. This should be reworded and trimmed. This sort of yawningly-boring detail is not needed in Chiropractic; it might be suited for Chiropractic education.

Besides you thinking this vital detail, which comes from a reputable source (WHO), which gives a representative sampling of the various degrees and educational paths obtained by details worldwide (to give a global POV), which is written neutrally, which is a core part of the education subsection, and which directly provides evidence that chiropractic is scientific (as opposed to a pseudoscience or fringe science as advocated by SA, OM, Jefffire, QG) is there a legitimate reason, besides 'boring' that you want to remove it? CorticoSpinal (talk) 18:21, 31 May 2008 (UTC)

• The WHO guidelines are not "a representative sample"; they are guidelines, which various countries are free to accept or reject, and which have not been accepted by the governments of most of the world's population. They represent a reasonable point of view which should be covered, but they are not by any means definitive, and should not be presented as the current state of affairs in practice.
• They are boring. This is not just my opinion; multiple other editors have agreed on that point. They may well be worth mentioning in a subarticle, but they can be just summarized here.

Eubulides (talk) 08:39, 2 June 2008 (UTC)

Again, boring is a subjective, personal point of view, and opinions differ between editors. They may not have been accepted by government of most of the world's population, but they HAVE been accepted by the CCEs of the countries with the majority of chiropractic colleges. DigitalC (talk) 00:00, 3 June 2008 (UTC)

• "Health care professionals with advanced clinical degrees can meet the educational and clinical requirements to practice as a chiropractor in 2200 hours." Again, this is part of a international guideline, not strictly a requirement; this is not made clear in the text. Also, it's not made clear that the 2200 hours includes 1000 hours of supervised clinical training. Eubulides (talk) 05:13, 31 May 2008 (UTC)
  • "not less than 2,200 hours over a two or three-year full-time or part time program, including not less than 1000 hours of supervised clinical training" - The 2200 hours includes the 1000 hours, however I agree that it should be worded to clarify that this is a guidelines, not a requirement. On the other hand, we may be giving undue weight to the 2200 hours by including it, as I don't know if this recommendation is followed anywhere.
    • Thanks, I'd support removing the 2200 hours issue from here, and moving it to Chiropractic education. It is rather an unimportant detail. Eubulides (talk) 08:39, 2 June 2008 (UTC)
• "Upon meeting all clinical and didactic requirements of chiropractic school, a degree in chiropractic medicine is granted." This sentence is too much detail and is unsourced. At the very least it needs to be sourced. Eubulides (talk) 05:13, 31 May 2008 (UTC)
  • "Upon meeting all clinical and didactic requirements of chiropractic school, a degree in chiropractic medicine is granted. The chiropractor may then be required to pass national, state, or provincial boards before being licensed to practice in a particular jurisdiction." I recommend that this is changed to "Upon finishing chiropractic education, the chiropractor may then be required to pass national, state or provincial boards before bring licensed to practice in a particular location". I disagree that this needs to be sourced. See WP:Reference#When_adding_material_that_is_challenged_or_likely_to_be_challenged. This is not the type of material that is contentious and likely to be challenged. On the otherhand, in QG's draft #6 (now struck out), he uses this site as a reference, which might satisfy requests of other editors, as may this [21]. DigitalC (talk) 11:16, 31 May 2008 (UTC)
    • That wording is much better, thanks. Some quibbles: non-experts won't know what "boards" are, so perhaps change "boards" to "examinations"? Also, change "national, state or provincial" to "national or local", for brevity and completeness (it could be that some localities are neither states nor provinces). Finally, it should be cited, and any one of the local sources would suffice as a citation for this (less-general) claim. Eubulides (talk) 08:39, 2 June 2008 (UTC)
      • How about "board examinations"? Does local really imply provincial or state level? Refernces are directly above your comment and can easily be incorporated. DigitalC (talk) 00:00, 3 June 2008 (UTC)
        • "Board examinations" would be better, thanks. Sorry, I guess I assumed there were exams in countries other than the U.S., Canada, and Australia, countries that might not have either states or provinces. But now that I think of it, those are the only 3 countries that have board exams, right? In that case, the list of the 3 countries should be mentioned, to avoid giving the incorrect impression that this is a universal practice. Eubulides (talk) 06:34, 3 June 2008 (UTC)
          • Its not just these 3 countries. For example, to practice in Europe or Australasia, one may need to write 'board' exams. The term 'board' exam is used, although it may be an exam for a regulatory college, or CCE exam. I don't see how it could give the impression that it is a universal practice, as it states "the chiropractor may then be required to pass national, state or provincial..." (my emphasis).
• "The chiropractor may then be required to pass national, state, or provincial boards before being licensed to practice in a particular jurisdiction. Depending on the state or province, continuing education (CE) may be required to renew these licenses and chiropractors may further specialize in fields such as Chiropractic Orthopedics (DABCO), Chiropractic Radiology (DABCR), and Chiropractic Sports Physician (DABCSP) by completing additional study and passing specified boards that are separate and distinctly different than medical boards." This material is completely unsourced. It needs a source. There is some duplication between this material and the "radiology" and "sports sciences" of Chiropractic #Scope of practice; I suggest trimming the material either here or there, as we don't need it both places. Eubulides (talk) 05:13, 31 May 2008 (UTC)
  • I'm not sure which section it is better in, Scope of Practice, or Education. I think that Education is probably a better spot for it, although a blurb that they can specialize would still be good in SOP. DigitalC (talk) 00:24, 3 June 2008 (UTC)
• "In the United States, chiropractic schools are accredited through the Council on Chiropractic Education (CCE) and recognized by the US Department of Education with the stated purpose of insuring the quality of chiropractic education by means of accreditation, educational improvement and public information and allowing for grants and loans to chiropractic schools and prospective chiropractic students." This material needs to be sourced. Does the DoE really recognize chiropractic schools directly? Also, this stuff is really boring and too much detail and doen't all belong here. "insuring the quality of"? "public information"? "grants and loans"? "prospective chiropractic students"? My goodness but the unnecessary words are really thick here.

• "Recently, CCE standards were integrated into the English speaking countries of Australia/New Zealand, Canada, and Europe. These councils have since developed CCE - International in an effort to maintain chiropractic education standards globally. The cited source says nothing about "recently" or "integrated" or "Australia" or "New Zealand" or "Canada" or "Europe". The text needs to be reworded to match the source, or a better source found. Eubulides (talk) 05:13, 31 May 2008 (UTC)
  • I propose a rewording to "The US CCE has integrated with CCEs in Australia, Canada, and Europe forming CCE - International to "assure excellence in chiropractic education and quality in the profession through accreditation"using this as a reference. DigitalC (talk) 11:47, 31 May 2008 (UTC)
    • That's better, but it still says "integrated". CCE - International is not an "integration". The quote is not accurate, as it contains wording like "assure" that is not in the source. (Ouch! Quotes must be accurate.) But let's not simply quote the source; let's say what CCEI does. CCEI's main accomplishment is to generate model accreditation standards with the goal of having credentials be portable internationally.[22] Let's say this rather than quoting its nearly-vacuous text about "excellence in chiropractic education". Eubulides (talk) 08:39, 2 June 2008 (UTC)
      • CCE-I is an integration, the source uses "join" (as in "join together" to "form one whole"). Further, the quote IS accurate, and the word "assure" is directly from the source, directly from the quoted section. DigitalC (talk) 00:00, 3 June 2008 (UTC)
        • Sorry about the quote: I must have been looking at the wrong citation. You're right, the quote is indeed accurate. However, the other points remain: let's talk about what CCEI does rather than just quoting their blurb about "excellence". Eubulides (talk) 06:34, 3 June 2008 (UTC)
• "Today, there are 18 accredited Doctor of Chiropractic programs in the USA, 2 in Canada, and 4 in Europe and the UK." The cited sources cover just the U.S. and Canada; they do not mention Europe. Please just copy the sentence and citations from #Education, licensing, and regulation 6.

• "Regulatory colleges and chiropractic boards are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency." The cited source is just about Canada, and only about regulatory colleges; it does not mention chiropractic boards. Eubulides (talk) 05:13, 31 May 2008 (UTC)
  • If we include the following reference [23] as well, it will also cover boards. DigitalC (talk) 12:14, 31 May 2008 (UTC)
    • Yes, that covers the boards (in the U.S.), but there's still the issue about Canada & colleges vs. boards and the U.S. Eubulides (talk) 08:39, 2 June 2008 (UTC)
      • Ah, I see what you are saying here. I think that is easily fixed with an and/or statement, as each location would have one or the other. So "Regulatory college and/or chiropractic boards are responsible..." DigitalC (talk) 00:24, 3 June 2008 (UTC) [in hindsight, I don't think an and/or would work]. In fact, I think it is fine the way it is. Reguatory boards, AND regulatory colleges are repsonsible, just not in the same jurisdiction. DigitalC (talk) 03:55, 3 June 2008 (UTC)
        • I suppose so. But now the current draft says there are colleges or boards in Mexico! How did that sneak in? I didn't see Mexico in the sources when I read them earlier. Is it really true that Mexico has boards? Eubulides (talk) 06:34, 3 June 2008 (UTC)
          • Yes they have a regulatory college, the "Colegio De Profesionistas Cientifico-Quiropracticos De Mexico" (College of Professional Scienfific-Chiropractors of Mexico). As currently referenced. DigitalC (talk) 07:08, 3 June 2008 (UTC)
• "The Federation of Chiropractic Licensing Boards (FCLB) oversees most of these regulatory bodies." The cited source does not mention "overseeing"; it's just a list of member bodies. The FCLB is more of a clearinghouse and forum; it does not have a formal oversight role. Eubulides (talk) 05:13, 31 May 2008 (UTC)
  • I agree with Eubulides that the FCLB does not oversee the boards, and I think it may be undue weight to mention the FCLB in this section. DigitalC (talk) 12:14, 31 May 2008 (UTC)

• Nothing is said about the distinction between straight and mixer schools. (QuackGuru also raised this point.) The straight/mixer distinction is worth mentioning briefly here, far more than the eye-glazing material about student loans. We do have a source for it, no? Eubulides (talk) 05:13, 31 May 2008 (UTC)

• Have you read #Education, licensing, and regulation 6 carefully? It has some good ideas, some along the above lines, some independent. I think it might help if you tried to read that draft carefully, just as we've tried to read this draft carefully. It does have flaws, but it has one important virtue: it's far better sourced.

Thanks. Eubulides (talk) 05:13, 31 May 2008 (UTC) :*"The cited sources cover just the U.S. and Canada; they do not mention Europe." The cited source clearly mentioned Europe, however there was a formatting error in the citation template. DigitalC (talk) 09:37, 31 May 2008 (UTC)[resolved]

• ""Most commonly, chiropractors obtain a first professional degree in Chiropractic medicine (DC or DCM).[198]" The cited source does not say anything about "Most commonly". It says only that DC or DCM are the recognized first-professional degrees. The source is a U.S. source so this would be for the U.S., which should be stated in the text (or a better source should be found)." I think the best way around this is to use QuackGurus wording, which is "Most commonly, chiropractors obtain a first professional degree in the field of chiropractic medicine." this then covers the B.AppSci, M.Sc (Chiro) etc. DigitalC (talk) 09:52, 31 May 2008 (UTC)
• "In North America, a 3 year university undergraduate education (90 semester hours) is required before applying to chiropractic college" - This should be changed to "In the United States...", using the CCE standards as a ref (p. 22). This is not true for Mexico or Canada(UQTR). Although, I guess using a CMCC reference as well, it could be said for Canada and the US, since UQTR is a university, not a chiropractic college... but thats just semantics. FTR, UQTR students enter directly from CEGEP [Possibly inaccurate information struck - UQTR is accredited by CFCREAB, as such must follow its standards].DigitalC (talk) 10:04, 31 May 2008 (UTC)

:*"followed by no less than 4200 student/teacher contact hours (or the equivalent) in four years of full‐time education. This includes a minimum of 1000 hours of supervised clinical training." Again, this should be referenced using the CCE standards and CFCRB standards, removing the 1000 hours part, which isn't mentioned in either document. Or, as Eubulides mentioned, it could all be rephrased to show the suggestions of the WHO, although I think its better to show the requirements. DigitalC (talk) 10:32, 31 May 2008 (UTC)[resolved]

• "It's tacky to have such an extensive quote. This should be reworded and trimmed. This sort of yawningly-boring detail is not needed in Chiropractic; it might be suited for Chiropractic education." It is interesting to see differing POVs (and I'm not talking NPOV here). I actually see this section as one of the highlights of this draft. It breaks up with wall of text with some bullet points. I see no reason to not quote the source here, and don't find it tacky. I also see this as an important detail, not a boring detail. There isn't WP:Policy over this type of thing, so it is best to get further input on disagreements like this. DigitalC (talk) 10:39, 31 May 2008 (UTC)

Unfortunately, it seems like Vassyana's plea to avoid nitpicking over minutiae was not followed by a couple of editors. I also disagree with Eubulides' claim that version 6 is "far better sourced". To me this is more of WP:IDONTLIKEIT than genuine concerns about content. There is a continuous attempt to remove the educational paths from the cited WHO source. Besides Eubulides personal opinion of it being 'boring' is there a more valid reason why it shouldn't be included? CorticoSpinal (talk) 18:16, 31 May 2008 (UTC)

Take another look at 3

I'm a little dizzy after trying to incorporate the suggestions above, but I think I got most. I'm still not happy with the first sentence, so could use some input there. I agree with DigitalC that the WHO statement with the formatting as it is actually makes the section more interesting, so I left it like that. Other changes were mostly fixing and adding references (thanks DigC) and moving and deleting what was already there... I agree that #6 is very close to being something I could agree to with a few changes (mostly cleanup)... see if we are any closer. -- Dēmatt (chat) 05:40, 1 June 2008 (UTC)

The long end run of WHO quotes is boooring stuff and undueweight. QuackGuru 09:47, 1 June 2008 (UTC)

Please explain how it is undue weight. This is the section on education and these are the international guidelines for chiropractic education expressed in a succinct and understandable way. I chose to use the exact quote in a bulletted fashion to highlight them and breaks up the text. We could rephrase them to remove the quotes, but I would still like to see the bulletted formatting. I unstruck the text. -- Dēmatt (chat) 14:09, 1 June 2008 (UTC)

They are just suggestions and guidelines and not something official. No reason has been given to give so much weight to something unofficial. This is the section on education and not education suggestions. Too much weight is being given for the suggestions. Besides, they are boring. There is a chiropractic education article for more detailed stuff. QuackGuru 16:00, 1 June 2008 (UTC)

One of the complaints that we get is that the article is too US-centric. Do you have any other sources about the requirements in other countries that we might consider as a replacement. I suppose we could use the CCE-International guidelines, but those, too, have to adopted by a country before they are effective. The WHO guidelines, especially using your suggestion to use the word "suggests", seems to be a good way to handle it? Remember, this does not mean that the techniques and procedures that chiropractors use (such as SMT) cannot be used by other professions; only that if they want to call it "chiropractic", they have to meet these guidleines. -- Dēmatt (chat) 18:14, 1 June 2008 (UTC)

I thought there was more detailed info about CCE - International but it got deleted. "The WHO guidelines, especially using your suggestion to use the word "suggests", seems to be a good way to handle it?" I disagree. The best way to handle the quotes is to delete the quotes. Draft 3 is very disappointing and a big step backwards. Draft #3 has been chopped up and detailed information has removed and the long WHO quotes remain. QuackGuru 20:43, 1 June 2008 (UTC)

I suppose we could put everything back in? Maybe just specific parts. Which ones do you want back in? -- Dēmatt (chat) 20:52, 1 June 2008 (UTC)

What is it that you oppose about the "WHO guidelines on basic training and safety in chiropractic"? Also, why is it that you feel that these are "not something official"? They are the official WHO guidelines. DigitalC (talk) 01:35, 2 June 2008 (UTC)

The guidelines does not always equal official standards. The guidelines are suggestions according to draft number 3. The quotes are boring, they are too long, and have weight problems. At this point, this draft has too many problems. This draft has things backwards. The boring quotes have been kept and useful information has been removed. For potential chiropractors, this section is essential. I hope we can create something that is both detailed and concise. I do not understand why quality information has been removed. QuackGuru 02:41, 2 June 2008 (UTC)

Actually, I preferred the longer version, but others wanted some things dropped out. I'm thinking it is going to be hard to make something that everyone likes, so we might have to go with things that are V and RS and NPOV. Then if we have disagreements, all we have to do is RfC again. Lets see what everyone else thinks. -- Dēmatt (chat) 03:19, 2 June 2008 (UTC)

QG, Just because the guidelines are recommendations/suggestions (thats what a guideline is, a guideline is not a requirement) does not mean they are not official. I for one think that they are what set this draft apart from the others as being better, and disagree with the assertion that they "are boring [and] are too long", which is really just a personal point of view. Specifically, which quality information was removed that you are objecting to? I believe that some things were removed per WP:RS, and others due to WP:UNDUE. DigitalC (talk) 04:27, 2 June 2008 (UTC)

The guidelines are not official world stanadards. The end run of quotes can be removed due to WP:UNDUE. QuackGuru 02:22, 3 June 2008 (UTC)

Please read my previous comments along with this edit summary. QuackGuru 19:45, 2 June 2008 (UTC)

I have read your previous comments, and they do not provide a valid reason for objecting to the WHO guidelines, nor do they explain specifically which "quality information" you object to the removal of. DigitalC (talk) 00:36, 3 June 2008 (UTC)

And in reply to your subsequent edit, no one is stating that they ARE official world standards. However, they are official WHO guidelines. Again, this is not a reason for their removal, and I don't see how it is undue weight. DigitalC (talk) 03:15, 3 June 2008 (UTC)

They are not official world standards. So therefore too much weight is being given to have long block quotes for merely suggestions. QuackGuru 03:47, 3 June 2008 (UTC)

Frankly, my eyes are starting to glaze over looking at this text, which is to me quite boring, for what must be the 10th time. But let me try again:

• "Most commonly" The cited source does not say anything about "Most commonly".
  • deleted. -- Dēmatt (chat) 14:13, 3 June 2008 (UTC)
• "In the U.S., minimum prerequisites" is supported by two sources, one of which is for Canada, not the U.S. Please drop the Canadian reference, or rewrite the text to match the source.
  • rewrote. -- Dēmatt (chat) 14:13, 3 June 2008 (UTC)
• "followed by no less than 4200 student/teacher contact hours". This sentence is worded as if the 4200 hours are a prerequisite for applying to chiropractic school! Please fix the wording. The 4200 hours are during school, not a prerequisite for school.
  • rewrote. -- Dēmatt (chat) 14:13, 3 June 2008 (UTC)
• Again, the quoted three bullet-points should be shortened and summarized. I'm not opposed to the material, or even to the bullets; but there is too much detail here.
  • I think the quote is likely the most succinct I can think to write it. You can give it a try, but I like the bullets. -- Dēmatt (chat) 14:13, 3 June 2008 (UTC)
• The 2200 hours are part of the same suggestion as the 4200 hours; this should be stated. Also, the 1000 hours applies equally to the 4200 hours and to the 2200 hours. This should also be stated.
  • Not clear on this one. -- Dēmatt (chat) 14:13, 3 June 2008 (UTC)
• "state or provincial" -> "local"
  • some provinces or states could be HUGE. Local sounds small. -- Dēmatt (chat) 14:13, 3 June 2008 (UTC)
• A source is needed for "Upon finishing .... licenses". And a period is needed after it.
  • Really?
• "has integrated with" isn't supported by the source.
  • How about "joined". -- Dēmatt (chat) 14:13, 3 June 2008 (UTC)
• The "assure excellence in ... accreditation" quote is fluff. Just say that the CCE-I has generated model accreditation standards with the goal of having credentials be portable internationally.[24] It's much better to say what the CCE-I has done than to quote its fluff about what it wants to do.
  • agree, rewrote. -- Dēmatt (chat) 14:13, 3 June 2008 (UTC)
• "Regulatory colleges and chiropractic boards..." The cited source says this is true for the U.S., Canada, and Australia, but apparently it's not true elsewhere. Please mention that this statement applies only to these 3 countries.
  • It may be true elsewhere. If we just put in those three, we lose others. -- Dēmatt (chat) 14:13, 3 June 2008 (UTC)

Hope this helps. Eubulides (talk) 08:39, 2 June 2008 (UTC)

• It does. Thanks to DigitalC above as well-- Dēmatt (chat) 14:13, 3 June 2008 (UTC)

So are we ready to insert education 3 into mainspace? DigitalC (talk) 23:10, 10 June 2008 (UTC)

Education, licensing, and regulation 4

This draft I wrote and now deleted is obsolete. QuackGuru 19:35, 2 June 2008 (UTC)

Comments on Education, licensing, and regulation 4

I have made some small adjustments. Some of the unnecessary references can be removed. Happy reading. _-Mr. ^o G-_ 03:45, 28 May 2008 (UTC)

First, its a misnomer to call this section 2. Dematt and myself have also already made alternate drafts. Although I do think yours is a good attempt, I still prefer Dematts though we could integrate bits of yours that reads well. It misses the degrees granted and incorrectly ascribes straight vs. mixer programs worldwide (this is primarily a US phenomenon). It also does omits the brief history info which was well sourced and relevant to the section. CorticoSpinal (talk) 04:06, 28 May 2008 (UTC)

I changed it from "2" to "4" to help to avoid confusion with 2 or 3 versions. This draft is the best of the lot so far. Thanks! Undoubtedly it could still use improvements but I will let others comment for now. Eubulides (talk) 09:05, 28 May 2008 (UTC)

I have made a few more improvements. QuackGuru 09:36, 28 May 2008 (UTC)

I changed them all to numbers, and refactored Eubilidies comment above, hopefully you can understand why, so that we can evaluate all of them based on their merits. -- Dēmatt (chat) 13:08, 28 May 2008 (UTC)

Education, licensing, and regulation 5

This draft I wrote and now deleted is obsolete. QuackGuru 19:36, 2 June 2008 (UTC)

Comments on Education, licensing, and regulation 5

Here is another variation for Wikipedians to review. QuackGuru 19:31, 28 May 2008 (UTC)

Which versions are viable candidates now? I see both "5" and "3" in your recent edits. There are a lot of drafts now and I don't want to waste time reviewing ones that are no longer active. Eubulides (talk) 21:19, 28 May 2008 (UTC)

I still think #3 is the best. -- Levine2112 ^discuss 02:00, 29 May 2008 (UTC)

I agree with Levine here. 3# seems to be the best candidate. DigitalC (talk) 05:46, 29 May 2008 (UTC)

Dematts (3) proposal is the best thus far as well. CorticoSpinal (talk) 21:34, 30 May 2008 (UTC)

Education, licensing, and regulation 6

I deleted this obsolete version. For the improved NPOV version. See the chiropractic article history. QuackGuru 03:12, 1 June 2008 (UTC)

Comments on Education, licensing, and regulation 6

Here is yet another variation for Wikipedians to review. There may be some low levels details that can be condensed and unnecessary refs can be removed. Thanks. QuackGuru 05:55, 29 May 2008 (UTC)

I commend you on a good attempt QG, and there's some good stuff in your draft that can definitely go into the subarticle Chiropractic education. That being said, I believe Dematts proposal is the best thus far and is more succint. CorticoSpinal (talk) 17:44, 29 May 2008 (UTC)

No specific objections have been made regarding draft six. Dematt's proposal is controversial. QuackGuru 19:09, 29 May 2008 (UTC)

• "In both cases, this includes a minimum of 1000 hours of supervised clinical training." What does in both cases mean? DigitalC (talk) 07:20, 30 May 2008 (UTC)
  • That quote isn't present in the current version of #Education, licensing, and regulation 6, so I assume this comment is obsolete? Eubulides (talk) 11:39, 30 May 2008 (UTC)
    • No specific objections have been made to number 6. So I added it to the article along with some improvements. QuackGuru 09:09, 31 May 2008 (UTC)
      • Why would you do such a thing? Consensus clearly does not exist, as evidenced by the current support for draft number 3. With everything happening so quickly on this talk page, I haven't even had a chance to fully review this draft yet. I don't understand why you won't wait for consensus BEFORE making major changes to an article. DigitalC (talk) 09:22, 31 May 2008 (UTC)
      • "Chiropractic education is divided into straight or mixer (progressive) educational curriculums depending on the philosophy of the institution." - Given that this website is talking about the structure of US Education, this statement should be modified to represent that it is talking about American education curriculums. DigitalC (talk) 09:31, 31 May 2008 (UTC)
      • You may also want to read through Talk:Chiropractic#Education_3_improvement_suggestions, as some of the suggestions affect this draft as well, as the wording is identical. (Eg: FCLB oversight) DigitalC (talk) 09:41, 31 May 2008 (UTC)
        • DigitalC has acknowledged he has not reviewed the material and therefore this edit was a blanket revert. No specific objections have been made at the time of my edit and my improvements have been ignored. What I added to the article was different than draft six. QuackGuru 09:47, 31 May 2008 (UTC)
          • • Please do not misrepresent my statements. I did not say I had not reviewed the material, I said I had not had a chance to review the material in its entirety. There are still significant problems with both the version you implemented into mainspace, draft #6, and other drafts. Again, I will quote the sign at the top of the page for clarity. "This is a controversial topic that may be under dispute. Please read this page and discuss substantial changes here before making them." The edit which you made was a substantial change, was not discussed, and did not have consensus. In addition, there were problems with the version you implemented, such as "In Canada, typically a 3 year university undergraduate education is suggested before applying for a chiropractic college". A 3 year undergraduate education is the minimum needed to apply for CMCC, but is NOT suggested as a prerequisite to UQTR. DigitalC (talk) 10:14, 31 May 2008 (UTC)
              • If it is just a minor wording that you think needs to be fixed then you could of just fixed it. Reverting an improvement to an entire section is clearly an NPOV violation. QuackGuru 10:35, 31 May 2008 (UTC)
                • No, it is not a NPOV violation. Please refactor your above comment where you misrepresented me. Any further discussion about these edits should take place on my talk page, as they don't relate to improving the article. DigitalC (talk) 12:17, 31 May 2008 (UTC)

Well, people should calm down. However, it was not a very helpful thing to do to put in an edit which did not have consensus. In an article like this, it is always much better to seek consensus on the talk page first, and then put it in the article. I think perhaps it is about time to ask for mediation on this article. ——Martin^phi ☎ Ψ Φ—— 23:29, 31 May 2008 (UTC)

I agree on both points: it was premature to add either draft 3 or draft 6, and mediation might be worthwhile. We already tried informal mediation, and it was a complete bust, so formal mediation would be the way to go. That will take some work, though.... Eubulides (talk) 08:39, 2 June 2008 (UTC)

Comments concerning all education, licensing and regulation drafts

• They are all missing components such as National Board examinations, State Board examinations, and the accredidation body; Council on Chiropractic Education, and FCER (education and research)and FSLB (state licensing regulation). -- Dēmatt (chat) 13:33, 28 May 2008 (UTC)
• They are missing specialization such as DACBO (chiropractic orthopedist), DACBR (chiropractic radiology), DABCN (chiropractic neurology), etc..
• They are missing the distinction between straight and mixer educational curriculums. It's notable enough for the US Dept of Education to note it's good enough to note for chiropractic. The US is the only jurisdiction in the world that actually separates the chiropractic educational system this way. Every other country in whole world, with the exception of New Zealand is exclusively mixer. This is a significant detail. Practice styles and belief systems are associated with the school matriculation. There's sources that proves this such as McDonald (2003). CorticoSpinal (talk) 06:01, 29 May 2008 (UTC)

Comments on Education, licensing, and regulation drafts

A Chiropractic Examining Board requires all candidates to complete a twelve-month clinical internship to obtain licensure.

http://www.life.edu/Current_Students/licensure.asp http://www.jcca-online.org/client/cca/JCCA.nsf/objects/V47-2-P81-P83/$file/V47-2-P81-P83.pdf

I found a couple of refs that might be useful. I suggest we improve the above draft to replace the current section. Thoughts? QuackGuru 16:31, 27 May 2008 (UTC)

The proposed additions (in #Education, licensing, and regulation 1) to Chiropractic #Education, licensing, and regulation draft are an improvement. Thanks for making the proposal here, and avoiding the temptation to edit directly. Eubulides (talk) 16:59, 27 May 2008 (UTC)

This draft (again) omits the various education degrees granted. Why do you keep on trying to delete this key piece of information? Also, you omitted all the new citations too which are relevant. Chiropractic education, licensing and regulation covers ALL of it, not just present tense. Please include those sections. Thanks. CorticoSpinal (talk) 17:02, 27 May 2008 (UTC)

None of the drafts specifically mentions any degrees. It's not a key piece of information at any rate, to say whether it's DC Flavor A or DC flavor B. It would be relevant and useful to mention DC. I suggest mentioning that. Currently the article uses the acronym "DC" without defining it, which is a real shortcoming, and the Education section is the logical place to define it. Eubulides (talk) 20:52, 27 May 2008 (UTC)

Actually, this proves how you don't get it. Only in North America are they DCs. Overseas they're MSc (Chiro) or BSc (Chiro). Skeptics claim there is no such thing as chiropractic science. I present evidence of the contrary. Not only that, it's a minimum of 7 years of schooling in North America, that's not the case overseas. Anyways, your argument has problems with logical fallacies. CorticoSpinal (talk) 22:43, 27 May 2008 (UTC)

None of the drafts specifically mentions any degrees, wither DC or MSc (Chiro) or BSc (Chiro). This is a shortcoming in all the drafts. This has nothing to do with chiropractic science; it's an issue of which degrees are granted. Eubulides (talk) 09:05, 28 May 2008 (UTC)

I think the point CorticoSpinal is trying to make is that these are 1) Different degrees than the DC/DCM, 2) That they are Bachelors of Science (or B. Appl Sci (Chiro)) or Masters of Science from publicly funded universities. Therefore, when critics say that these Chiropractors are anti-science, they are calling into question the reputability of Science degrees from these institutions. DigitalC (talk) 05:53, 29 May 2008 (UTC)

Bingo Where's Orangemarlin when you need him?  ;) CorticoSpinal (talk) 06:15, 29 May 2008 (UTC)

A sentence asserts the guidelines are official guidelines. Are the guidelines official guidelines or merely suggestions. The next sentence says: The WHO guidelines suggest... This is confusing. QuackGuru 17:30, 27 May 2008 (UTC)

Official guidelines are still just that - guidelines. They are not requirements. DigitalC (talk) 05:53, 29 May 2008 (UTC)

Seeing as Eubulides keeps on deleting cited material and is trying to water down education (as he attempted with scope of practice) I have included a succint draft that introduces the salient points. It is critical to include the different degrees DCs get, not all chiropractors receive the doctorate in chiropractic. Some programs are 4 years, some are 5, some are Masters of Science some are Bachelors of Science. These are important facts to note. Chiroskeptics who claim chiropractic is fringe must deal with the fact that outside the US, chiropractic is integrated in public universities and are receiving Bachelors and Masters degrees OF SCIENCE. These are mixer schools; they're not promoting straight/Palmer chiropractic. The skeptics here only want that side of the story covered (even though they form a minority) and obstruct any attempts to tell the other side and especially a non-US side. CorticoSpinal (talk) 18:58, 27 May 2008 (UTC)

• "Keeps on deleting"? I have not deleted any material from Chiropractic #Education, licensing, and regulation since May 14. We are discussing possible improvements, not any actions I have taken on Chiropractic.
• It is not "watering down" to remove boring and overly detailed material. On the contrary, it strengthens Chiropractic to limit it to highly-useful and relevant material.
  • The boring material you refer is notable enough for the WHO. It's not boring Eubulides if it's not controversial. All your edits here either play up controversy by using poor sources such as Ernst, Ernst-Cantor, or attempt to drum some up out of nowhere. CorticoSpinal (talk) 23:30, 27 May 2008 (UTC)

• The WHO generates reams and reams of boring material. Eubulides (talk) 09:05, 28 May 2008 (UTC)

• None of the drafts mention Masters of Science or Bachelors of Science. Furthermore, it's not at all clear that this level of detail is needed here; it can go in Chiropractic education.

That level of detail doesn't belong here? It's less than 10 words. Why are you fighting so hard to prevent it's inclusion. Even Dematt's draft has included it. CorticoSpinal (talk) 23:30, 27 May 2008 (UTC)

We are talking about far more than 10 words of boring material. Eubulides (talk) 09:05, 28 May 2008 (UTC)

To each their own I suppose. So to clarify, you object to listing the various educational paths for lincensure throughout the globe? CorticoSpinal (talk) 16:52, 28 May 2008 (UTC)

Yes. That is excessive detail here. It should be in Chiropractic education. Eubulides (talk) 21:19, 28 May 2008 (UTC)

You seem to dispute all the details Eubulides. DigitalC has also said you have been pedantic. I would use tendentious, but that's just me. Either way, you might want to look at what admin Vassyana said yesterday, here, about arguing minutiae. Thanks. CorticoSpinal (talk) 06:08, 29 May 2008 (UTC)

• #Education, licensing, and regulation 1 mentions the topic of public universities outside the U.S.

Eubulides (talk) 20:52, 27 May 2008 (UTC)

Dematt's draft is superior to both yours and mine. I endorse his draft. It would be nice if you could compromise too and let Dematt try to work his magic. Thanks. CorticoSpinal (talk) 23:30, 27 May 2008 (UTC)

I am sure we can work together starting with Dematt's draft. But it will need a lot of work, as described elsewhere. Eubulides (talk) 09:05, 28 May 2008 (UTC)

Doubt it needs as much work as you imply, but its agreed that we shall use Dematts draft as the template and starting point. CorticoSpinal (talk) 16:52, 28 May 2008 (UTC)

Well, I'm in Britain and things are pretty much exactly the same here. Jefffire (talk) 19:48, 27 May 2008 (UTC)

It's my understanding that chiropractic in Britain is more integrated into the system than here. But then, the whole system is different isn't it, isn't it harder to be an MD.. and what we call MDs here are what you call Mr.? I may be totally off base here. -- Dēmatt (chat) 20:46, 27 May 2008 (UTC)

I'm not aware of any significant differences between the quality of UK and US MD's, but what I meant is that Chiropractic is not considered mainstream medicine. I wouldn't say it any more integrated than in the US. Jefffire (talk) 21:00, 27 May 2008 (UTC)

Something tells me it is more integrated than the US and that the BCA said chiropractic had the most potential to be integrated in the mainstream. I'll ask my colleague at AACC for materials/sources that can shed more light. CorticoSpinal (talk) 23:30, 27 May 2008 (UTC)

I added my version above as well, it's a compromise version of sorts, though I think it needs building of the regulation section as well as licensing or the title should change. -- Dēmatt (chat) 19:10, 27 May 2008 (UTC)

If Jefffire would be so kind to perhaps tell us a bit about the educational system in the UK that would be helpful. I'm aware of Anglo-European, Welsh Institute and McTimmoney. I believe the first two have formal associations with universities as well. One of the biggest oversights of the article is it's heavy US-centric look without giving the rest of the chiropractic world their due. There is now officially more schools of chiropractic outside the US than within in. Also, all schools except New Zealand are mixer. So, of the 35 schools of chiropractic in the world, I believe only 7-8 are straight with 6-7 coming from the USA. USA is the only jurisdiction in the world whereby the education is divided into straight or progressive (mixer). These details need to be in the article. They're important for various reasons. CorticoSpinal (talk) 20:14, 27 May 2008 (UTC)

Details about things like the Welsh Institute's funding arrangements do not need to be in Chiropractic. They can be in Chiropractic education. Eubulides (talk) 20:52, 27 May 2008 (UTC)

Who mentioned anything about funding arrangements? CorticoSpinal (talk) 23:30, 27 May 2008 (UTC)

The main point, as I understand it, is that the chiropractic colleges outside the U.S. are at government-sponsored universities. Eubulides (talk) 09:05, 28 May 2008 (UTC)

The main point is that, outside the US, chiropractic education is almost exclusively taught in public universities which is in contrast to the US where its almost exclusively private schools (except Bridgeport). CorticoSpinal (talk) 16:52, 28 May 2008 (UTC)

Yes, that's the main point, and it can be made without a long list of countries. Eubulides (talk) 21:19, 28 May 2008 (UTC)

• IMHO, I think Dematt's (#3) version above is the most clear and concisely written. That said, I do like the way that CorticoSpinal's version opens with a brief overview of the history of chiropractic education. I agree that there should be a section (perhaps separate from education) discussing regulation and licensing. -- Levine2112 ^discuss 20:45, 27 May 2008 (UTC)

Dematt's may be clear and concise, but it has serious problems with citations and POV. Please see #I lost track below for more details. Eubulides (talk) 20:52, 27 May 2008 (UTC)

Draft 1 is too much of a mess to work with and suffers from more citation and NPOV issues. Let's start with Dematt's version as a base of this discussion and work out a consensual version from there. See below. -- Levine2112 ^discuss 21:33, 27 May 2008 (UTC)

All the drafts have serious citation problems; Draft 1 has the fewest. NPOV is harder to measure. We can start with any of the versions, of course; Dematt's hasn't addressed more of the bullets in #Education draft needed work, but it may well be that it's easier to fix those bullets one by one in a better-structured draft. Eubulides (talk) 21:56, 27 May 2008 (UTC)

I support Dematt's draft as a compromise. Eubulides' complaints regarding citations are not valid. Your opinion on draft 1 is just that, an opinion. Which I do not share. So, please, stop pushing your views on the rest of of us. Thanks. CorticoSpinal (talk) 22:33, 27 May 2008 (UTC)

Forgive me, but I don't think there should be a whole lot about education. I thought we wanted to make the article less boring!;) —Preceding unsigned comment added by CynRN (talk • contribs) 03:08, 28 May 2008 (UTC)

Dematt, I think it would be preferred that rather than highlighting the US CCE we use the Council on Chiropractic Education International. This is more globally representative and represents the CCE(USA) CCE(Canada) the CCE(Europe) and the CCE(Oz). There might be good tibits in there too. CorticoSpinal (talk) 16:41, 28 May 2008 (UTC)

I continue to be puzzled by which of the drafts is currently worth reviewing. Edits seem to be happening to two sets of drafts at the same time. This makes it very difficult to follow the intent. Can someone please explain what's going on vis-a-vis these drafts? Thanks. Eubulides (talk) 08:47, 29 May 2008 (UTC)

Chiropractic is Fringe: The rebuttal

Clearly Filll is not up to date on his research nor is applying evidence-based principles. I know that already because Filll endorsed a 1966 disparaging quote on Chiropractic. Filll also makes several misrepresentations here that need to be debunked:

"pro-chiropractic editors come to some sort of consensus and resolution with the mainstream editors and proscience editors amd mainstream medicine editors on this page FIRST."

• Filll implies that "pro" chiropractic editors need to come to resolution with proscience editors. Filll implies that chiropractic and chiropractors are not scientific. Filll is attempting to straw man pro-chiropractic editors claiming they are neither scientific nor mainstream. The literature says otherwise.

"This is not an advertising venue for pseudoscience and voodoo. Sorry."

• If Filll would provide an example that Chiropractic is endorsing pseudoscience or voodoo that would be helpful. Also, if Filll coould provide evidence that mainstream chiropractic is pseudoscientific that would be helpful. Otherwise, Filll has just discredited himself with a stupid comment that has has no validity whatsoever.

"And by any measure that is reasonable among the experts in the field, chiropractic is a very FRINGE treatment."

• If Filll could provide any evidence of any measure that experts in the field suggest that chiropractic (SMT?) is fringe treatment that would be helpful. Because the vast majority of the literature disagrees with you. And you say you represent the mainstream? Lol! CorticoSpinal (talk) 00:45, 28 May 2008 (UTC)

Chiropractic is a FRINGE alternative medical practice by many different measures. First, it is mainly prevalent in the US, and to a lesser extent in Canada and Australia. Although it is present in other countries, it is far less common in these. Even in the US, where it is most common, there are only 53,000 chiropracters [25] compared to 633,000 physicians and surgeons [26]. When considered on a worldwide basis, this is a very very minor treatment option. Even in the US, over their entire lives, only 1/5 of the US population has ever had an encounter with a chiropracter. And this in spite of their much cheaper cost and the problems with US healthcare costs. On a dollar basis, chiropractic is minor indeed.

Looking at the Palmer theory, it is clearly complete nonsense. He claimed that 95% of all disease was due to "subluxations" which have been shown to not even exist. Even using a witch doctor word like "subluxation" in the way we do in this article really tells me this article is in terrible shape.

When you can show me that more than half of the PhDs and MDs who work at the NIH have been fired and replaced by DCs, and more than half of the PhDs and MDs who work at the CDC have been fired and replaced by DCs, then I will agree with you that Chiropractic is mainstream. However, one has to go a ways before that will happen I suspect.

So I am sorry, I have to beg to differ, but the strong impression I have is that chiropractic falls in the category of "FRINGE". I will grant you that there are a couple of studies that show it has some value in very isolated very very very narrow circumstances in lower back pain problems, although whether this is greater than a placebo is debatable.--Filll (talk | wpc) 20:20, 28 May 2008 (UTC)

• Lets play with your numbers to see if they are a valid argument. Do you consider optometry "fringe"? There are roughly 33,000 optometrists in the US (BLS data), and 53,000 Chiropractors (BLS data). There are 15 Optometry schools in the US, 2 in Canada, and 3 in Australia. There are 18 Chiropractic colleges in the US, 2 in Canada, and 3 in Australia. You say that in the "US, over their entire lives only 1/5 of the US population" [sampled] has seen a Chiropractor. In the province of Alberta, 1/5 of the population (sampled) had seen a Chiropractor within the last year. As for Palmer theory, you are now talking about a minority of Chiropractors. As far as I know, subluxation, as a hypothetical construct has not been "shown to not even exist", however I know that many Chiropractors reject the use of the word subluxation. DigitalC (talk) 01:09, 29 May 2008 (UTC)

• If one may offer a more succinct arguement: There is what is called "mainstream medicine". Chiropractic is not a part of it. What is not mainstream, is fringe. QED. Jefffire (talk) 20:28, 28 May 2008 (UTC)

It's not that simple. Some elements of chiropractic are fringe: e.g., using spinal adjustments to treat autism, something for which there is zero scientific evidence). Some elements are not fringe, even if there is controversy about them: e.g., using SMT to treat lower back pain, as even Ernst, a sharp critic, says that this may help in a subgroup of patients (Ernst 2008, PMID 18280103). It is certainly true that the medical establishment has not yet fully accepted chiropractic as mainstream (e.g., see Meeker & Haldeman 2002, PMID 11827498), so in that sense it is not mainstream. But this does not mean that chiropractic is entirely fringe either. It is a bit of a hybrid: a profession at the crossroads, as it were. Eubulides (talk) 21:19, 28 May 2008 (UTC)

Essentially, what Filll and Jefffire have given us are their own fringe ideas. Allow me to demonstrate by us looking at some evidence:

• Once fringe, chiropractic care now gets mainstream acceptance
• Chiropractic Care Moving From Fringe to Mainstream
• chiropractic joins the medical mainstream
• Chiropractic itself can no longer be considered a fringe therapy
• Mainstream Makes Adjustments
• Once on the fringe, chiropractic joins the medical mainstream

Accordingly it does seem that the popular belief nowadays is that chiropractic - though once considered fringe - is not not considered as such by the mainstream based on the growing scientific support. After all, what is fringe? Our own Wikipedia defines fringe as ideas viewed as marginal or extremist by the mainstream. Well, since the mainstream apparently doesn't think chiropractic is fringe, the only thing fringe around here are the ideas of those still maintaining that chiropractic is still fringe! ;-) -- Levine2112 ^discuss 21:39, 28 May 2008 (UTC)

I think that there are some WP:REDFLAG issues with the "evidence" you cite. Many of them are obviously chiropractic websites with the goal of making themselves look more mainstream than they are. Others are mainstream news articles which are notoriously bad for determining what is the opinion of the experts. Why not get some references from the organizations of medical doctors and scientists who are able to best evaluate the subject to back up your claims? ScienceApologist (talk) 22:09, 28 May 2008 (UTC)

Incorrect. And your "one bad apple spoils the bunch" tactics don't fly here. -- Levine2112 ^discuss 00:48, 29 May 2008 (UTC)

How about the only apple in the bunch of lemons is spoiled? ScienceApologist (talk) 08:41, 31 May 2008 (UTC)

Please look closer. We have a medical journal in Australia, mainstream newspapers, magazine. The one chiropractic source is actually just a reprint of the New York Daily News article. No ref flags. Sorry, that argument holds no water. The sources above demonstrate that the mainstream media and science no longer consider chiropractic "fringe". Thus, the belief that chiropractic is fringe is ironically a fringe belief. -- Levine2112 ^discuss 22:30, 28 May 2008 (UTC)

The article in MJA contends that chiropractic is not mainstream medicine, rather it claims that because a large minority uses chiropractic it has to be examined closely. The no longer considered "fringe" comment is a red herring extraordinaire: googled for and ripped from the context of the actual article [27]. You obviously didn't read WP:REDFLAG carefully. Get some better sources and stop misconstruing the ones you do find. ScienceApologist (talk) 22:41, 28 May 2008 (UTC)

Incorrect. And your "one bad apple spoils the bunch" tactics don't fly here. -- Levine2112 ^discuss 00:48, 29 May 2008 (UTC)

No. You've established that chiropractic true believers think that chiropractic is mainstream and not fringe. That's quite different. ScienceApologist (talk) 19:38, 29 May 2008 (UTC)

The 'true believer' label is a red-herring and straw man attack. We could apply the same logic and call ScienceApologist a 'true denier' of chiropractic. It's the same thing. Most importantly, It has nothing to do with the the topic at hand: Namely, there is strong evidence, from high impact mainstream, peer-reviewed journals that supports the claim that chiropractic is not fringe but rather mainstream health care in 2008. (Or far closer to it in a sliding scale context than it is to fringe and comparisons to 'alien abductions Flat Earth, Creationism, AIDS Denialism, and other nonsense. There is also evidence of this in verifiable, reliable and reputable lay sources such as the New York Times and many other distinguished and notable papers. You have presented nothing that supports your claim that chiropractic is fringe, nor have you produced any evidence that disputes the sources presented. In short, you have produced nothing but hot air on this topic. You have, however presented, rather tendentiously I might add, your personal opinion that chiropractic is fringe and a pseudoscience. Given your track record, SA, I'd be careful to how much you civilly push your POV. CorticoSpinal (talk) 03:54, 30 May 2008 (UTC)

Come on now guys. The article, to be NPOV, must contain both the "true believer" POV, and the "true denier" POV. Get over it and get on with including both POV. Be inclusionists (builders of the encyclopedia) rather than deletionists (destroyers of the encyclopedia). Just use good sources that present both POV in a representative manner. Try writing for the enemy for a change, or at least enable the opposing POV's inclusion, rather than preventing its inclusion. -- Fyslee / talk 04:28, 30 May 2008 (UTC)

No one is arguing that we shouldn't report true believer POVs in here: that's what the article is ostensibly about anyway. We are only arguing that we should simply characterize it as such. The claim that "true denier" POV exists can also be attributed to true believers. However, there is a group of people hoping to write the entire article from a true-believer perspective that heralds chiropractic as the new fountain of youth that will invigorate all of medicine. This kind of ridiculous posturing needs to be resisted. ScienceApologist (talk) 08:41, 31 May 2008 (UTC)

Precisely. Well put. We don't need a censured and updated version of the story, we need the whole story. -- Fyslee / talk 16:52, 31 May 2008 (UTC)

No, but if it is true that modern chiro, like modern medicine, is no longer a magical operation, but has good mainstream and scientific support, then that fringe element is part of the history, not the frame of the article. Is chemistry alchemy? ——Martin^phi ☎ Ψ Φ—— 23:33, 31 May 2008 (UTC)

The problem is that chiropractic has both. Its fringe element is not history; it is still quite active among a large fraction of chiropractors, and still promotes chiropractic care for conditions like high blood pressure for which there is zero scientific evidence. (See, for example: Thyer B, Whittenberger G (2008). "A skeptical consumer's look at chiropractic claims: flimflam in Florida?". Skept Inq. 32 (1).) Conversely, there is some scientific support for some treatment forms; even Ernst, a critic, says that spinal manipulation might be effective for some patients with low back pain, with the implication that more research is needed. (See Ernst 2008, PMID 18280103.) One cannot dismiss chiropractic as being entirely fringe; nor can one accept it as being entirely mainstream. It has strong elements of both. Eubulides (talk) 08:39, 2 June 2008 (UTC)

My impression was that the fringe elements, the straight ones versus the mixed ones, is on a ratio of perhaps 10% straight. So at least what you have there is a reason to make a clear distinction in the article between the scientific support for each, and to give a different treatment to one versus the other. I think people are most worried that the whole of the field will be portrayed as fringe- that is, basically the mixers will be tarred with the same brush as the straights. And others are eager for it to be portrayed as fringe. It's all about debunking stuff like chiro. So you have to meet somewhere in the middle, where the fringe elements won't be minimized, but the validated elements of the field, and the fact that it is widely accepted in the medical establishment and not looked down upon in a lot of ways will also be communicated to the reader. So basically I think we agree on the basics. My impression was however that some people wanted the whole article to be under FRINGE whereas really that's only justified for part of the material. ——Martin^phi ☎ Ψ Φ—— 05:13, 3 June 2008 (UTC)

Please see #10% straight? below. Eubulides (talk) 06:34, 3 June 2008 (UTC)

10% straight?

I'm curious as to where that "10% straight" figure came from. It sounds low to me. Part of this depends, of course, on what one means by "straight"; whether one is "straight" is not a black-and-white issue.

For more about this, please see McDonald et al. 2003 (ISBN 0972805559, doi:10.1016/j.sigm.2004.07.002, lay summary). This survey of North American chiropractors reported that nearly 90% of surveyed chiropractors wanted to retain the term vertical subluxation complex and opposed having adjustments be "limited to musculoskeletal conditions"; when asked to estimate the percent of visceral (i.e., non-musculoskeletal) ailments in which subluxation is a "significant contributing factor", the mean response was over 60%. These are all "straight" positions. Also, a high percentage of chiropractors espoused fringe theories like homeopathy (supported by over 80% of surveyed chiropractors).

Even though I don't have hard evidence, I agree with you that more chiropractors would call themselves "mixers" than "straights". However, the survey suggests that this doesn't mean that they're entirely off the hook as far as WP:FRINGE goes. Eubulides (talk) 06:34, 3 June 2008 (UTC)

The confusion can be resolved if one keeps in mind that both straights and mixers can hold the same POV on the vertebral subluxation (VS). The difference is strictly in regards to choice of treatment methods, not necessarily in beliefs about disease causation. Mixers add other methods to their use of spinal adjustments. While ultra straights will believe in the old Palmerian "one cause, one cure" "Big idea" and use only adjustments, most mixers hold modified positions about disease causation and treatment methods that are still affected by the original "Big idea." It is of course only among mixers that the possibility exists for reform ideas, and a small portion of mixers are reformers who openly reject VS, and a larger portion of mixers who admit to other causes of diseases than VS. Paradoxically they still adhere to a predominant role for adjustments, even while admitting that the spine is not related to all diseases. It's hard to shake their education and heritage. -- Fyslee / talk 06:47, 3 June 2008 (UTC)

These two arguments make assumptions that vertebral subluxation equates to fringe. We need to understand that VS is just what chiropractors call the lesion that they treat. Other types of therapists treat these lesions as well and are well within mainstream thought. They just call it something different. IOWs, VS has at least 5 components (take a quick look) when describing a vertebral joint problem; 1)misalignment and/or fixation, 2)compressed or irritated nerve, 3)muscle spams/weakness/or atrophy (around the involved joint), 4)local inflammation (at the joint), 5)pathological changes at the site (arthritic changes) and global loss of homeostasis (effects on the body). A VS can involve ONE or ALL of the above, so when you ask a chiropractor in a chiropractic survey if he/she "believes" in subluxation, he/she may be thinking what 90% of physical therapists are thinking when asked if they believe in fixated joints, or orthopedists if they believe in ruptured discs (this is a combination of misaligned, inflammed and irritated nerve). So just because a chiropractor thinks that "vertebral subluxation" exists, doesn't make him nuts, only that he is not speaking your language. The only fringe in chiropractic are those that think they can cure cancer, polio, or things like diabetes. Notice that this does not mean that chiropractors who treat these patients are fringe, only the ones that think they are "curing" it or an alternative to medical treatment for it. That group is surely less than 10%. And not all of them are straights. -- Dēmatt (chat) 13:05, 3 June 2008 (UTC)

Point taken on the term "subluxation", but the other two points remain: in that same survey 90% of chiropractors opposed having adjustments be "limited to musculoskeletal conditions", and when asked to estimate the percent of visceral (i.e., non-musculoskeletal) ailments in which subluxation is a "significant contributing factor", the mean response was over 60%. That latter response is uncomfortably close to saying that adjustments have a role in curing ailments like diabetes etc. It's just one survey, of course, but other surveys also show that a large fraction of chiropractors hold important non-mainstream views. Colley & Haas 1994 (PMID 7884327) reported that of surveyed chiropractors "One-third agree that there is no scientific proof that immunization prevents disease, that vaccinations cause more disease than they prevent, and that contracting an infectious disease is safer than immunization." More-recent Canadian surveys reported 27.2% and 29% of chiropractors being antivaccination (Busse et al. 2005, PMID 15965414). It's hard to call opinions like these anything but "fringe". In other words, the "10% straight" claim (which so far has no supporting evidence), even if it were true for some definition of "straight", doesn't by itself resolve the question as to how much "fringeness" is in chiropractic practice. Eubulides (talk) 16:50, 3 June 2008 (UTC)

Well, I can see how that looks fringe, but again context is important - particularly when we are looking at surveys. Surely mainstream considers that pain can lead to emotional and physical manifestions, ie. stress and depression play a role in disease - even if we just consider the effects on blood pressure alone much less the cortisol effects,etc., etc.. Both stress and depression are known to be manifestations of chronic pain. It then isn't that unusual to consider something that is painful - especially chronically painful - as a significant contributing factor in health and wellbeing - physically, mentally and socially. I don't have to tell anyone in health sciences this stuff - it's new name is the psychosocial model. It's the notion that a patient should be treated in an area of the spine that has no signs of dysfunction just because there is an organ problem that gets its nerve supply from that region that might be considered fringe, but it's not because science refutes it, it just isn't well studied. If we called all medicine fringe that wasn't well studied, chiropractic would be in good company. I'm not sure that we can consider the vaccination issue as a reason to call the profession fringe, or even a large portion, basically because that is outside of their scope. IOWs, these things don't make chiropractors fringe and we do know that 90% of chiropractors treat only neuromusculoskeletal problems, whether they call them subluxations or sprains and strains. I agree that the types of chiropractor straight or mixer have nothing to do with mainstream either, because there are fringe elements in both, the words have political meaning to some, but have nothing to with mainstream. Even if you considered homeopathy, acupuncture, and supplements fringe, that says nothing about chiropractic. So the most we could say is that some chiropractors practice fringe techniques. -- Dēmatt (chat) 20:43, 3 June 2008 (UTC)

I agree with almost everything you said—except for the number. I don't agree that "90% of chiropractors treat only neuromusculoskeletal problems". I don't know of any source for that number, and I think the percentage is much smaller than that. It could well be that 90% of the visits are for NMS problems, but that is not the same thing as saying that 90% of chiropractors treat only NMS. For a recent source on this topic, please see: Thyer B, Whittenberger G (2008). "A skeptical consumer's look at chiropractic claims: flimflam in Florida?". Skept Inq. 32 (1). This source found that three-fourths of the office representatives of surveyed chiropractors in Tallahassee said that chiropractors could treat high blood pressure, arthritis, or both, even though there's no scientific evidence that chiropractic care is effective for these conditions. The paper also reports on another case in Ontario where 72% of surveyed chiropractors said that they could help with chronic ear infections in a two-year-old child. Eubulides (talk) 21:27, 3 June 2008 (UTC)

I'm glad you asked that. That is the point I was trying to make... chiropractic <> SMT... Diet, exercise, stress reduction are all part of a chiropractor's arsenal for helping patients that also have high blood pressure. That doesn't mean that they are out of the mainstream. For acute ear infections, the current protocols are a wait and see attitude (rather than immediate antibiotics). Chiropractors have otoscopes and can watch an ear as easy as anyone else. Sure, they are aware of mastoiditis and the risks, why wouldn't you want a chiropracotr to check for these things. This is not out of the mainstream. As far as chronic ear infections, does this assume that medicine hasn't worked? Maybe it is time for alternatives or complementary choices. -- Dēmatt (chat) 21:48, 3 June 2008 (UTC)

Again, I agree with what you say about chiropractic ≠ SMT, diet, exercise, etc., but… the Ontario story was about chronic ear infections; and the problem isn't the wait-and-see attitude, it's that chiropractors advocate using SMT (in particular, upper-cervical manipulation) to treat chronic ear infections. See, for example, the ACA's web page on the subject. There isn't any scientific evidence that SMT is effective for chronic ear infection, so in that sense it is not a mainstream treatment. Eubulides (talk) 07:24, 4 June 2008 (UTC)

Is chiropractic "alternative"?

Thank-you both for responding. First, Jefffire, your argument is flawed. It is the fallacy of a false dichotomy. Next, onto Filll. Unfortunately, your argument is based on a very narrow synthesis of literature which essentially leads tooriginal research that you are presenting here. Perhaps if we examined Fillls argument a bit closer in detail we can point out the deficits in the arguments being raised.

"First, it is mainly prevalent in the US, and to a lesser extent in Canada and Australia. Although it is present in other countries, it is far less common in these."

So, it is firmly established in North America, including the world's only superpower, is also established firmly in the UK, developing nicely in Europe and is in entrenched in public universities outside North America. Would the World Health Organization bother to develop safety and training guidelines if it were fringe? Also, is your opinion, consistent with the opinion of the expert researchers on the topic? Well, I won't cite a paper written by a DC, but the following passage is from a review by an MD.

“ Even to call chiropractic "alternative" is problematic; in many ways, it is distinctly mainstream. Facts such as the following attest to its status and success: Chiropractic is licensed in all 50 states. An estimated 1 of 3 persons with lower back pain is treated by chiropractors.1 In 1988 (the latest year with reliable statistics), between $2.42 and $4 billion3 was spent on chiropractic care, and in 1990, 160 million office visits were made to chiropractors.4 Since 1972, Medicare has reimbursed patients for chiropractic treatments, and these treatments are covered as well by most major insurance companies. In 1994, the Agency for Health Care Policy and Research removed much of the onus of marginality from chiropractic by declaring that spinal manipulation can alleviate low back pain.5 In addition, the profession is growing: the number of chiropractors in the United States—now at 50,000—is expected to double by 2010 (whereas the number of physicians is expected to increase by only 16%).6 ”

There's more Filll, but I'm not trying to make you look stupid. I'm just seeing if your position is dogmatic skepticism or rational skepticism.

"Even in the US, over their entire lives, only 1/5 of the US population has ever had an encounter with a chiropracter. And this in spite of their much cheaper cost and the problems with US healthcare costs."

Do you think this has to do with the fact that the American Medical Association was found guilty of an anti-trust and anti-competition lawsuit by the United States Supreme Court and that the AMA's policy until 1990 was to "contain and eliminate" chiropractic? and may have resumed its practices again?

"On a dollar basis, chiropractic is minor indeed."

• Thanks for sharing your opinion. Unfortunately, Wikipedia requires reliable sources to support the claims made. Fortunately this has been addressed, in part, by Kaptchuk (1998).

""Looking at the Palmer theory, it is clearly complete nonsense. He claimed that 95% of all disease was due to "subluxations" which have been shown to not even exist. Even using a witch doctor word like "subluxation" in the way we do in this article really tells me this article is in terrible shape.""

Out of curiosity, Filll, could you provide evidence that

1. Palmer Theory is being used today by the mainstream of the profession
2. Subluxations/joint dysfunction (manipulable lesion) has been found not to exist and
3. That the use of the word subluxation proves that the article is in terrible shape.

Here's a bit of facts for you to chew on. First, your assessment is completely invalid, unreliable and dated. First, straights are the minority. Let me repeat. Straight chiropractors represent the minority viewpoint. Every single school outside the USA except 1 (New Zealand) teaches a mixer/integrative/evidence-based curriculum. That's 16 mixers program to 1 straight. Taken as a whole, there are 35 accredited schools of chiropractic globally, only 8 of which teach the straight model, 7 of which are located in the USA. Wikipedia policies are that we represent the majority view and does so in a global manner. Your asinine comments are not congruent with Wikipedia policies in this regard.

So, what exactly is "Palmer Theory". Well, there really is none. The concept of subluxation (joint dysfunction) has been revised and modernized throughout the years. You see, you're basing your views on a 100 year old concept and like most uninformed individuals, perpetuate stereotypes and falsehoods. Let's read an exerpt of the latest of "chiropractic theory" from DeVocht (2006) from Palmer School of Chiropractic:

“ Chiropractic is based on the theory that intervertebral joints can become stabilized in some aberrant situation that may lead to biomechanical and/or neurologic alterations. It originally was thought that it was a simple matter of a vertebra getting out of alignment relative to the adjacent vertebrae and consequently applying pressure on the spinal nerve root as it exited the spine through the intervertebral foramen. The subluxation, as this condition has been termed, was thought to sometimes cause the impediment of action potentials as they passed through that nerve. This “foot on the hose” concept provides an easily visualized explanation as to how subluxations could cause any of a myriad of symptoms in whatever region that nerve happened to supply.

As research began to be done, it became apparent that the mechanisms involved are not as straightforward as originally thought. Nevertheless, the general notion of some sort of deleterious lesion involving the spine and/or adjacent structures with far reaching implications that can be affected by spinal manipulation can be explained by other mechanisms. For example, it has been theorized that edema or inflammation of tissues in or around the inter-vertebral foramen sometimes could cause enough pressure on the spinal nerve roots to interfere with nerve impulses passing through them.26 Some have hypothesized that rotational misalignment of the cervical vertebrae could twist the dura mater causing the dentate ligaments to pull directly on the spinal cord.20 One other theory, of many, is that spinal kinematics can be impaired by localized joint fixations of various etiologies.36 That is why some chiropractic approaches involve manual flexion of the spine- the clinicians are looking for specific areas of restricted motion.

Because the exact mechanisms are not known does not negate the validity and usefulness of the general concept of a subluxation. The term, which is ingrained in the profession, is somewhat of a misnomer because it no longer seems that there is always an abnormal displacement of one vertebra relative to the others. The entire practice of spinal manipulation is based on the concept that there must be some kind of lesion in the spine that responds favorably to manipulation. Therefore, other more accurately descriptive names have been suggested, such as manipulatable lesion. There is no reason to perform spinal manipulation if one is not convinced that there is some kind of lesion present that would respond to manipulation. Although the specific mechanisms involved are not known, it has been empirically shown that there are specific indicators that typically are associated with a spinal lesion that is likely to respond to manipulation (a subluxation) such as joint restriction, muscle spasm, and/or pain.

”

"When you can show me that more than half of the PhDs and MDs who work at the NIH have been fired and replaced by DCs, and more than half of the PhDs and MDs who work at the CDC have been fired and replaced by DCs, then I will agree with you that Chiropractic is mainstream. However, one has to go a ways before that will happen I suspect."

There's a lot wrong with this argument. First, it is an appeal to authority fallacy. In addition to being appeal to belief fallacy as well as an appeal to ridicule. In fact there are so many logical fallacies in your arguments that you really to need to read this. It's hard to have a meaningful and productive conversation with someone when their arguments are so flawed and unsound. The CDC comment is a red-herring. DCs are primarily for MSK disorders. So, that's not a valid comparison nor statement.

"So I am sorry, I have to beg to differ, but the strong impression I have is that chiropractic falls in the category of "FRINGE". I will grant you that there are a couple of studies that show it has some value in very isolated very very very narrow circumstances in lower back pain problems, although whether this is greater than a placebo is debatable.--Filll (talk | wpc) 20:20, 28 May 2008 (UTC)"

Just to be clear, you think chiropractic care for LBP is less effective than placebo? That is your official position on this stance? (drools....)

So, considering that your arguments fail the litmus test, perhaps you can bring new arguments (not riddled with fallacies either) that I can debunk. It's been a pleasure providing you with some (badly needed) continuing education. Also, your opinions are not congruent with the majority on SMT and chiropractic care. Please refrain from continuing this civil POV push which suggests that SMT and chiropractic is fringe (similar to Flat Earth, Creationism and Homeopathy. Last time I checked none of those topics were covered at the World Health Organization. CorticoSpinal (talk) 21:59, 28 May 2008 (UTC)

It is quite clear that close textual analysis of CS's citations that are to actual experts do not argue that Chiropractic is mainstream medicine, just that millions of people use it. Well, millions of people use a lot of fringe things (look at homeopathy, creation science, UFOs, etc.) Whether people use it or not does not determine whether it is fringe or not. Expert evaluation does, and expert evaluation is pretty clear that there isn't much that can be said that chiropractic has been shown to medically benefit. A number of the other sources are obvious WP:REDFLAGs. ScienceApologist (talk) 22:09, 28 May 2008 (UTC)

I think the larger picture here reveals that fringe and mainstream are not an either/or set of demarcation. Rather, is is a sliding scale. Like black and white with all shades of gray in between. That's the problem with labeling based on narrow-thinking and bias - some people want so badly for something to be labeled one thing, that they fail to realize what kind of scale they are dealing with. Currently, based on modern sources, chiropractic slides much more towards mainstream than it does toward fringe. -- Levine2112 ^discuss 22:35, 28 May 2008 (UTC)

You're right about everything but the last sentence. You have yet to provide us with the high-quality sources needed to establish that chiropractic is mainstream medicine. ScienceApologist (talk) 22:44, 28 May 2008 (UTC)

Incorrect. All I set out to do was to show that Chiropractic is not fringe. I have demonstrated that clearly with reliable mainstream sources. -- Levine2112 ^discuss 00:50, 29 May 2008 (UTC)

Yet, you failed to adhere to the standards outlined in WP:REDFLAG. ScienceApologist (talk) 08:41, 31 May 2008 (UTC)

When more than half the healthcare practitioners in the US are chiropracters, and when the surgeon general is replaced by a chiropracter general, then Chiropractic will not be FRINGE. Until then...--Filll (talk | wpc) 22:02, 28 May 2008 (UTC)

Again, is optometry fringe? Is dentistry fringe? Is podiatry fringe? Is chiropody fringe? Where is the optometrist general? The dentist general? The podiatrist general? Why would we want half of the healthcare practitioners in the US to be specialized in focusing on NMS disorders? Your arguments are flawed and do not contribute to enhancing this article, nor to the encyclopedia. DigitalC (talk) 01:40, 29 May 2008 (UTC)

Is it your position that chiropractors are "specialists"? In what anatomical or physiological sense are they specialists? Are they spinal doctors? ScienceApologist (talk) 19:38, 29 May 2008 (UTC)

There ARE problems with the word 'specialist' (for instance, to see many specialists, one needs a referal from an MD ie: to see a dermatologist). However, I would assert that chiropractors focus on NMS issues. Why you ignored that above, and then asked if they are "spinal doctors", I don't know. Again, if you look at the research, aside from asthma, infantile colic, and cervicogenic headache, there isn't adequate evidence for non-musculoskeletal conditions - as such, an evidence based chiropractor would not be treating non-NMS conditions. DigitalC (talk) 01:10, 30 May 2008 (UTC)

Just as a point of information: the evidence for asthma, infantile colic, and cervicogenic headache is about the total package of chiropractic care, including unmeasured qualities such as belief and attention. The evidence does not support any particular treatment. See Hawk et al. 2007 (PMID 17604553).

The official identity of Chiropractic medicine and chiropractors are indeed [the spinal health care experts in the health care system.] Why the anti-chiropractic editors dispute this is beyond me. CorticoSpinal (talk) 04:02, 30 May 2008 (UTC)

That quote is the brand platform promoted by the World Federation of Chiropractic's position. But that doesn't mean it's the mainstream medical position. The WFC's definition is also controversial among chiropractors. One chiropractor criticized the WFC's definition for its failure to place proper limits on chorpractors who treat general health problems, saying that the WFC's definition is "plunging the profession deeper into pseudoscience and away from establishing an identity for chiropractors as back-pain specialists". See: Homola S (2008). "Chiropractic: a profession seeking identity". Skept Inq. 32 (1). Eubulides (talk) 01:08, 31 May 2008 (UTC)

Are you suggesting, Eubulides, that the WFC is a fringe organization that deserves to be doubted? The organization that represents the chiropractic profession globally. The organization that is recognized by the World Health Organization. Bingo. Not fringe anymore. So, given that it is a legitimate (mainstream) organization that represents the chiropractic profession globally with Dr. Haldeman as the lead scientitst in the Research division, we shouldn't argue with the experts, just as you've always said. The opinion of mainstream allopathic (conventional) medicine is irrelevant. Chiropractic defines itself, not the medical profession. This is the critical difference between FRINGE and mainstream. The mainstream gets to define itself. Mainstream medicine has tried to kill chiropractic. So, what are we left with: the opinion of one man, (Samuel Homola who edits at Quackwatch with Stephen Barrett and who's previous papers have been rebuked; this time he writes in a non-indexed, biased, non-peer-reviewed magazine that is trying to trump, subvert and cast doubt on the reputability of the identity agreed by WFC and by extension the WHO? Weren't you the has said close to 150 times (I've counted) that "we shouldn't reach down into primary sources". And you bring a skeptical inquirer article to the table to discredit the WFC? You are falsifying any real controversy, but rather trying to create one by suggesting that the opinion of disputed, critic of chiropractic who has zero weight in the scientific arena somehow should be seriously taken with weight to dispute the obvious? Homola's personal opinion that has zero evidence to support his theory that chiro will go fringe by adopting the Identity Paper has got to be one of the more ridiculous claims I've seen yet since editing here. So now you dispute the official, verifiable and reliably sourced identity of chiropractic by the WFC with a hit-piece article in the skeptical inquirer. I guess to determine the weight and determine which source should be included we need to determine if the Skeptical Inquirer carries more weight than the World Health Organization, for it is the WHO admitted the WFC into the fold 1997 who and has represented the chiropractic profession at WHO since that time.[28]. At least the contrast in our arguments and editing practices at chiropractic has become abundantly clear. CorticoSpinal (talk) 08:29, 31 May 2008 (UTC)

I did not say the WFC is fringe. I said only that its position does not represent mainstream medical opinion. This is not a black-and-white situation, where something must be either entirely fringe or entirely mainstream. Also, I disagree that the opinion of conventional medicine is irrelevant; it's quite important. Eubulides (talk) 08:39, 2 June 2008 (UTC)

For the record, Samuel Homola has not been a Chiropractor since 2000, as far as I know. DigitalC (talk) 07:32, 31 May 2008 (UTC)

Yes, Homola is a retired chiropractor. Eubulides (talk) 07:56, 31 May 2008 (UTC)

Let the Surgeon general speak for himself. You're being owned, Filll. Go get a napkin and wipe that egg off your face. Until then... CorticoSpinal (talk) 22:06, 28 May 2008 (UTC)

I removed a personal attack perpetrated by CS above. Also, Filll's point is well-taken. The title itself speaks to the fact that surgery is mainstream while chiropractic is not. Even the video you cite indicates that chiropractic is not part of mainstream medicine. Ergo it is fringe. ScienceApologist (talk) 22:09, 28 May 2008 (UTC)

Restored the evidence. -- Fyslee / talk 17:10, 31 May 2008 (UTC)

Comments on Chiropractic is Fringe: The rebuttal Section 3

This section seems to be devoted to debating whether "chiropractic" is "fringe". Would someone please explain to me why this is being debated on this talk page? I just re-read WP:FRINGE and don't see what part of it this thread might be concerned with. Feel free to reply on my talk page if this is something everybody else around here already understands. I can see how it may be useful at a page such as Asthma to decide whether the chiropractic theory of treatment of asthma is "fringe" and not notable enough to be mentioned in that article, but I don't see how a decision as to whether "chiropractic" (the profession? a theory of?) is "fringe" or not would have any bearing on the content of this article: either way, the article will be based in a balanced way on the reliable sources.☺ Coppertwig (talk) 01:01, 30 May 2008 (UTC)

• The survey indicates that the vast majority of chiropractors do not consider chiropractic to be mainstream medicine. This is true independently of the old antipathy between the fields. And the survey's results are not contradicted by any other source presented on this talk page.
• I see some quibbling as to whether chiropractic is "mainstream medicine" versus "mainstream health care". But one can easily find sources saying that chiropractic is not mainstream health care as well. For example, Langworthy & Cambron 2007 (PMID 17693332) write, "As the chiropractic profession in the United States (US) and United Kingdom (UK) continues in its efforts for full recognition in mainstream health care,..." indicating that the authors do not believe that chiropractic is mainstream health care yet. Another example: the title of Hirschkorn & Bourgeault 2004 (PMID 15847969), which is "Conceptualizing mainstream health care providers' behaviours in relation to complementary and alternative medicine", indicates that the authors do not consider chiropractic to be mainstream health care. I don't see any evidence that the distinction between "mainstream medicine" and "mainstream health care" is a huge one in practice, in this regard.
• The effectiveness of chiropractic care is a topic under genuine dispute. In some cases (treatment of low back pain, at least for some categories of patients) the evidence is relatively strong, and chiropractic supporters are not fringe, nor are the skeptics fringe (as the evidence is not overwhelming). In other cases (for example, treatment of autism) the scientific evidence is nonexistent, and it's fair to say chiropractic is fringe. And there are some gray areas in between, where some evidence does exist but it's low quality; this is where things get tricky.

Eubulides (talk) 01:08, 31 May 2008 (UTC)

Coppertwig, labelling chiropractic fringe is the core issue namely for two reasons: research (science) and legitimacy. Currently allopathic (medical doctors) research (MD/PhD) by default gets more weight and sets the tone. Research done by and favourable to chiropractic researchers (DC/PhDs) published in mainstream (health care) journals is denied proper weight in the most crucial areas (Safety, Efficacy, Research/Science, Cost-Effectiveness). The majority of the research which demonstrates chiropractic care is just as safe if not more effective than conventional medical management for low back pain, neck pain and other neuromusculoskeletal disorders. Yet, this dominant view, by multi-disciplinary panel of experts worldwide is being deliberately subverted by presenting the disputed, flawed and biased research of one individual: Edzard Ernst, MD, a vocal critic of chiropractic. It is argued then, the extremist critical Ernst should be given at a minimum as much, if not more weight (and tone) than a international majority consensus (whose research has either been a) deliberately marginalized and b) deliberately omitted in a cherry picking of sources and quotes to subvert the majority of the scientific literature (yet again).

Fringe is everything. Its the whole context of the article, the way information is perceived (and delivered) its the rules of the game (less weight, less detail to tone). Filll wants this article flushed down the toilet. Proponents here have invested literally thousands of hours trying to get the Chiropractic story to reflect the current state of affairs (2008) and not an article that is peppered with deliberate "attacks" that play up the fringe element of chiropractic care (treating non-musculoskeletal disorders) and presents it with undue weight that changes the whole tone and context of the material surrounding. It's these covert attacks to the article (and remember, I have proposed a Criticisms section where all the controversies, disputes and challenges can be and should be handled). I'm a fair editor. I haven't been given a fair shake because anti-chiropractic editors have portrayed me as some anti-scientific, POV warrior, mongrel because they believe that I'm a fringe practitioner and thus should be doubted at every turn. It's made editing here constructively virtually impossible. Wake up call to all of WIkipedia editors: being a non-traditional health care provider does not mean they are a) fringe and b) anti-scientific. Au contraire, they merely emphasize and research different therapies and a model/system of health (Holism). Why is different being portrayed as fringe? If you're no different than allopathic medicine you are automatically fringe? Is this the standard and the final say of Wikipedia on this subject? This is what is at stake. This decision will set a precedent for all CAM pages here. If chiropractic is fringe, then every single CAM profession, modality and science is, by extension fringe. If chiropractic is determined to share more attributes of a mainstream, legitimate health care professional than a fringe medical practitioner based on the the quality of the evidence presented alone (as opposed to personal opinion and vote stacking puppet shows) then similar disputes occuring at Acupuncture and other CAM pages has a template to follow and a process of evaluating and judging the strength asking 2 basic questions: (1) Does the evidence demonstrate, by and large, that the topic at hand is WP:FRINGE and (2) Is there reliable evidence/sources that suggests otherwise and to what extent? I hope I have presented the case clearly. Perhaps this discussion belongs someplace bigger and away from the kamakazi tactics of some editors.

Proponents of chiropractic care who make the valid argument that chiropractic is at a minimum much more part of the mainstream (health care) than fringe, if not already part of it. It completely changes the dynamics of editing. Evidence (with much, much more available) from reliable, non-disputed sources have supported the claim the chiropractic medicine is part of mainstream health care (and not to be conflated with mainstream allopathic medicine, the specific profession) and no evidence has been provided that it is still fringe, circa 2008. Contemporary chiropractic is scientific. Bachelors and Masters Degrees in Chiropractic Science are been awarded by public, government-sponsored universities. The fringe argument also applies to the science of chiropractic medicine which insists there is no such thing as 'true' chiropractic science because it is fringe and a pseudoscience. A bit of education on the matter and then a a little applied common sense (rather than dogmatic skepticism that is uninformed) decidedly (and perhaps surprisingly) proves the point made by pro-chiropractic editors. As it stands, the anti-chirorpractic editors are pushing (civilly and uncivlly) that chiropractic medicine is fringe despite evidence presented to the contrary. CorticoSpinal (talk) 05:52, 30 May 2008 (UTC)

Thank you for your reply, CorticoSpinal. I recognize that you're trying to address my question, but I'm sorry: I'm completely missing your point! If there are peer-reviewed scientific publications giving evidence of benefit of chiropractic treatment, then regardless of whether "chiropractic" (some particular theory of?) is labelled "fringe", those publications need to be represented in the article, balanced by other, more critical sources. Surely there are enough reliable sources about chiropractic that we don't need to resort to using self-published websites and such as sources? While labelling something "fringe" allows self-published websites etc. to be used, it doesn't require that they be used, and for this article I don't think it's necessary. So, what would be different about the article depending on whether "chiropractic" is classified as "fringe" or not? ☺ Coppertwig (talk) 12:22, 30 May 2008 (UTC)

I agree that this article should be handled as a mainstream article and we do not lower the bar to dealve into the fringe elements of chiropractic any more than we would lower the bar to dealve into the fringe elements of medicine. Chiropractic is "mainstream enough" to keep our content reliable from peer reviewed sources and be able to say whatever we need to say. We do not need to make any WP:Points to create a FA article. -- Dēmatt (chat) 13:43, 30 May 2008 (UTC)

I agree that the article should only cover the chiropractic fringe the way that any article (Evolution, say) should briefly discuss closely-related fringe theories (such as creationism). The current treatment in Chiropractic#Scientific investigation does that: it is almost entirely about mainstream chiropractic care. Eubulides (talk) 01:08, 31 May 2008 (UTC)

Coppertwig, while I definitely agree with your logic, the problem is that currently chiroskeptic editors are treating Chiropractic by default is fringe. Accordingly the research I try to include in crucial areas of safety, efficacy, cost-effectiveness is being given the fringe treatment, getting less weight, worse tone and less credibility. Basically, MD/PhD research on chiropractic or SMT is being given superior weight than research by DC/PhD at Chiropractic because the chiropractic viewpoint on its own research is interpreted as fringe and automatically at odds with mainstream health care. That's not the case at all. Look at the TaskForce thread. Some major players are DC/PhDs, (but do not dominate the representation of the TaskForce as suggested repetitively by Eubulides despite the evidence to the contrary) and its even led by a DC/MD/PhD. Yet the interpretation is that the document is a mainstream chiropractic one and not a mainstream science one. It's implied that chiropractic and science are at odds despite the obvious fact that its clearly not. CorticoSpinal (talk) 19:46, 30 May 2008 (UTC)

This mischaracterizes the dispute in question. The current article uses high-quality reviews from all sources, including chiropractic sources. The dispute in question was over whether we should ignore the guidelines in WP:MEDRS, override the opinions of published and detailed reliable reviews by experts in the field, and highlight results of primary studies that the reviews did not think worthy of mention. Eubulides (talk) 01:08, 31 May 2008 (UTC)

One question, is Edzard Ernst debunking the fringe elements of chiro, or the stuff that seems to have some effect on back and neck pain? Is this the only source which is extremely critical? If so, then is this being presented as the view of most doctors? If it is, then is there anything backing up the claim that this is the veiw of most doctors? What exactly is said to be wrong with sources like this? I'm sorry to ask all this, but my god, it's a long talk page.

The way it looks to me is that there is solid evidence and mainstream support for the practice of chiro.

"Manipulation has been shown to have a reasonably good degree of efficacy in ameliorating back pain, headache, and similar musculoskeletal complaints,13 and some chiropractors limit their practices to these conditions. While precise statistics are not available, a majority of chiropractors adhere to the method’s original theories, and continue to claim that chiropractic manipulation cures disease rather than simply relieving symptoms."

But, there is theory and claims which have almost no support. If this were merely treated as seperate issues in the article, as it is in the sources, that might solve a problem? ——Martin^phi ☎ Ψ Φ—— 22:50, 30 May 2008 (UTC)

" While precise statistics are not available, a majority of chiropractors adhere to the method’s original theories, and continue to claim that chiropractic manipulation cures disease rather than simply relieving symptoms."

That last statement is patently false quoted here is patently false, but the rest of it is spot on. First, the majority group is the mixers (of the 35 accredited schools world wide only 8 are straight 27 are not). Next, DeVocht (2006) has nicely illustrated the controversy over theory here. It should be noted this is from Palmer College, which is the minority view yet it still has universal elements (manipulable lesion) Next, and most important is that the literature (tertiary source) provided by the World Health Organization in 2005 states explicitly here the basics of chiro theory; none of which mentions anything of disease and adhering to the palmers methods (which is why mixer chiropractic separated and differentiated itself from straight chiropractic). What source made the claim? Who wrote it? Professional designation? Was it an MD? MD&DC and other multidisciplinary collaboration? If not, that's problematic; Medicine has always tried to marginalize chiropractic and was found guilty by the US Supreme Court of anti-competitive practices trying to contain, disrupt and eliminate the chiropratic profession. CorticoSpinal (talk) 23:50, 30 May 2008 (UTC)

Hmmm, so there is a minority of chiropractors who follow the original philosophy and who do say that chiro cures diseases besides back pain related stuff. That's a significant minority, but unless there is disagreement about how much of the profession believes those ideas (from other editors here) the subject could be treated mainly from the mainstream sources which say it works for back and neck. In that case, what we'd have is a section of the article covered by FRINGE, in which case one would describe the ideas, and say also whatever criticisms have been leveled at them, or their influence on practice. However, this section could be isolated pretty well, and treated more as a belief with a potential for harm if the chiropractor acted out of that belief. Treating the whole article as FRINGE because of the beliefs of a minority would be an unfair way of doing things. Unless, of course, there are sources which I'm not yet aware of. I'm not sure here, might want to take some of this back. There is also the issue of our not trying for truth, but for sources, and the above is a pretty good source. Thoughts? ——Martin^phi ☎ Ψ Φ—— 05:48, 31 May 2008 (UTC)

• In "the above is a pretty good source" which source are you referring to?
• Things are more complicated than that, I'm afraid. Mixers also treat for conditions other than back pain.
• Mainstream sources are not in agreement for back and neck. Please see Chiropractic#Effectiveness for details, and look for "Low back pain" and "Whiplash and other neck pain".
• It is not so easy to isolate which part of Chiropractic is "fringe". Some sections (e.g., Chiropractic#Vertebral subluxation are quite "fringish", and some (e.g., Chiropractic#Safety are not, but some (e.g., Chiropractic#Philosophy) cover both the "fringe" and the "non-fringe" parts and separation would be difficult.

Eubulides (talk) 07:56, 31 May 2008 (UTC)

• "Things are more complicated than that, I'm afraid. Mixers also treat for conditions other than back pain." Sure they do, they also treat the rest of the neuromusculoskeletal system. For instance, what is the best treatment for tennis elbow? plantar fasciitis? thoracic outlet syndrome?. While we're at it, don't physical therapists treat conditions other than back pain? Does that mean they are fringe? AFAIK the scope of practice overlap between the two professions is huge. PTs also manipulate, although they call their manipulatable lesion (clinical entity) a "joint fixation" or "facet sprain" (as do some mixers), instead of a "subluxation". DigitalC (talk) 03:44, 5 June 2008 (UTC)

• I wrote "back pain" and "back and neck" in response to Martinphi's comments about "mainstream sources which say it works for back and neck". I agree that Mixers also treat for other conditions, but unfortunately there's little scientific evidence for effectiveness against these other conditions. I don't know the answers to your questions; I agree that the scope of practice overlap is large. Eubulides (talk) 07:05, 5 June 2008 (UTC)

There isn't necessarily "little scientific evidence for effectiveness against these other conditions", it depends on the modality being used, such as ultrasound for plantar fasciitis.DigitalC (talk) 07:46, 5 June 2008 (UTC)

Yes, that's true. By "other conditions" I meant only those conditions for which we have reliable reviews concerning chiropractic care. Eubulides (talk) 19:46, 5 June 2008 (UTC)

Challenge

Template:RFCsci I claim that WP:FRINGE applies to this article. Who disagrees/agrees and why? ScienceApologist (talk) 19:38, 29 May 2008 (UTC)

You're not giving me a chance to say I agree? OrangeMarlin ^{Talk• Contributions} 19:42, 29 May 2008 (UTC)

What theory are you asserting that WP:FRINGE applies to? DigitalC (talk) 01:18, 30 May 2008 (UTC)

It's not a poopularity contest, SA. It's about evidence. Remember Stephen Colbert and African Elephants? You can easily manipulate and distort "facts" if you are uninformed and don't provide any reliable evidence to support the claims made. Anyone can canvass anyone to get "consensus". You, or any other anti-chiropractic editor has yet to provide any evidence that suggests chiropractic is fringe. There is compelling evidence to the contrary, however. CorticoSpinal (talk) 02:34, 30 May 2008 (UTC)

I would agree that WP:FRINGE applies to this article, but I am starting to think that it is too dangerous to hold that position.--Filll (talk | wpc) 19:31, 30 May 2008 (UTC)

I also agree that WP:FRINGE applies to this article. Chiropractic does have strong fringe elements; a sizeable minority of chiropractors are straights, for example, and are definitely fringe by the standards mainstream science. However, I disagree that every topic in chiropractic is covered by WP:FRINGE. There are areas where chiropractic is merely controversial, and is not fringe; evidence-based treatment of low back pain, for example.

Filll, you have nothing to be afraid of here. If so, I would have been dead a long time ago. -- Dēmatt (chat) 00:42, 31 May 2008 (UTC)

Commenting here as an uninvolved editor, I think that there might be a case both ways. Chiropractic is not yet quite mainstream, but is almost mainstream- see this source. However, I think there should be little argument here, because as I see it, the most mainstream sources such as the NIH give chiro an NPOV treatment, in that they are not overly negative or overly positive. Thus there should be little argument about the best sources. Because of this, saying that chiro is covered by FRINGE would not help to promote either the POV of debunkers or the POV of those who wish to present chiro as completely accepted and scientifically fully established.

This concluding quote from what looks to me like one of the more critical sources should not be any problem:

"Contemporary chiropractic philosophy recognizes its partnership with the greater body of philosophy and science in general. Most contemporary chiropractors and their organizations distinguish between what is known and what is believed. Chiropractic belief systems embrace the holistic paradigm of wellness while incorporating deterministic materialism for the establishment of valid chiropractic principles. Chiropractic’s philosophic foundation serves as the basis for theoretical development, not a substitution for it (Phillips, 1992)." [29]

This is also a mainstream source, and should not be objectionable to those who promote chrio:

"Scientifically rigorous general population-based studies comparing chiropractic with primary-care medical patients within and between countries have not been published."

I doubt anyone wants to say that chiro is completely established. There should not be too much contention here, because I don't think there is much tension between the "chiropractic POV" and the "mainstream POV" as reflected in the sources. Most of the article can probably be written without too much attention to attribution of opinion, because most of it will be agreed upon between the two perspectives, if the mainstream sources are followed.

The CNN article is highly negative, but one of the lesser sources.

It would help to have a summary of the debate, and it would help if you archived this talk page.

If you want to achieve consensus, and avoid sanction in the end, stop the name calling completely. ——Martin^phi ☎ Ψ Φ—— 19:34, 30 May 2008 (UTC)

Thanks for the comments. I agree with their overall thrust; unfortunately the devil is in the details.

• The sources you give are a too old to be included in this article, compared to what's already there, and the sources already included in the article make the same basic points; the problem is that these points are under dispute here.
• This talk page is archived; any topic not touched in 14 days is automatically archived by a bot.
• It would indeed help to have a summary of the debate, but nobody has taken the (considerable) time to write one. It would take a lot of time to write one primarily because editors would argue a lot about what its contents should be. It really is quite dysfunctional, I'm afraid.

Eubulides (talk) 01:08, 31 May 2008 (UTC)

Ok, a question. And please bear in mind I never knew anything about chiro before today.... and basically I'm not sure how effective requesting comments on such a complex issue is going to be. But, what is the mainstream view of chiro? I mean, if it isn't what I see at NIH and the other sources. I know that the mainstream view of the philosophy is that it is not supported- no form of vitalism is supported by mainstream science at least. But the other part, the part where they are doing good to backs- what is the mainstream view of that? What are the sources there? I get the impression that most of the sources say it does good, but one or two question that. So is the mainstream view that it does good, per the NIH, or something else? And, shouldn't the info in "Scope of practice" be above the philosophy section? ——Martin^phi ☎ Ψ Φ—— 02:23, 31 May 2008 (UTC)

• You have to be careful here. The "NIH" source you cite is actually the U.S. National Center for Complementary and Alternative Medicine. Although it falls under the NIH umbrella, it is not a mainstream-medicine organization; it focuses on CAM, which by definition is not mainstream medicine. In the past NCCAM has supported obvious pseudoscience such as remote viewing and distant healing. It has its supporters (enough to get Congressional funding, after all; NCCAM was created for political reasons, not for scientific ones) but it also has sharp critics (for example, [30]).
• The mainstream view of chiropractic is what is being disputed here. On the one side we have proponents of chiropractic who say that the mainstream view is represented by the The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and that sources critical of chiropractic are fringe. On the other side we have those less supportive of chiropractic, who would point to (say) the American Pain Society/American College of Physicians clinical practice guideline, which only weakly recommends spinal manipulation as one alternative therapy (among many) for spinal low back pain in nonpregnant adults when ordinary treatments fail (see Chou et al. 2007, PMID 17909210), or maybe to the Swedish guideline for low back pain, which removed chiropractic manipulation as a treatment option in 2002 (see Murphy et al. 2006, PMID 16949948).
• That's just the short version. For more details about what mainstream sources say about effectiveness, please see Chiropractic #Effectivness.

Eubulides (talk) 07:56, 31 May 2008 (UTC)

• Lets look at those ACP guidelines again. For acute LBP, how "many" "alternative" therapies are recommended? One could also point out that those 2002 Swedish Guidelines are obsolete - and that they have been replaced by the European guidelines way back in 2006. For acute LBP they recommend "Consider (referral for) spinal manipulation for patients who are failing to return to normal activities". They also state that "Back schools (for short-term improvement), and short courses of manipulation/mobilisation can also be considered." for chronic LBP (among other options). And now we're back to equating SMT w/ Chiropractic again. DigitalC (talk) 03:34, 5 June 2008 (UTC)

• For acute low back pain, the ACP guidelines recommend the consideration of only one alternative therapy (SMT) for patients who do not improve with standard care. For chronic or subacute LBP, they recommend consideration of eight therapies, one of which is SMT. My understanding is that the European guidelines do not replace national guidelines; is that incorrect? Do you have a source on this point? If the Swedish guidelines have been replaced, Chiropractic should be updated; no point referring to obsolete guidelines. Eubulides (talk) 07:05, 5 June 2008 (UTC)

Why would the European guidelines NOT replace national guidelines? What are they for then? Interestingly enough, I can't find a 2002 guideline for backpain from SBU, only a 2000 guideline, which DOES recommend SMT ("For chronic low back pain, there is strong evidence (A) that: • manual treatment/manipulation, back training, and multidisciplinary treatment are effective in relieving pain."). Looks like I will have to chase the sources. DigitalC (talk) 07:50, 5 June 2008 (UTC)

I am still confused why we are refering to the 2002 Swedish Guidelines, when we have the more recent European Guidelines, of which, Sweden was a member country (that, and as far as I can tell, the 2002 Swedish Guidelines have been repealed, as they no longer appear on the website, but the 2000 guidelines do). DigitalC (talk) 07:25, 12 June 2008 (UTC)

Chiropractic does not cite the 2002 Swedish guidelines directly; it cites Murphy et al. 2006 (PMID 16949948), which talks about the Swedish guidelines along with four other national guidelines. I wouldn't expect the European guidelines to supersede the Swedish, any more than I would expect the WHO guidelines on education to supersede CCE accreditation standards in the U.S. I'm leery about assuming that the 2002 guidelines have been repealed and the 2000 guidelines reverted to; that sounds like an extraordinary event and I'd expect some documentation of it. Eubulides (talk) 08:15, 12 June 2008 (UTC)

A little context helps

"In contrast, the more recently updated guideline (2002) made no recommendation to use SMT as a treatment intervention for the acute phase of LBP, possibly because the guideline developers based their treatment recommendations on grade of recommendation “A,” which represents the highest level of evidence. ... Meanwhile, the Danish guideline (2000) based all of their treatment recommendations on a grade of recommendation B" - A little context helps. They don't provide a reference to the 2002 guideline. DigitalC (talk) 08:08, 5 June 2008 (UTC)

Yes, context helps. Similar context is given in Chiropractic, which makes a similar contrast between the Swedish guidelines and the American. Eubulides (talk) 19:46, 5 June 2008 (UTC)

No similar context is given. "There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain.[104] For example, a 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,[105] 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." This statement implies that the Swedish guidelines are evidence of controversy regarding efficacy, and that the Swedish guidelines don't consider SMT effective. However, the source used explains that the change might not be due to any controversy, but due to the fact that the Swedish guideline developoers "based their treatment recommendations on grade of recommendation "A"..." DigitalC (talk) 23:30, 5 June 2008 (UTC)

• I agree that two points are conflated here.
• The first point is that there is continuing conflict on efficacy; this is supported by the following quote from the start of the source's "Discussion" section: "Our study showed that there is insufficient evidence to suggest that the 5 LBP guidelines reviewed should be updated based on best evidence (1999–2004). Inconsistencies in the evidence suggest that there is continuing conflict of opinion regarding: efficacy of SMT for treatment of nonspecific or uncomplicated LBP; optimal time in which to introduce this treatment approach; whether SMT is useful for treatment of chronic LBP; and finally, whether subacute LBP actually exists as a separate category requiring a specific treatment approach in its own right."
• The second point is that there is doubt about the reliability of the guidelines due to the levels-of-evidence issue that you mentioned. This is supported by the following quote from the start of the 3rd paragraph of the "Discussion" section: "The mostt 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."
• Chiropractic#Effectiveness currently mentions only the first point; it should also mention the second.
• The "For example" in Chiropractic#Effectiveness is not in the source and should be removed. The source does not give the 2007 U.S. guideline as an example.
• I propose the following change to take the abovementioned points into account. In Chiropractic#Effectiveness under Low back pain, change from this:

"There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain. For example, a 2007 U.S. guideline weakly recommended SMT 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."

to this:

"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 SMT 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."

Eubulides (talk) 06:12, 6 June 2008 (UTC)

No further comment, so I installed the above change with the further minor editorial change of replacing a period by a semicolon. Eubulides (talk) 04:32, 9 June 2008 (UTC)

I haven't looked through this section or followed this conversation, so I reserve judgement for now. Just right off the top, I would wonder why we use a 2002 study after a 2007 study. I'll take a better look a little later and if I have any concerns I'll bring them up then. -- Dēmatt (chat) 12:34, 9 June 2008 (UTC)

I don't know what is meant by "2002 study" here. Both the original and the revised text cite Murphy et al. 2006 (PMID 16949948) and Chou et al. 2007 (PMID 17909210). Eubulides (talk) 20:01, 9 June 2008 (UTC)

I've taken a look at the sources and am concerned that we have again reached conclusions that were not reached by the sources. IOWs, we have created a little WP:SYN. The juxtapositioning of the text seems as if we are casting a negative light on something that we should presenting NPOV. -- Dēmatt (chat) 13:12, 9 June 2008 (UTC)

By "negative light" which phrases do you mean? Certainly there are several negative phrases in the low back pain section of Chiropractic #Effectiveness (e.g., "no longer suggest considering SMT"), but there are several positive phrases too (e.g., "good evidence supporting SMT"). The area is controversial, and Chiropractic needs to present both sides as fairly as possible; inevitably this means that some negative light will be cast, as well as some positive light. Eubulides (talk) 20:01, 9 June 2008 (UTC)

Ok, I'll try and review more of those sources later. My general impression is that the mainstream view could be summed up overall as "chiro is not completely proven but is widely accepted even within medical practice for back pain, but sometimes incorporates mystical elements which do not have any support in medical science." Is that right? If the article could be written with that general tone, would that be a good article? ——Martin^phi ☎ Ψ Φ—— 23:51, 31 May 2008 (UTC)

I'm not sure I'd agree with the "chiro is not completely proven but is widely accepted..." wording. More accurate would be "it is controversial whether chiropractic care is effective, but it is partly accepted...". Quoting Chiropractic#Effectiveness, "There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain. For example, a 2007 U.S. guideline weakly recommended SMT 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." This is not what I'd call "wide acceptance" or "not completely proven". Eubulides (talk) 08:39, 2 June 2008 (UTC)

Challenge continued

• I doubt given our respective histories on CAM articles that either Martinphi or I may be considered completely uninvolved, but I broadly agree with the above assessment. Clearly, anything involving subluxations is obviously fringe at best, but even Quackwatch agrees that chiropractors can treat neuromusculoskeletal problems. If I recall correctly, the profession is currently debating with itself over whether it should practice specialized physical therapy or abandon itself to mysticism. WP:FRINGE applies to the latter view, but not to the view of chiropractic as a minor health-allied profession. We should make this distinction clear and report on percentages as appropriate. - Eldereft ~(s)talk~ 22:03, 30 May 2008 (UTC)

Yes, exactly, very good analysis. I've had one or two edits to Homeopathy article and just a few on the talk page- that's about all for me on alternative med. ——Martin^phi ☎ Ψ Φ—— 23:20, 30 May 2008 (UTC)

A very interesting comment by Eldereft. I agree with 90% of it. I wouldn't call it a "minor allied health profession" because frankly, the sources don't even come close to saying that but they do some primary contact provider for NMS. The "debate" that you referred to is over, the World Federation of Chiropractic, in 2005 has positioned chiropractic as the spinal health care experts in the health care system. It also states that chiropractic should focus on

• Ability to improve function in the neuromusculoskeletal system, and overall health, wellbeing and quality of life.*
• Specialized approach to examination, diagnosis and treatment, based on best available research and clinical evidence with particular emphasis on the relationship between the spine and the nervous system
• Tradition of effectiveness and patient satisfaction
• Without use of drugs and surgery, enabling patients to avoid these where possible
• Expertly qualified providers of spinal adjustment, manipulation and other manual treatments, exercise instruction and patient education.
• Collaboration with other health professionals
• A patient-centered and biopsychosocial approach, emphasizing the mind/body relationship in health, the self-healing powers of the individual, and individual responsibility for health and encouraging patient independence.

So, it's a done deal. Primarily NMS yet with a overall holistic approach to health and well-being. The percentages are also clear: 90-95% of DCs treat NMS disorders (primarily back and neck pain), 5-10% treat non-NMS. I've been trying to get this crucial point across for months now. CorticoSpinal (talk) 00:01, 31 May 2008 (UTC)

I view with great skepticism any claim that the debate is "over" or that "it's a done deal". Remember, this is chiropractic we're talking about: put 3 chiropractors in the room and ask them a question, and you're bound to get at least 4 strongly held and widely varying answer. Certainly the WFC approach is not universally held by chiropractors: Homola, a chiropractor, argues that the WFC's definition is "plunging the profession deeper into pseudoscience and away from establishing an identity for chiropractors as back-pain specialists". See: Homola S (2008). "Chiropractic: a profession seeking identity". Skept Inq. 32 (1).

Maybe what we need to get from this is that when we talk about Neuromusculoskeletal(90-95%) we can use mainstream editing, but when we talk about the vitalistic (non-materialistic) aspects of subluxation and innate intelligence(5-10%), whether past or present, we need to treat it as a Fringe theory - meaning that we explain it NPOV, but give the mainstream view more weight. I'm okay with that... does that work for others? The trick is that we have to be able to differentiate who uses what concepts, because it is not fair to either side (reform or straight) to burden them with the other's baggage or jargon. -- Dēmatt (chat) 00:35, 31 May 2008 (UTC)

Those percentages do not sound right, as I expect that far more than 5-10% chiropractors are straights. (I have no idea where those percentages came from; can anyone cite a source?) Furthermore, the vitalistic stuff is important when explaining chiropractic history, so it needs to be covered more than just the current percentage of practitioners would suggest, if only in Chiropractic #History. Finally, as the McDonald survey shows, the distance between straights and mixers is not as far as a simple "straights vitalistic, mixers materialistic" discussion would suggest. Eubulides (talk) 01:08, 31 May 2008 (UTC)

Being a straight DC doesn't imply fringe. Straights by and large majority treat MSK issues, they're just more likely to treat non NMS ones. Vitalism was used to differentiate legally and is better represented by holism today. The concept still stands: the whole is greater than the sum of its parts. Was it Aristotle or Plato who said that? Regardless, I support Dematts suggestion its sensible, but lets not bring skeptical inquirer articles and Homola into this: We have DC/PhDs who produce far better articles with better content on the same subject. Homola has direct ties with Stephen Barrett and his views are completely fringe. See his article in 2006 in Clin Ortho which was rebutted by Dr. Hart and throttled by DeVocht's counterpoint which was a far superior piece of research. Bottom line should be, the identity issue is officially put to rest, primarily NMS yet overall health, and the majority of the profession should not be discredited because of the fringe aspects of a minority of practitioners. Good call by MartinPhi as well. We're moving in the right direction; this is positive, productive dialogue for a change. CorticoSpinal (talk) 01:46, 31 May 2008 (UTC)

Not surprisingly I disagree with the characterization of Homola's recent publications: I think they're of higher quality than DeVocht's paper. I also disagree that the identity issue has been put to rest. It's not just Homola who says that chiropractic still suffers from a high degree of internal confusion. See, for example, the WCA's take on the WFC's position.[31] Eubulides (talk) 07:56, 31 May 2008 (UTC)

The WCA is the most fringe element of the profession and they are not to be taken seriously whatsoever. We don't give the WCA any weight because the WCA has no credibility, inside or outside chiropractic. Again, you want to drum up a false sense of controversy, using a fringe source and more fringe association (WCA) and make it doubt the mainstream view. This line of argumentation now is getting very weak and tiresome. I think you've exhausted your last life line, the WCA card has been played and it will be summarily debunked and proven as fringe. Another attempt to have the fringe view of chiropractic exploited to discredit and dispute the notability and credibility of the mainstream view regarding chiropractic identity and the WFC. CorticoSpinal (talk) 09:33, 31 May 2008 (UTC)

In reply to CorticoSpinal's message of 19:46, 30 May 2008 (UTC): I think what you're talking about has nothing to do with the WP:FRINGE guideline (or if it does, would someone tell me which part? though see re parity, below). Rather, I think it's about what sources are considered reliable sources of sufficient reliability and notability to be worth mentioning. However, even here I think labelling some things as "fringe" or not is of little use. WP:Reliable sources#Extremist and fringe sources says that fringe stuff "should be used only as sources about themselves and in articles about themselves or their activities". So if some chiropractic sources are fringe, then this article is the place to use them. If they are not fringe, then this is still the place to use them. How would labelling chiropractic as fringe or not make any difference to the content of this article?

On the other hand, labelling some particular parts of chiropractic philosophy as being on the fringe of chiropractic, as Eubulides suggests (last section of [32], and "I agree that the article should only cover the chiropractic fringe the way that..."), does seem useful to me. Besides presenting the mainstream science POV of chiropractic, this article should describe the beliefs held by most chiropractors, and those held by a minority of chiropractors should also be more briefly mentioned, but those fringe views held by a tiny minority of chiropractors should not be mentioned, per WP:UNDUE.

QuackGuru also mentioned WP:Fringe theories#Parity of sources. I'm puzzled as to why it's those who think this article is already too pro-chiropractic who are trying to get it labelled as "fringe" so that sources not normally classified as RS can be used to describe the chiropractic point of view or in order to override Wikipedia:WikiProject Medicine/Reliable sources#Using primary sources to "debunk" the conclusions of secondary sources to allow use of certain sources, presumably the ones CorticoSpinal is trying to get included but which have been called primary sources. Anyway, I think there are enough good sources about chiropractic that we don't need to invoke WP:FRINGE to allow lower quality sources: we only need to debate which sources are good and why. I think labelling all of "chiropractic" as either "fringe" or "mainstream" would be an overgeneralization that would not be particularly useful for that.

Sorry, Dematt, but I don't understand at all what you mean by "mainstream editing".

Trying to get a single yes-or-no answer as to whether all of "chiropractic" is "fringe" and using that to switch this article to one of two very different forms depending on the answer to that question is not my idea of how WP:NPOV works. (If at some later date chiropractic gradually crosses some threshold and becomes no longer "fringe", would the article have to suddenly switch to a very different form at the precise moment chiropractic is determined according to Wikipedian consensus to have crossed that threshold?)

I think Fyslee has hit the nail on the head in this diff: "Come on now guys." ☺ Coppertwig (talk) 14:10, 31 May 2008 (UTC)

• The main point of WP:FRINGE, as I understand it, is a comparative one: that fringe views should not receive undue weight when compared with the general mainstream. So, when the topic is Chiropractic, the issue is the weight with which the several schools of practise should be presented. If the McTimmoney school, for example, is a minor one, then it should not get too much attention. If one is taking a wider view of chiropractic's merits vs osteopathy, physiotherapy, surgery, acupuncture or whatever, then this would be addressed in a more general article such as Back pain. This article is not the place to make this comparison since the topic here is specifically Chiropractic. So, in conclusion, it seems logically obvious that Chiropractic cannot be fringe within its own article. Colonel Warden (talk) 20:01, 31 May 2008 (UTC)
  • The dispute is not over whether chiropractic's merits should be compared to osteopathy etc. Almost none of that is in Chiropractic now. The dispute is over what weight to give sources supportive of chiropractic, as opposed to sources critical of chiropractic, in sections like Chiropractic#Effectiveness and Chiropractic#Safety; also, whether to include sources whose effectiveness or safety results are partly derived from non-chiropractic data. Eubulides (talk) 08:39, 2 June 2008 (UTC)

• That is a different issue and the key factor there would be the independence of the sources to avoid COI. We should look for impartial judges of such issues. This would tend to exclude those with a commercial interest in promoting or denigrating the practise. Note also that we should not give undue weight to such issues. The article's section on cost effectiveness seems dubious for example - I'd like to see some evidence that the cost-effectiveness of this form of treatment is a significant issue which merits the attention given. If the idea is that the FRINGE label can be used as an excuse to turn the article into an attack like the homeopathy one then the answer is an emphatic NOT. Colonel Warden (talk) 23:43, 3 June 2008 (UTC)

• If we excluded everybody who had a commercial interest in promoting or denigrating chiropractic, the article would become practically empty. No D.C. could be a source; no M.D. either. Such a standard is unrealistic. The vast majority of high-quality sources on chiropractic are by D.C.s or M.D.s (or both).
• The cost-effectiveness of chiropractic is a valid topic. Dozens (perhaps hundreds) of scholarly papers have mentioned the subject. For a few recent examples, see Leboeuf-Yde & Hestbæk 2008 (PMID 18466623), Stochkendahl et al. 2008 (PMID 18377636), Ernst 2008 (PMID 18280103), and Bronfort et al.' 2008 (PMID 18164469).

Eubulides (talk) 07:24, 4 June 2008 (UTC)

Don't know what it's like in other countries, but in Australia, chiropractic pretty much means musculoskeletal. [33] When you go there you get an adjustment, and the cost of an adjustment at various concessions is the only price on the wall. In order to practice as one you have to have a Bachelor of Applied Science from a university - ironically the same ones that hand out medical and physiotherapy degrees. Normal health funds here (e.g. [34], [35]) will pay part of an adjustment and a fair percentage of chiropractic X-rays (in fact I got the latter on Medicare! [36]) It's certainly not fringe science. That being said, claims reminding one of 1920s ads of things that can cure cancer or AIDS or epilepsy or whatever, would certainly be fringe if they were put as fact. Orderinchaos 20:43, 4 June 2008 (UTC)

Request for comment

Education, licensing, and regulation

There are a variety of Education, licensing, and regulation drafts. I suggest we choose the best draft and continue to move the article forward.

Scientific research vs Scientific investigation

Which section name do Wikipedians prefer. Scientific research or Scientific investigation for the section title. QuackGuru 02:00, 31 May 2008 (UTC)

A better name would be "Evidence basis". Not all the material in this section is scientific; some of it is based only on case studies. Eubulides (talk) 07:56, 31 May 2008 (UTC)

I prefer to stay with Scientific research. Most of the research is scientific. QuackGuru 17:30, 1 June 2008 (UTC)

Vertebral subluxation

Chiropractic#Vertebral subluxation This section is not about history. I suggest we move the section and perhaps expand on the subluxation theory. Thoughts? QuackGuru 02:00, 31 May 2008 (UTC)

I agree with moving the section; I've already suggested moving it to Chiropractic#Philosophy; see #Other POV issues above. Also, Chiropractic#Schools of thought and practice styles should be made a subsection of Chiropractic#Philosophy, as schools of thought are inevitably tightly bound to philosophy. Eubulides (talk) 07:56, 31 May 2008 (UTC)

My thoughts are that we should focus on forming a consensus on effectiveness and education first, before moving on to other sections. I'm not trying to stonewall here, but there is no rush. Given the amount of talk page space we take up discussing 1 section, I think its better that we don't try to fix every section at once. We ARE making progress. DigitalC (talk) 07:16, 31 May 2008 (UTC)

I disagree. I think that every proposal should be considered as long as editors are willing to entertain them. I, for one, am willing to review QG's proposals. If you aren't, that's fine, but there's no need to prevent others from reviewing them. ScienceApologist (talk) 07:30, 31 May 2008 (UTC)

I moved the philosophy stuff to the philosophy section. QuackGuru 09:13, 31 May 2008 (UTC)

I agree with DigitalC here. Sometimes I think we have an ADHD problem as we never finish a section before we move to something else. If it is consensus we are working for, then we all need to making these decisions together until it that particular section is finished. If not, then we can all edit the article boldly, but it will be protected in a matter of hours again. -- Dēmatt (chat) 03:01, 1 June 2008 (UTC)

similar cost-benefit sentences

An initial study found that the benefits of chiropractic care for neck pain seem to outweigh the possible risk. When compared with treatment options such as physiotherapeutic exercise (also performed by a chiropractor), the risk-benefit balance does not favor SMT. These two above sentences are similar and should both be in the cost-benefit section together. QuackGuru 02:00, 31 May 2008 (UTC)

I agree that it makes no sense to separate those two sentences. As discussed in #Comments on 2008-05-25 issues list above, the sentence based on the primary source is dubious and the simplest thing would be to remove it, along with its source. Fancier solutions are also possible, such as summarizing the primary source more carefully, or putting in another primary source to balance the dubious one. Eubulides (talk) 07:56, 31 May 2008 (UTC)

Which paper does that sentence come from? Because the majority of the research suggests the opposite (risk balance does not favour SMT). CorticoSpinal (talk) 02:31, 31 May 2008 (UTC)

Both sentences are referenced. QuackGuru 03:06, 31 May 2008 (UTC)

That wasn't my question. I'm asking you about which paper that it came from and who the author was. CorticoSpinal (talk) 05:15, 31 May 2008 (UTC)

Check the article. ScienceApologist (talk) 07:23, 31 May 2008 (UTC)

I checked the article, and easily found that the two sources in question are Rubinstein et al 2007 (PMID 17693331) and Ernst & Canter 2006 (PMID 16574972). Eubulides (talk) 07:56, 31 May 2008 (UTC)

That's what I thought. The Ernst citation disagrees with the majority of the literature yet being used to subvert the majority opinion. More weight issues. More Ernst. Interesting. Thanks. CorticoSpinal (talk) 17:41, 31 May 2008 (UTC)

I don't doubt that the Ernst citation disagrees with the majority of the literature written by chiropractors, and that this literature in turn is a majority of the literature about chiropractic; but that is not the same thing as saying that the Ernst-supported material is not mainstream. Eubulides (talk) 08:39, 2 June 2008 (UTC)

Medical opposition neutrality

Chiropractic#Medical opposition describes a debate between conventional medicine and chiropractors. The debate can be covered more neutrally. QuackGuru 03:06, 31 May 2008 (UTC)

Yes, I read that, and it was part of my question: Is that the worst it gets? Statements on this talk page lead me to believe there is a resounding rejection of chiropractic by the scientific and medical establishment in general, which could be inserted. I skipped the history, as it doesn't relate to the current debate. ——Martin^phi ☎ Ψ Φ—— 03:24, 31 May 2008 (UTC)

I'm not sure what you mean by "worst it gets", but currently Chiropractic #History, which contains Chiropractic #Medical opposition is the section with the most POV problems in Chiropractic. I wouldn't agree with rewriting Chiropractic to reflect mainly a "resounding rejection of chiropractic by the scientific and medical establishment in general", as that doesn't describe mainstream opinion accurately. It's not that negative. Eubulides (talk) 07:56, 31 May 2008 (UTC)

I'm basically having a problem getting up to speed on the basic subject matter. I do see that basic wiki process needs to be better adhered to. I think you need mediation. I think there is disruptive editing. I think if you want to avoid ArbCom, that people should be more reasonable. For example, there are very fringe elements here. We need to acknowledge that there is a lot of fringe stuff, and let that be reflected in the article. At the same time, statements here lead me to believe there was indeed a resounding renunciation somewhere, but that isn't true. All there is is questioning of the positive sources, and one negative source, Ernst. I'm not sure whether Ernst represents the mainstream or not. Can you tell me if he does? If he does, is there a source saying so? If he doesn't, why not include him, but not as a major theme? Again, I'm only here for POV problems and for wiki process, I have no POV on the subject itself. ——Martin^phi ☎ Ψ Φ—— 02:13, 1 June 2008 (UTC)

• Formal mediation would make sense, yes. The biggest disputes here are about which sources are reliable and which represent mainstream opinion (for some definition of "mainstream").
• Please see DigitalC's comment below, and my followup, for whether Ernst is "mainstream".

Eubulides (talk) 08:39, 2 June 2008 (UTC)

There are editors that argue that Ernst represents mainstream opinion, and editors that argue that he doesn't. I haven't seen any evidence that he DOES represent mainstream opinion, but I have seen evidence put forward that he doesn't. For instance, the guidelines of the American College of Physicians & American Pain Society, recommend as follows: "Recommendation 7: For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence)." So here we have the American College of Physicians recommending SMT for acute, sub-acute, and chronic low back pain, as therapy with PROVEN BENEFITS. Now, which represents mainstream opinion more here, Ernst, or the ACP? Now, lets see how this is worded in the aricle? "For example, a 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail," DigitalC (talk) 00:58, 2 June 2008 (UTC)

• Ernst's work is cited more often about chiropractic in scholarly works than is Haldeman (perhaps the leading D.C. researcher), and a spot-check suggests that most of the citations to his work is positive. For details, please see #Comments on Scientific investigation 3C (look for the words "spot-check" and "Google Scholar" in that section). In that sense, at least, Ernst's work is mainstream.
• If there's something wrong with the quoted wording in the article, can you please suggest specific improvement to it? I do notice the "nonpregnant adults" as not being in the source's text that you quote, but it is supported by other text of the same source.

Eubulides (talk) 08:39, 2 June 2008 (UTC)

• It is a major civil-POV push. If it was a moderate strength recommendation, we wouldn't write "moderately recommends". Yes, the strength of the recommendation is "weak", but to word that as "weakly recommends" is not NPOV. DigitalC (talk) 02:19, 5 June 2008 (UTC)

• The phrase "weakly recommends" is not NPOV; it is used by the ACP itself when describing its recommendations whose strength is weak. For example, the ACP's summary (PMID 17975179) of their 2007 COPD clinical practice guideline says "The ACP weakly recommends that doctors and patients should: 1. Consider a combination of inhaled drugs if the FEV1 is less than 60% and symptoms continue during treatment with 1 drug. 2. Consider pulmonary rehabilitation for patients with COPD symptoms and an FEV1 less than 50% predicted." Eubulides (talk) 07:05, 5 June 2008 (UTC)

MartinPhi, that is history and the opposition story has changed, medicine has partially embraced chiropractic care (TaskForce, integrative medicine models) yet a fringe element within it continues to critically attack it, via "research" now such as Ernst'. I could add about 5 references regarding the deliberate misattribution of strokes to chirorpactors despite the fact no chiropractor was involved in the treatment yet received 'chiropractic manipulation'. It's that kind of shadiness that has gone on. The AMA also recently tried to prevent chiropractors from conducting examinations outside the spine in a clearly anti-competitive move that actually breached the US Supreme Court decision ruled against the AMA. Also, one must differentiate between chiropractic integration into mainstream medicine vs. integration into mainstream health care. One is occurring (medicine) where one has already occurred (licensure, regulation, reimbursement, governmental and health agency recognition, use of services, scientific contributions, etc.). More evidence that chiropractic is mainstream as opposed to fringe. Quack we haven't heard your opinion yet, I'm going to assume you believe Chiropractic is fringe but I'd rather you tell the community for yourself your stance on this issue. Cheers. CorticoSpinal (talk) 05:27, 31 May 2008 (UTC)

Again, Ernst's work represents mainstream criticism of chiropractic, published in reputable journals and widely cited. It is not "fringe" by any reasonable measure. Eubulides (talk) 07:56, 31 May 2008 (UTC)

Yes, that's so. I've been doing some further reading and thinking. Ernst represents an element within the mainstream which is critical of chiro. He's published in reputable journals, and no doubt has an (unknown) amount of support from people who can be considered mainstream. I've seen a lot of very mainstream sources, though, which lead me to believe that though he represents an element within mainstream, he does not represent the overall gist of mainstream opinion, but rather one extreme within the spectrum which is "mainstream." Reading the replies here, and the sources, I see chiro as having critics, and as incorporating fringe elements. But in general, it is not a profession which the mainstream can be said to reject or even to be generally "down on." We need to cover the fringe elements here as fringe, that is to say, we need to say "this part of chiro theory and practice does not have scientific/mainstream support." But Ernst does not represent the mainstream, any more than the MD doctors who are all for chiro represent the mainstream. The article simply needs to make clear this dynamic and the way it has changed over the years. Ernst is a good source, but his point of view should not be the basis for the article as a whole. We need to take all the sources into account. That's as far as I've come on an opinion, and of course I'm quite willing to be swayed either way.

Criticism of the fringe views which exist within chiro is not a problem. For example, I found this article, which makes it clear that chiro still has a large component of fringe ideas within it [37]. Yet I think that chiro nevertheless is fairly mainstream in medical practice, though not completely so. Does this sound like I'm taking the general picture into account? ——Martin^phi ☎ Ψ Φ—— 01:50, 2 June 2008 (UTC)

I appreciate your fresh outlook. I tend to agree, but my perspective is somewhat with my nose against the wall, which occasionally creates double vision ;-) This type of information is extremely helpful in giving us direction for the article. Keep them coming. You might notice, though, that User:CorticoSpinal has been blocked (hopefully temporarily), otherwise he might have more to add. -- Dēmatt (chat) 02:20, 2 June 2008 (UTC)

After following this argument for some time, I am coming to the viewpoint that perhaps Ernst is somewhat extreme, within "mainstream". I second: "Ernst is a good source, but his point of view should not be the basis for the article as a whole." (It hasn't and won't be 'the basis' at all, anyway. Just one factor) There is considerable evidence that chiropractic is effective for back pain and the European back pain guidelines take this into account...just one example. "UK National Clinical Practice Guideline Evidence Review states: "Within the first 6 weeks of acute or recurrent low back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared." [38]--—CynRN ^(Talk) 05:30, 2 June 2008 (UTC)

• I agree with the basic outline of what Martinphi said, and in particular that Ernst does not represent the mainstream, just as the Bone and Joint Task Force does not represent the mainstream.
• This is reflected by differing national guidelines as well: CynRN says the UK guideline favors chiropractic, whereas Murphy et al. 2006 (PMID 16949948) says the Swedish guideline no longer favors it (it used to, but this got changed in 2002). My own vague impression is that national guidelines tend to favor chiropractic in countries where chiropractic is more strongly established and tend not to favor it where other forms of CAM are stronger.
• It is controversial whether chiropractic is "fairly mainstream in practice". One can find recent sources either way. The above discussion found multiple reliable sources saying that chiropractic is not "mainstream" (for some value of "mainstream"), and multiple reliable sources saying that it is "mainstream" (ditto).
• This is why Chiropractic #Scientific investigation gives reasonable space to both kinds of mainstream views. There is no real consensus in this area; both sides should be given. Ernst is certainly not the basis for the Chiropractic as a whole, which is as things should be.
• Other mainstream medical sources use much stronger wording than Ernst does. See, for example, Fink 2002 (PMID 12379082), which says "The dictionary deefines quackery as 'the pretension to medical skill.' In my opinion, which is unchanged by Meeker and Haldeman's paper, that describes chiropractic." You don't see Ernst using such extreme words. And yet Fink's views, I expect, are fairly common in mainstream medicine. (I don't know of any opinion poll in this area, alas.)

Eubulides (talk) 08:39, 2 June 2008 (UTC)

Incorrect. Ernst's work is disputed and has been invalidated. His opinion on the subject is fringe because it is a) extremist and b) refuted by the majority of the literature. So, regardless of where Ernst' review was published his conclusions are diametrically opposed to conclusions of the TaskForce. We're comparing the strength of those 2 papers. CorticoSpinal (talk) 17:54, 31 May 2008 (UTC)

Ernst's work has certainly been disputed, but it has not been invalidated, and it is certainly not "refuted by the majority of the literature". Eubulides (talk) 08:39, 2 June 2008 (UTC)

WP:REDFLAG. The TaskForce document is written by chiropractors who are not reliable sources when it comes to whether mainstream medicine has embraced chiropractic care. You can see that the Task Force received its funding mainly from chiropractic organizations here. Small wonder they declared chiropractic to be as effective and safe as they did! We can hardly expect chiropractors to be reliable when they admit to their agenda to make chiropractic a part of the "mainstream". No, we need consistent statements from medical doctors who are not chiropractors to establish this so-called "fact". ScienceApologist (talk) 07:28, 31 May 2008 (UTC)

Complete misuse of REDFLAG. The document has 16 MDs to 8 DCs as important authors. Regardless, your statement that the literature is somehow fudged should be withdrawn. That is a grossly biased statement that has absolutely no merit. You, an editor who represents the fringe viewpoint are giving your PERSONAL OPINION to rebuke the character of Dr. Haldeman. Wikipedia doesn't work that way, SA. You need evidence to back up your claim. So far, there isn't any. Quite simply the TaskForce is multidisciplinary document that has more MD representation than DC. Thats a fact. Also, we don't need statements from medical doctors to demonstrate that chiropractic is part of mainstream health care. MDs want to supress DCs, generally speaking. That doesn't mean that the public, governmental and health agenecies other health care providers, legilators, scientists and others haven't already brought chiropractic into the mainstream. Bottom line: evidence has been presented that chiropractic is moreso mainstream (health care not medicine (profession)) if not completely part of mainstream health care. You have provided no evidence that it is fringe. Please provide evidence rather than conspiracy theories that question the integrity of the TaskForce. Thanks. CorticoSpinal (talk) 17:54, 31 May 2008 (UTC)

The above comment confuses a document (Hurwitz et al. 2008, PMID 18204386), with a task force. They are different things, and statistics about one don't necessarily apply to the other. Certainly evidence has been supplied from reliable sources who do not consider chiropractic to be part of mainstream health care; see Langworthy & Cambron 2007 (PMID 17693332) and Hirschkorn & Bourgeault 2004 (PMID 15847969), both mentioned above. Eubulides (talk) 08:39, 2 June 2008 (UTC)

That brings us to the other issue; whether chiropractic = spinal manipulation(SMT). We've made some statements about chiropractic's effectiveness/cost effectiveness and safety when we are using research about spinal manipulation. IOWs, there are things that SMT is not appropriate for, but that doesn't mean that other techniques that chiropractors use are not effective. This implies that chiropractors aren't capable of determining the best procedure for any particular condition. In reality, chiropractors are apparently better at this than other professions as they have higher patient satisfaction rates, so why do we add doubt to their ability to treat these conditions. The reality is that mainstream scientists (not the same as mainstream medicine) are very much aware of this and are currently working to find out why. Meanwhile, we dont' have to paint a glowing picture or make claims that are not heavily backed by mainstream medicine, but we don't need to downplay them either. We need to treat them as if they were writing about physical therapy or orthopedists. It's a tricky dichotomy, but chirorpactic care does not equal SMT and any of our sections on chiropractic efficacy, efficiency, or safety should make this distinction as well. As an example, the Hurwitz references a chart that shows that manipulation has not been evaluated enough to determine its effectiveness for neck pain, but we have taken things out of context to imply that SMT is not any more effective than any other treatment (or something to that effect). I think this is what CorticoSpinal has been complaining about cherry picking the research, though I wouldn't have phrased it as being that intentional. -- Dēmatt (chat) 14:57, 2 June 2008 (UTC)

• It's true that the article currently summarizes the effectiveness of various chiropractic treatments, without going into the issue as to whether chiropractors are capable of determining the best treatment for each case. It would be helpful to briefly discuss that issue too, if we can find a reliable source about it.
• Chiropractic#Utilization and satisfaction rates does mention satisfaction rates; chiropractors indeed do quite well by that measure (though not as well as pharmacists :-).
• I agree with your comments on the right way to cover chiropractic, and that it's tricky.
• Currently Chiropractic#Scientific investigation attempts to make it quite clear when the results are about chiropractic care in general, or a particular treatment form (often SMT). If this isn't clear enough, the wording should be improved.
• Which chart are you referring to? I just now looked at Hurwitz et al. 2008 (PMID 18204386), and the only occurrence of the string "chart" that I found was in the phrase "Uncharted territory" (which somehow seems appropriate…).

Eubulides (talk) 16:45, 2 June 2008 (UTC)

History

The lead paragraph for the history section is a bit too short. I think it should be expanded. Any suggestions? QuackGuru 09:20, 31 May 2008 (UTC)

My suggestion is that the lead paragraph should summarize all of chiropractic history, that the rest of Chiropractic #History be merged into Chiropractic history. I.e., that Chiropractic #History should be trimmed down to one paragraph. I realize this suggestion will take quite a bit of work. Eubulides (talk) 08:39, 2 June 2008 (UTC)

Arabian Nights tidbit

It was suggested that more context should be added to the Arabian Nights tidbit. Thoughts? QuackGuru 17:41, 1 June 2008 (UTC)

Sorry, I forget. What sort of context was asked for, and why? Eubulides (talk) 08:39, 2 June 2008 (UTC)

Read this comment. QuackGuru 19:12, 2 June 2008 (UTC)

Thanks, I reread that, and I don't see the need for further context. It wasn't clear from the comment what information was being requested, so perhaps I'm just misunderstanding the request. Eubulides (talk) 19:45, 2 June 2008 (UTC)

OK, never mind, just leave it. I looked at where it says "Arabian Nights" in the source, and it doesn't explain it either. I suppose maybe it means fictional, made up in desperation in order to save something. I'm sorry I hadn't looked at the source before I commented in the first place. ☺ Coppertwig (talk) 23:20, 3 June 2008 (UTC)

Archiving

I suggest a lot of old threads should be archives. Further, there are a lot of obsolete education drafts that can also be archived. This talk page is way too long. QuackGuru 17:50, 1 June 2008 (UTC)

Perhaps you could start by choosing one of the versions of education drafts that you submitted which you support, and archive the rest? DigitalC (talk) 00:39, 2 June 2008 (UTC)

Threads inactive for 14 days were archived automatically. I just now changed that to 10 days; that should help a bit. 7 days seems a bit aggressive to me. Eubulides (talk) 08:39, 2 June 2008 (UTC)

Requests for comment on Education, licensing, and regulation improvements

Education, licensing, and regulation 7

Chiropractors obtain a first professional degree in the field of chiropractic medicine. The U.S. and Canada require a minimum 90 semester hours of undergraduate education as a prerequisite for chiropractic school. Matriculation through an accredited chiropractic program includes at least 4200 student/teacher contact hours (or the equivalent) of full‐time education. The World Health Organization (WHO) guidelines suggest three major educational paths involving full‐time chiropractic education, along with a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.

The WHO guidelines also suggest that health professionals with advanced clinical degrees, such as medical doctors, can meet the educational and clinical to practice as a chiropractor in 2200 hours. In both cases (4200/2200 hours) this includes a minimum of 1000 hours of supervised clinical training. Upon graduation, the chiropractor may then be required to pass national, state, or provincial board examinations before being licensed to practice in a particular jurisdiction. Depending on the location, continuing education may be required to renew these licenses.

In the U.S., chiropractic schools are accredited through the Council on Chiropractic Education (CCE). The CCE-USA has joined with CCEs in Australia, Canada, and Europe forming CCE - International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally. Today, there are 18 accredited Doctor of Chiropractic programs in the USA, 2 in Canada, and 4 in Europe. All but one of the chiropractic colleges in the U.S. are privately funded, but in several other countries they are in government-sponsored universities and colleges.

Regulatory colleges and chiropractic boards in the U.S., Canada, and Australia are responsible for protecting the public standards of practice, disciplinary issues, quality assurance and maintenance of competency. There are an estimated 53,000 chiropractors in the U.S., 6526 in Canada, 2500 in Australia,[39] 1,500 in the UK, and about 90,000 internationally. In the U.S., Chiropractic education is divided into straight or mixer (progressive) educational curriculums depending on the philosophy of the institution.

Comments on Education, licensing, and regulation 7

I started this thread. Please do not comment above of my comments. Interleaving comments can be confusing. There are other drafts. For example, there is draft 3: Talk:Chiropractic#Education.2C_Licensing.2C_Regulation_3. I consider draft 3 to be obsolete and irrelevant now. QuackGuru 18:29, 8 June 2008 (UTC)

I have made some important improvements with this draft. All of the unnecessary references should be deleted. If an editor thinks any ref is unnecessary then please consider removing it. QuackGuru 21:55, 3 June 2008 (UTC)

I am of the opinion that this version is slightly better than the other 6 above. Are there any dissenting opinions? ScienceApologist (talk) 23:21, 3 June 2008 (UTC)

My eyes continue to glaze over when reading this stuff. In some ways, 7 is better than 3 (it fixes some obvious bugs in the wording). In some ways it's worse. We should combine the virtues of both. In the spirit of doing that, here are some comments on 7 that would help improve it so that it's better than 3.

• The usual style is "U.S.", no? 7 sometimes says "US", sometimes "USA". It should be consistent.
• "prerequisite before applying to a chiropractic school" → "prerequisite for chiropractic school"
• "no less than a 4200 student/teacher contact hours" → "at least 4200 student/teacher contact hours"
• "in four years of full‐time education during school" → "of full‐time education" (the extra details aren't needed)
• "Internationally, to help standardize and ensure quality of chiropractic education, in 2005 the" Remove.
• "The WHO voluntary guidelines" → "The WHO guidelines" Guidelines are voluntary; no need to say it twice.
• "suggest for health professionals" → "suggest that health professionals"
• ", such as medical doctors," Remove; not needed.
• "that includes a minimum of 1000 hours of supervised clinical training". This 1000-hour requirement also applies to the 4200 number. It sounds odd to see it mentioned only with the 2200 number. The simplest fix would be to remove this phrase. A better fix would be to reword it to make it clear that the 1000 applies to both the 4200 and the 2200 number.
• "Upon finishing chiropractic education" → "Upon graduation"
• "Depending on the location (state or province)" → "Depending on the location"
• "(CE)" Remove; not used.
• "with the stated purpose of insuring the quality of chiropractic education" Remove this advertising fluff. We should say what the organizations do and not repeat their promotional material.
• "CCE standards has accrediting bodies worldwide." This sentence is not clear. CCE is U.S., right?
• "These councils have developed CCE - International in an effort to maintain chiropractic education standards globally." Here, 3 is much better than 7 as it is more specific about CCE-I's goals and actions. Use 3's wording: "The CCE-USA has joined with CCEs in Australia, Canada, and Europe forming CCE - International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally."
• "All but one of the chiropractic colleges in the US are privately funded, but in several other countries they are in government-sponsored universities and colleges. Today, there are 18 accredited Doctor of Chiropractic programs in the USA, 2 in Canada, and 4 in Europe." Reverse the order of these two sentences.
• "The Federation of Chiropractic Licensing Boards (FCLB) is a member list of most regulatory bodies." This sentence is not clear. Perhaps remove it?
• "There are an estimated 53,000 - 70,000 chiropractors in the USA, 6000 in Canada, 2500 in Australia, 1,500 in the UK, and about 90,000 internationally." Don't use the 70,000 estimate; it's older and from a less-reliable source. The 2006 number for Canada was 6526; use the source in draft 3 for this. I don't see anywhere in the source http://www.ccea.com.au/images/PDF/Migration/Attachment%20E%20-%20Recognised%20Quals.pdf where there's an estimate of 2500 in Australia; remove that source and remove the "2500". The 90,000 estimate is dubious and should be removed; it relies an an estimate of 65,000 in the U.S.[40] which is worrisomely higher than the more-reliable BLS estimate.

Hope this helps. Sure wish we could get this section out the door; the continuing "dueling drafts" is worrisome. Eubulides (talk) 07:24, 4 June 2008 (UTC)

Thanks for the input Eubulides. Hopefully we can hammer out a version for education within the next week. DigitalC (talk) 03:02, 5 June 2008 (UTC)

Again, one of the big differences I see between Education 3 and Education 7 is the treatment of the WHO guidelines. On that basis alone, I have to say that Education 3 is better. DigitalC (talk) 03:02, 5 June 2008 (UTC)

• For Outside editors, please see also Talk:Chiropractic#Education.2C_Licensing.2C_Regulation_3 DigitalC (talk) 02:45, 5 June 2008 (UTC)

There were comments inserted above my comments which was rude. QuackGuru 18:29, 8 June 2008 (UTC)

I am sorry that you considered it rude QuackGuru, however opening an RfC on draft #7 without mentioning that there are other drafts under consideration that outside editors might not be aware of (ie - responding to the RfC) was disruptive, and I was attempting to fix the situation. I do not see how it could be considered confusing in this instance, and you have been warned before about altering others comments. Now that you have mentioned that there are other drafts, I don't mind my comment being moved. However, although you may consider draft 3 to be "obselete and irrelevant now", that does not make it so. DigitalC (talk) 01:11, 10 June 2008 (UTC)

Is there any specific objections to draft #7. I think this is the only draft worthy of mainspace. QuackGuru 01:37, 11 June 2008 (UTC)

• The way that "In the U.S., Chiropractic education is divided into straight or mixer (progressive) educational curriculums depending on the philosophy of the institution." is included flows poorly. The paragraph talks about regulatation, the number of chiropractors, and then this non sequiter.
• Not enough detail is given to the WHO guidelines on education. Draft 3 is much better in this respect. DigitalC (talk) 03:12, 11 June 2008 (UTC)

The way that the straight or mixer (progressive) educational curriculums is included flows great. Please provide a specific suggestion on how to improve the flow if you disagree.

Too much detail is given to the WHO guidelines on education in draft #3. The long end run of WHO quotes are suggestions and not official world standards. Draft #7 fixes the problems with the WHO quotes. QuackGuru 06:31, 11 June 2008 (UTC)

• My specific suggestion would be to remove it entirely. It definitely does not flow great, as it is not related to the number or chiropractors worldwide, nor to regulation.
• Please stop with the strawman argument that they "are not official world standards". No one is claiming that they are standards. They are however official WHO guidelines. I have pointed this out previously, and this appears to be a case of WP:IDIDNTHEARTHAT. DigitalC (talk) 06:52, 11 June 2008 (UTC)

The WHO guidelines are merely suggestions and not world standards. The suggestions should not be given so much weight as in draft #3 because they are not official standards and the quote are boring. Draft #7 fixed the WHO problem quotes. The educational curriculums is about education and thus related to Education, licensing, and regulation section. QuackGuru 07:06, 11 June 2008 (UTC)

Another occurence of WP:IDIDNTHEARTHAT. No one is claiming that the WHO guidelines are 'world standards'. Please stop with this strawman argument, it is disruptive and tendentious editing. DigitalC (talk) 00:22, 13 June 2008 (UTC)

For those of us who have not been following the debate between drafts 3 and 7 (and I admit that I am one of them: let's face it, this stuff is really boring), can someone please briefly summarize the differences between them and why these differences matter? Eubulides (talk) 17:58, 11 June 2008 (UTC)

ScienceApologistwrote in part above: I am of the opinion that this version is slightly better than the other 6 above.

Eubulides wrote in part above: In the spirit of doing that, here are some comments on 7 that would help improve it so that it's better than 3.

Draft 7 is clearly better than draft 3. Draft 7 fixes the WHO problem quotes, draft 7 is fully referenced, and draft 7 has the educational curriculums. QuackGuru 16:46, 12 June 2008 (UTC)

The last I saw, Levine, me, and DigitalC agreed with 3 and Eubilides had issues with both 3 and 7 if his issues were fixed. Did you address those fixes in Eubilides' list above? Maybe if we put both versions here we can compare them again one to one. There might still be some tweaks we can do to both. -- Dēmatt (chat) 17:01, 12 June 2008 (UTC)

Levine2112 never saw the finished versions of draft 3 or 7. Eubilides had objections with draft 3 that were never fixed such as the WHO quotes. Draft 7 is NPOV while draft 3 has the WP:WEIGHT problems with the WHO quotes. Draft 7 is fully referenced while draft 3 has a lack of references. QuackGuru 17:08, 12 June 2008 (UTC)

I agree that draft 7 in some ways is better than draft 3, and would like to see these improvements merged into Chiropractic. But I'm afraid I haven't yet seen a concrete proposal as to how to do this. QuackGuru, how about if you propose specific changes to what's in Chiropractic now? This could be in the form of a bullet list. It's helpful if each change is isolated in the list. Obviously it's easy to generate a diff listing between the two drafts, and I'm not asking for that; I'm asking for a brief description of each particular change to Chiropractic and why it's needed. Eubulides (talk) 17:18, 12 June 2008 (UTC)

• The long WHO quotes should be removed from draft 3.
• Draft 3 is not fully referenced like draft 7.
• Draft 7 has more info on the chiropractic numbers worldwide.
• Draft 7 includes educational curriculums.
• Draft 7 explains: "In both cases (4200/2200 hours) this includes a minimum of 1000 hours of supervised clinical training."
• Draft 7 uses the same U.S. style.
• Draft 7 has already merged parts of draft 3 into draft 7 such as "The CCE-USA has joined with CCEs in Australia, Canada, and Europe forming CCE - International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally."

The changes are needed in order to achieve NPOV. For example, the end run of WHO quotes are merely suggestions that are undueweight and not necessary. QuackGuru 17:48, 12 June 2008 (UTC)

• From QuackGuru - The long WHO quotes should be removed from draft 3.

Your argument that it is undue weight doesn't make sense. If we don't quote the WHO then all we do is reference the countries (like this and this) themselves that use those methods. If it's the formatting you don't like, well, that is just your preference and that is not enough. If there is a reason that the source is wrong, thent hat is another thing, but you haven't shown that. More later.. -- Dēmatt (chat) 18:45, 12 June 2008 (UTC)

It's boring to have such an extensive length of quotes. This sort of detail is not needed in Chiropractic. It might be useful for Chiropractic education. The section is supposed to be a summary and not a block of quotes or a reference to those countries that use the methods. QuackGuru 18:58, 12 June 2008 (UTC)

I disagree that it is boring, and really doesn't matter if it is. Besides, that is not a valid reason to delete valuable information. -- Dēmatt (chat) 19:12, 12 June 2008 (UTC)

This section is supposed to be summary of Chiropractic education. Why should we overly promote suggestions that are not official world standards yet. Wikipedia should not be used to promote suggestions to become official world standards. These WHO quotes are being given too much prominence. QuackGuru 19:24, 12 June 2008 (UTC)

• From QuackGuru - Draft 3 is not fully referenced like draft 7.

Which ones aren't referenced? -- Dēmatt (chat) 19:23, 12 June 2008 (UTC)

• From QuackGuru - Draft 7 has more info on the chiropractic numbers worldwide.

I have no problem with adding those numbers to 3, but I think Eubilides was concerned about the quality of one of the sources. more later... -- Dēmatt (chat) 19:34, 12 June 2008 (UTC)

I have a problem with adding those numbers to 3. We should start with draft 7 and move forward. Draft 3 is a step backwards from draft 7.

Writing "more later..." will not change the fact that draft 7 is far better than draft 3.

Once graduated, the chiropractor may... is not referenced. Starting with a lower quality draft 3 is odd. There is information that is not referenced and the references are not fully formatted. These problems are fixed by using draft 7. Draft 7 is better worded and includes interesting information such as educational curriculums.

I removed the source that Eubilides had a concern with and used a book to reference the remaining chiropractic numbers. Gordon Waddell (2004). The Back Pain Revolution. Churchill Livingstone. {{cite book}}: Cite has empty unknown parameter: |chapterurl= (help) If editors prefer, the remaining chiropractic numbers can be removed from draft 7.

Again, this section is supposed to be summary of Chiropractic education. Why should we overly promote suggestions that are not official world standards yet. Wikipedia should not be used to promote suggestions to become official world standards. The disputed blocks of WHO quotes are being given too much prominence.

Draft 7 is better than draft 3. Draft 3 is on the wrong end of NPOV and should be greeted with a revert for the reasons stated above. QuackGuru 19:58, 12 June 2008 (UTC)

• Repeatedly stating that draft 7 is better than draft 3 does not make it so. Draft 3 is not "promoting" the WHO guidelines any more than draft 7 is. What specific information do you feel is not referenced? DigitalC (talk) 00:18, 13 June 2008 (UTC)

I have explained specifically what is not referenced in my previous comment. Draft 3 is overly promoting the WHO standards while draft 7 is not. The WHO quotes are not law. The block of WHO quotes are merely suggestions. QuackGuru 00:27, 13 June 2008 (UTC)

Again, please stop with the strawman arugment. No one is stating that the WHO guidelines are Law. Neither draft 3 nor draft 7 are PROMOTING the WHO guidelines. The WHO guidelines are not "merely suggestions", they ARE Official World Health Organization International Guidelines. However, a guideline is not a standard, a rule, or a law (and again, no one is claiming that it is) - it is just that, a guide. Please, for the sake of moving forward on this article, stop with the WP:IDIDNTHEARTHAT] DigitalC (talk) 00:34, 13 June 2008 (UTC)

• QG stated - "I removed the source that Eubilides had a concern with and used a book to reference the remaining chiropractic numbers. Gordon Waddell (2004). The Back Pain Revolution." This source was removed from draft 3 because it was unreliable for this information. That is, the numbers in it disagree with more reliable sources (for example, see the number of chiropractors this source states are in the US). DigitalC (talk) 00:34, 13 June 2008 (UTC)

Because the WHO quotes are suggestuions and not world standards we should not use them in an education section that is supposed to be a summary. The WHO guidelines are official for WHO but are not offical world standards. They are merely a guide or a suggestion to have world standards.

DigitalC stated in part: "This source was removed from draft 3 because it was unreliable for this information. That is, the numbers in it disagree with more reliable sources (for example, see the number of chiropractors this source states are in the US)." Please provide the differences and evidence that it was removed from draft 3. Please provide the evidence that the book is unreliable for the international chiropractic numbers. QuackGuru 00:47, 13 June 2008 (UTC)

• The source states that there are "about 70,000 Chiropractors" in the US. We know from more reliable sources (ie - US government Bureau of Labour and Statistics) that there are closer to 53,000 Chiropractors in the US. Why would we assume that this source gives accurate numbers for the others? Further, this also deserves a failed verification tag, as the source does not comment on the number of Chiropractors in Australia. I will add that shortly. DigitalC (talk) 01:15, 13 June 2008 (UTC)
• QuackGuru wrote "Because the WHO quotes are suggestuions and not world standards we should not use them in an education section that is supposed to be a summary." This doesn't seem to make sense. You use the same source in draft 7, yet fail to explain what the 3 educational paths are. A source is either valid (RS & V), or not - if it is, then quoting it seems fine, and if it isn't, it shouldn't be used at all. Are you objecting to the use of the WHO guidelines as a source? DigitalC (talk) 01:22, 13 June 2008 (UTC)

Using the long end run of boring WHO quotes is overly promoting a guideline that are not world standards.

DigitalC wrote: "Back Pain Revolution, by Gordon Waddell (page 62). [41] states 70,000 in the US, 6000 in Canada, 1500 in the UK, and 90,000 internationally. For the record, this information has been in the article for ages. You cry foul when others object to information that has been in the article previously, but then turn around and do the same. Now do you understand that while we are discussing something on the talk page, we might as well get it right?"[42]

I thought the source was good enough for DigitalC. QuackGuru 06:35, 13 June 2008 (UTC)

• I disagree that quoting the WHO is promoting their guidelines, let alone overly promoting them. DigitalC (talk) 07:24, 13 June 2008 (UTC)
• Perhaps we should get more input on this issue. Should we be using sources that disagree with facts (not opinions) stated in more reliable sources? Both the pediatrics article QG referenced, and the Waddell book state 70,000 Chiropractors in the US (While the US BLS states ~53,000). One gives 5000 for Canada, one gives 6000, and the currently cited source uses 6500. One says 1300 for the UK, the other 1500. The pediatrics article says there are smaller numbers in ~50 other countries, while a more reliable source says ~90 countries. How do we deal with such variation in the sources?

(outdent) As for the "70,000", the Pediatrics article (Campbell et al. 2000, PMID 10742364) merely cites an older advocacy source (FACTS Bulletin VI, 1999) for the "70,000". The FACTS Bulletin is less reliable than the Bureau of Labor Statistics, and its numbers are also significantly older. I assume the Waddell book is similar (Google Books won't let me read Waddell); certainly it's older. I see no good reason to mention numbers from older, less-reliable sources. As for the "50" versus "90" countries, which two sources are we talking about? I'd rather not wade through all of the above discussion to tease this out. Eubulides (talk) 17:20, 13 June 2008 (UTC)

There are an estimated 53,000 chiropractors in the U.S., 6526 in Canada, 2500 in Australia,[43] 1,500 in the UK, and about 90,000 internationally. Here is the complete sentence. We are not talking about the 70,000 number. We are talking about a few other numbers: "2500 in Australia, 1,500 in the UK, and about 90,000 internationally." What numbers and what sources should we use to verify the other numbers. 2,500, 1,500, and 90,000 is sourced but are there better sources and numbers we should use instead or is the sentence adequate. QuackGuru 18:05, 13 June 2008 (UTC)

All things being equal, I still prefer version 3 over version 7 (for many of the weaknesses outlined above by various editors). -- Levine2112 ^discuss 23:03, 13 June 2008 (UTC)

In looking up you guy's quote, and reading the above, I searched for the word "suggestion," and didn't find it. Then I searched for the quote, and found this:

There are many slight variations on the following models: however, in general, there are three major educational paths involving full‐time education: • A four‐year full‐time programme within specifically designated colleges or universities, following 1‐4 years of suitable pre‐chiropractic training in basic sciences at university level; for an example, see Annex 2. • A five‐year bachelor integrated chiropractic degree programme offered within a public or private university, with student entrance based upon the applicant’s matriculation status and the university’s admission requirements and quota restrictions. • A two or three‐year pre‐professional Masters programme following the satisfactory completion of a specifically designed bachelor degree programme in chiropractic or a suitably adapted health science degree.

In the index that's under Models of chiropractic education

QG says "Why should we overly promote suggestions that are not official world standards yet......the WHO quotes are suggestuions and not world standards we should not use them in an education section that is supposed to be a summary." But that's what they are, a summary, no?

I agree with QG about the quotes, they should be summarized, it's better writing. And if these are not suggestions but a summary of what is, there is no need to quote because it's just a common account of things, not something in any way controversial. ——Martin^phi ☎ Ψ Φ—— 05:38, 14 June 2008 (UTC)

I agree with Martinphi and QuackGuru that the quotes should be summarized. Martinphi's arguments are good ones. Eubulides (talk) 09:23, 14 June 2008 (UTC)

Improving the cost-benefit section

I finally sprung some time free to review the Chiropractic#Cost-benefit section, which got added on May 14 without previous discussion, and which has mutated a bit since then without much discussion. Here are my comments, along with a proposed rewrite #Cost benefit 2. Please comment at #Cost-effectiveness 2 comments. Eubulides (talk) 23:46, 4 June 2008 (UTC)

• The sources tend to prefer "cost-effectiveness" to "cost-benefit", so the section title and discussion should use "cost-effectiveness". Eubulides (talk) 23:46, 4 June 2008 (UTC)
• The organization of the section is confusing. For example, it starts off with the cost-effectiveness of maintenance care, which one would expect to find later (as maintenance care comes after initial care). Eubulides (talk) 23:46, 4 June 2008 (UTC)
• Sentences often do not hook together well. They often seem to be isolated sentences without any connection. Contradictory sentences are sometimes put next to each other, with no explanation. Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "The cost-effectiveness of maintenance chiropractic care is unknown and not well researched. Of the limited quantity of studies found, there is diversity in the findings." The source (Leboeuf-Yde C & Hestbæk 2008, PMID 18466623) says only that the cost-effectiveness is unknown. The bit about "there is diversity in findings" is not about cost-effectiveness; it is about other properties of maintenance care. This should be reworded to simply say "The cost-effectiveness of maintenance chiropractic care is unknown." Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "Of the various interventions available, the most cost-effective treatment for lower back pain could not be determined because of the lack of more higher quality evaluations." The "could not be determined" leaves the reader hanging. "Could not be determined" by whom? More context is needed here. Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "Spinal manipulation appears to be relatively cost-effective for chronic lower back pain." This directly contradicts the previous sentence, but the contradiction is not addressed or explained. Also, this cites a primary source for chronic low back pain (Haas et al. 2005, PMID 16226622), not a secondary review. As per WP:MEDRS such sources must be used with a great deal of caution, but caution was not exercised here. Let's drop this primary source and instead use a recent reliable review coauthored by Haas, namely Bronfort et al. 2008 (PMID 18164469). This secondary source addresses cost-effectiveness for chronic low back pain, citing several high-quality primary sources. I suggest using the sentence "A 2008 review of treatments for chronic low back pain found two studies reporting no difference in cost-effectiveness for chiropractic versus physical therapy, one arguing for cost savings for chiropractic versus hospital outpatient management, and one, and one concluding that SMT is a cost-effective addition to general-practice best care." Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "The cost-effectiveness of spinal manipulation therapy has not been demonstrated beyond a reasonable doubt." Again, this contradicts the previous sentence. More context is needed. This sentence is citing a critical review (Ernst 2008, PMID 18280103). I suggest rewording it to "A critical 2008 review concluded that the cost-effectiveness of chiropractic spinal manipulation has not been demonstrated beyond reasonable doubt." But (looking below) I see that this sentence is largely duplicative of another sentence supported by a more-specific Ernst review. Let's remove this sentence; it doesn't really add anything. Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "The data indicates that SMT typically represents an additional cost to conventional treatment." This sentence is about cost, but the section is about cost-effectiveness. The article should be mentioning the cost-effectiveness results of the source, not its cost results. I suggest "A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain." Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "After initial therapy, preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care." This cites an older review (Cherkin et al. 2003, PMID 12779300) and is superseded by information already given supported by newer reviews on the same subject; it should be removed. Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "Chiropractic managed care may reduce overall health care costs." This cites a primary study (Legorreta et al. 2004, PMID 15477432) that is already covered by the already-cited recent reviews; as per WP:MEDRS it should be removed. Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "When comparing primary care physicians (PCPs) medical management to nonsurgical nonpharmaceutical chiropractic management approaches (CAM-oriented PCPs), a followup study demonstrated with some reservations both a reduction in clinical and cost utilization of in-hospital admissions, hospital days, outpatient surgeries and procedures, and pharmaceutical costs when compared with using conventional medicine IPA performance alone." This is about cost, not cost-effectiveness. Also, this is a relatively extensive discussion of a primary study (Sarnat et al. 2007, PMID 17509435) that is too recent to be reviewed. We must take great care in citing primary studies as per WP:MEDRS. Since the primary study is not about cost-effectiveness this one is an easy call: it doesn't belong here and let's remove it. Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "An initial study found that the benefits of chiropractic care for neck pain seem to outweigh the possible risk." This cites a primary study (Rubinstein et al. 2007, PMID 17693331) so as per WP:MEDRS should be scrutinized closely. The study is about risk-benefit, not cost-benefit, so it's a bit dubious to put it here. As mentioned above, in #Comments on 2008-05-25 issues list, the source is dubious, as it has no control groupof any kind, and it has no risk-benefit model to support its claim that the "the benefits of chiropractic care for neck pain seem to outweigh the potential risks". Since this study is misplaced in Chiropractic now, one possible fix is to move the risk part of this study to Chiropractic#Safety and the benefit part to Chiropractic#Effectiveness; but a simpler fix, given the WP:MEDRS issue, is to omit this sentence from the article. If it is included somewhere, the info should be clearly identified as coming from just one primary study. Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "When compared with treatment options such as physiotherapeutic exercise (also performed by a chiropractor), the risk-benefit balance does not favor SMT." Again, this is about risk-benefit, not cost-benefit, so it doesn't really belong here. A much better home for this statement is Chiropractic #Safety. However, I suggest omitting it from the article entirely, as the review (Ernst & Canter 2006, PMID 16574972) doesn't have a risk-benefit model and its assertion about risk vs benefit is not well supported. I suppose it could be included if the Rubinstein et al. is included, but neither source inspires much confidence on this particular point. Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "In occupational low back pain, the research found that shorter chiropractor care had a benefit for reducing work-disability recurrence and a longer chiropractic care did not show a benefit for preventing work-disability recurrence." This is about benefit, not cost-benefit. It cites a primary study (Wasiak et al. 2007, PMID 18000417) and should be scrutinized carefully as per WP:MEDRS. It doesn't really belong in this article, as Chiropractic#Effectiveness is already chock-full of more-relevant claims supported by reviews. Eubulides (talk) 23:46, 4 June 2008 (UTC)
• "SMT helps to reduce time lost due to workplace back pain, and thus employer savings." This cites one ancient source (Frank et al. 1998, PMID 9645178) and one older non-peer-reviewed consultant report[44]. Both sources are too low in quality to make the cut here. Also, the claim is not about cost-effectiveness; it is merely about benefits. It should be removed. Eubulides (talk) 23:46, 4 June 2008 (UTC)

Here's the draft rewrite. Again, please comment at #Cost-effectiveness 2 comments below. Eubulides (talk) 23:46, 4 June 2008 (UTC)

Cost-effectiveness 2

A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings. A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain. A 2005 systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention. The cost-effectiveness of maintenance chiropractic care is unknown.

Cost-effectiveness 2 comments

(Please add comments here.) Eubulides (talk) 23:46, 4 June 2008 (UTC)

• A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific placebo effects) remains uncertain.
  • I don't see any of this in the source. Do we have the right one? -- Dēmatt (chat) 01:22, 5 June 2008 (UTC)

• I just now checked the source, and the following quotes support the abovementioned claim. First, the abstract says "Estimates of the incremental cost of achieving improvements in quality of life compare favorably with other treatments approved for use in the National Health Service. Because the specific efficacy of the complementary therapies for these indications remains uncertain, and the studies did not include sham controls, the estimates obtained may represent the cost-effectiveness [of] non-specific effects associated with the complementary therapies." Second, the discussion section says: "Second, estimates of cost-effectiveness based on data from clinical trials without sham controls compare favorably with other treatments approved for use in the NHS. Third, the specific treatment effects of the complementary therapies for the indications in question remains uncertain. We therefore strongly suspect that such studies may be estimating the cost-effectiveness of non-specific treatment effects." Eubulides (talk) 07:05, 5 June 2008 (UTC)

Wow, but that is comparing all kinds of complementary care. You are quoting sections that do not address chiropractic care. Why are we talking about the effectiveness of all of complementary care on the chiropractic article. The section that discusses chiropractic care never uses the words cost effective. It makes statements about effectiveness and cost, but it doesn't make a definitive statement about cost vs effectiveness. IOWS, the source states that chiropractic care was more effective than hospital staff treatment at 6 month, 12 month, 2 years and even more at 3 years follow up. The cost was 165 for chiropractic vs 111 for hospital. I agree that the cost-effectiveness of a treatment that fails is not cost-effective, but this source says that chiropractic fails less often. How is that less cost effective? Besides, this source supports that chiropractic care is more effective and hospital care. I suppose that if we really want to make inferences from this by equating it with cost effectiveness, then I suppose we could use the positive remark under effectiveness somewhere, but I'm not sure we want to consider it as that would be SYNful. Just like the education section, we need to get closer to the sources. This is what this source says under the section on chiropractic care:

• Cost-Effectiveness of Manipulation Provided by Chiropractors or the NHS for Low Back Pain

• • Meade et al. (7,8) published a clinical trial of 741 patients with low back pain who were randomized to treatments provided by either chiropractic or NHS hospital outpatient clinics. Treatment was at the discretion of the therapists involved; chiropractors used chiropractic manipulation in most patients, hospital staff mostly used Maitland mobilization or manipulation or both. Patients treated by chiropractors received 44% more treatments than those treated in hospitals. Patients were followed up for 2 years after treatment in the initial study and at 3 years in the follow on. Oswestry questionnaires were administered by post and the results reported initially (6) for 1 and 2 years were based on a much reduced dataset. We report here the more complete data from the follow on (8). At 6 weeks, the difference in Oswestry score was not statistically significant. At 6 and 12 months after treatment cessation, there were small differences in Oswestry score between groups of 3.31 (0.51–6.11, P < 0.02, n = 607) and 2.04 (–0.71 to 4.79; P = NS, n = 579), respectively, in favor of chiropractic. At 2 years, the difference had increased to 3.02 (0.08–5.96, P < 0.05, n = 541) and by 3 years it was 3.18 (0.16–6.20, P < 0.05, n = 529). Only direct costs of treatment provided during the intervention period were considered; mean costs of chiropractic and hospital-based treatments were £165 and £111 per patient, respectively. The follow-on (7) showed that a higher proportion of patients in the chiropractic group than the hospital group sought further treatment of any kind for back pain after completion of the trial treatment. Between 1 and 2 years after trial entry 42% of patients treated with chiropractic and 31% of hospital-treated patients sought such treatment but the additional cost of this further treatment was not accounted for.

Basically, this becomes an effectiveness issue again. It's the same Ernst argument. That any cost is not worth it because he doesn't see any benefit or at least he chalks it up to placebo. I'm okay with that, but we need to balance that one man's research with the rest. Now I see what CorticoSpinal was saying. -- Dēmatt (chat) 14:11, 5 June 2008 (UTC)

Therefore, the most we can say from this study that would not be SYN or OR and accurately reflects the source and help to make the sentence proevious to it NPOV would be somthing like:

• "A 2006 UK systematic cost-effectiveness review found that reports on complementary care that are based on data from clinical trials without sham controls remains uncertain."

-- Dēmatt (chat) 14:44, 5 June 2008 (UTC)

Canter et al.'s conclusions were based not only on the Meade et al. studies that you mention, but also on the UK Beam studies on low back pain, which also involved chiropractors (along with other professions). The UK Beam studies generated results more-favorable to chiropractic, and these results caused Canter et al.'s overall conclusions to be more favorable to chiropractic than they otherwise would have been. This explains why the wording proposed in #Cost-effectiveness 2:

"A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific placebo effects) remains uncertain."

is more favorable to chiropractic than the wording you propose:

"A 2006 UK systematic cost-effectiveness review found that reports on complementary care that are based on data from clinical trials without sham controls remains uncertain."

Eubulides (talk) 19:46, 5 June 2008 (UTC)

Let's consolidate all this at the bottom. It's about the same thing. -- Dēmatt (chat) 13:20, 6 June 2008 (UTC)

• A 2005 systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention. The cost-effectiveness of maintenance chiropractic care is unknown.
  • I haven't read the sources yet, but if this is what they are saying then why do we want a cost effectiveness section? Just to say we can say we don't know anything seems to be a waste of space? -- Dēmatt (chat) 01:26, 5 June 2008 (UTC)
    • There are many claims on the Internet that chiropractic care is more cost-effective than common alternatives. Chiropractic itself made such a claim pretty much continuously from August 2006[45] to May 12,[46] a period during which Chiropractic cited several obsolete reports supporting the claim. There is clearly significant interest in cost-effectiveness, both among Wikipedia editors and in the scholarly literature, so it's worth a brief mention from recent high-quality reviews saying the topic lacks good evidence. Eubulides (talk) 07:05, 5 June 2008 (UTC)

Okay, I can see that we should have a section on cost effectiveness. But Bronford is a review of efficacy not cost effectiveness. Even Ernst is about efficacy. The statement that the recent high-quality reviews saying the topic lacks good evidence is not what these two soiurces are about, unless we cherry pick. If we do, then the Bronfort source is the most recent isn't it? It takes into account all of the prior research, including Ernst, and it states pretty strongly that SMT is cost effective.. However, if we going to use either of these sources then we should be calling the section Efficacy.

-- Dēmatt (chat) 17:29, 5 June 2008 (UTC)

• Canter, Coon & Ernst 2006 (PMID 17173105) is about cost-effectiveness, not efficacy. The first word in its title is "Cost-effectiveness".

Agree, Ernst et al. is about cost-effectiveness but he qualifies it by saying that it is not cost effective because he thinks it is not efficacious. He is saying that if something is not effective then it can't be worth it no matter how cheap it is. That really makes it a question of efficacy. If he felt it was efficacious, then his argument would be invalid, because SMT would be more cost effective. See what I mean. -- Dēmatt (chat) 03:24, 6 June 2008 (UTC)

I don't see anywhere in "Ernst et al." (actually, Canter, Coon & Ernst 2006, PMID 17173105) where it says that the authors think chiropractic is not cost effective because they think it is not efficacious. I suspect you're thinking of some other paper coauthored by Ernst? The fact that you're calling it "Ernst et al." suggests that. But the draft doesn't refer to any other papers by Ernst; it refers only to Canter et al. 2006.

BTW, if research determines that chiropractic methods are efficacious, then Ernst's argument becomes moot. It appears that is what the Task force results are all about. It is important that we present this very carefully and accurately. -- Dēmatt (chat) 03:28, 6 June 2008 (UTC)

But Canter et al. 2006 doesn't say chiropractic methods are not efficacious. So their discussion of cost-effectiveness would not be moot if chiropractic methods were determined to be efficacious. Eubulides (talk) 06:12, 6 June 2008 (UTC)

No, we're talking about the same Cantor/Ernst review. The last sentence in the link provided is:

• Because the specific efficacy of the complementary therapies for these indications remains uncertain, and the studies did not include sham controls, the estimates obtained may represent the cost-effectiveness non-specific effects associated with the complementary therapies.(emphasis mine) See what I mean. He is saying that because efficacy is not certain, they aren't cost effective. He makes a good point and one that we need to treat fairly. Again, though, since these conversations are getting spread out, let's bring them to the bottom and go over one at a time. -- Dēmatt (chat) 14:29, 6 June 2008 (UTC)

• OK, I followed up below. Eubulides (talk) 17:43, 6 June 2008 (UTC)

• Bronfort et al. 2008 (PMID 18164469) is about management of chronic low back pain; this is narrower than cost-effectiveness of chiro in general (since it's just CLBP) but it's also wider (because it's about all topics relevant to management of CLBP, not just cost-effectiveness of chiropractic care). The draft citation refers to its section "Reimbursement", which covers cost-related issues. The 2nd paragraph of this section is about cost-effectiveness, and is what is summarized in #Cost-effectiveness 2.

Bronfort is bigger than anything yet and is part of the Neck Pain Task FOrce (and more current). By choosing only the "reimbursement" section we are essentially plucking primary sources - so it would be better to go directly to those sources - because Bronfort is not making that statement that we are sttributing to him(them). There is nothing wrong with going to the sources if that is what you want to say, but Bronfort is about efficacy of SMT for chronic low back pain so thatis what his source should be used for. -- Dēmatt (chat) 03:24, 6 June 2008 (UTC)

• This is the Cost-effectiveness section, so the only part of Bronfort et al. that's relevant is its discussion of cost-effectiveness. Bronfort et al. is also cited (twice) in Chiropractic#Effectiveness: there, we're relying on the paper's efficacy discussion. It is a big paper and it has results relevants to multiple sections of Chiropractic.
• Which statement are we attributing to Bronfort et al. that they are not actually making?
• I'd rather not cite primary sources directly; I'd rather cite a high-quality review like Bronfort et al.
• Bronfort et al. is not merely about efficacy of SMT for chronic low back pain; it is about all aspects of management of CLBP with SMT and mobilization. This includes several issues other than efficacy, including safety, clinical guidelines, mechanism, diagnostic testing, indications, and cost. It's true that over half of Bronfort et al. is about efficacy; but the rest of the paper is still significant work.

But not cost effectiveness, the last paragraph suggests further research into cost effectiveness. Again, see below. -- Dēmatt (chat) 13:20, 6 June 2008 (UTC)

OK, I followed up below. Eubulides (talk) 17:43, 6 June 2008 (UTC)

• The "Reimbursement" section of Bronfort et al. does not cite Ernst; Bronfort and Ernst are at sharp odds on chiropractic and in this area (as others) we can't really rely on Bronfort's opinion of Ernst's work or vice versa.

Sharp odds doesn't wash when it comes to science. There is only good science, better science and bad science. Bronfort does not give his opinion of Ernst, he describes how he responds to Ernst to make his study better... he states that this meta-analysis includes 6 more studies of higher quality that address Ernst's concerns. That is what we expect scientists to do. The ball is now in Ernst's court, not the other way around. -- Dēmatt (chat) 03:24, 6 June 2008 (UTC)

Again, there seems to be some confusion here. The part of Bronfort et al. that you mention is not about cost-effectiveness, and is not relevant to #Cost-effectiveness 2 or to this thread. (It is relevant to other parts of Chiropractic, where it's already cited.) The ball is not in Ernst's court as far as cost-effectiveness goes, as Bronfort et al. neither cite nor address the cost-effectiveness points raised in Canter, Coon & Ernst 2006 (PMID 17173105) (this is the paper that #Cost-effectiveness 2 cites). Eubulides (talk) 06:12, 6 June 2008 (UTC)

We're not disagreeing. See below. -- Dēmatt (chat) 13:20, 6 June 2008 (UTC)

Eubulides (talk) 19:46, 5 June 2008 (UTC)

• Well done, Eubulides. I agree with your changes. Thank you for your diligent work and organized presentation, as usual.
  The section should have been discussed on the talk page before being inserted into the article.
  In reply to Dematt's question about why to have the section: we do have things to say about cost-effectiveness, as said in the first two sentences. The third sentence is a differing opinion, for NPOV: in other words, perhaps some people think we don't know the cost-effectiveness while others think we know some things about it; also, it says we can't draw "definitive" conclusions but this doesn't rule out the possibility that some other kind of conclusion or information might still be available: preliminary conclusions, or suggestive evidence or something. The last sentence is about maintenance care, which does not contradict the idea that we may be able to say something about acute care.☺ Coppertwig (talk) 12:27, 5 June 2008 (UTC)

• • I have to respectifully disagree, Coppertwig, please look again. Unless I missed the part the part that says chiropractic care was cost effective. Two negatives don't make NPOV. The way we have it wriotten, we have forgotten to tell them what each side of the controversy says before we make the negative statment. It would have to state both POVs with V and RS and then we can use one that says "we just don't know". The source are about efficacy, not cost effectiveness. -- Dēmatt (chat) 17:29, 5 June 2008 (UTC)

• The sources are indeed about cost-effectiveness; please see my followup above.
• The current draft attempts to cite both partisan sides of this controversy (Bronfort et al. on one side, Canter et al. on the other); it then follows up with two less-partisan (albeit not non-partisan) sources (van der Roer et al., Leboeuf-Yde & Hestbæk) who say we don't have enough data.

Eubulides (talk) 19:46, 5 June 2008 (UTC)

• Each side of what controversy, Dematt? What negative statement? The first two sentences seem to me to be saying roughly the same thing: that there's some evidence that chiropractic care is cost-effective but not overwhelming evidence. The last two sentences say there isn't enough evidence, but barely contradict or don't really contradict the first two sentences: the last sentence doesn't contradict them because it's focussed on maintenance care specifically. Dematt, I'm sorry, but I just don't know what you mean in much of your comment. Your second sentence doesn't parse. I don't know what "two negatives" you're referring to. Do you mean that there's another source that should be included that's been left out? If so, what is it? (I haven't actually read the sources yet).☺ Coppertwig (talk) 01:32, 6 June 2008 (UTC)

I'm sorry Coppertwig, of course you are just making your assessments on the pubmed links. You need the whole article. As an example, part of the summary from the Bronfort source states their conclusions this way:

• For mixed (but predominantly chronic) LBP, there is strong evidence that SMT is similar in effect to a combination of medical care with exercise instruction. There is moderate evidence that SMT is superior to general practice medical care and similar to physical therapy in both the short and long term. There is limited evidence of short- and longterm superiority of SMT over hospital outpatient care for pain and disability. There is also limited evidence of short term superiority of SMT over medication and acupuncture.

My assessment is that our first sentence did not reflect the spirit of the author's intent(Bronfort's 2008 meta-analysis), not to mention the analysis was about efficacy, not cost effectiveness. The sentences that we quote are primary research that Bronfort makes no comment on, he just cites them as the sources of cost effectiveness - (one study arguing for cost savings for chiropractic versus hospital outpatient management, one study concluding that SMT is a cost-effective addition to general-practice best care, and two studies reporting no difference in cost-effectiveness for chiropractic versus physical therapy.). Our sentence improperly suggests that this was what the meta-analysis concluded, which is far from it. The summary was about efficacy - and it was much more supportive of SMT (which again <> chiropractic). The summary from Bronfort never mentions cost effectiveness. We then adds "placebo" in the next sentence which wasn't even used in the Cantor/Ernst paper. That's just not good wikipedian reporting and won't get us to Good Article status. BTW, Bronfort is a later study than Ernst (and Bronfort addresses Ernst's first paper), yet we have written the sentences as if Ernst was commenting on Bronfort... When we say that we can't consider any research that doesn't consider shams, etc., that was before Bronfort. This is what Bronfort said:

• Ernst review is severely limited in its approach because of an incomplete quality assessment, lack of prespecified rules to evaluate the evidence, and several erroneous assumptions [44]. Ernst goes further to conclude that bias exists in systematic reviews performed by chiropractors, particularly members of our group. We refuted this assertion [44], and have attempted to be as transparent as possible in our methodology, which details a priori defined standard and acceptable methods for conducting systematic reviews [45,46]. Table 7 summarizes the conclusions from the latest systematic reviews. The conclusion of this review, which includes the results of the latest published RCTs, is consistent with the latest high-quality evidence-based systematic reviews [47,48].

Hopefully this helps. If you want, I can suggest an alternative. -- Dēmatt (chat) 02:28, 6 June 2008 (UTC)

(I later inserted the #How we are using the sources subsection header to break things up.) Eubulides (talk) 17:43, 6 June 2008 (UTC)

How we are using the sources

• Again, the Bronfort-Ernst controversy you're mentioning is not about cost-effectiveness and so is not relevant to #Cost-effectiveness 2. It is about efficacy, and it is already discussed in Chiropractic #Effectiveness (which cites Bronfort et al.). Bronfort et al. do not address the Ernst paper that #Cost-effectiveness 2 cites.
• I don't see any improper suggestion in #Cost effectivness 2's summary of Bronfort et al. It merely says "A 2008 review of treatments for chronic low back pain found one study arguing X, another study concluding Y, and two studies reporting Z." There's no conclusion there; there's just a list of studies assembled by a team of experts (who can be presumed to do a good job assembling studies). That being said, if you can see an improper suggestion there somewhere, please suggest wording to fix the problem. I'm sure we can work something out. Or, if you prefer, we can simply remove the first sentence of #Cost-effectiveness 2 (though this sounds a bit drastic).
• You're correct that the summary uses "placebo" where the source uses "non-specific effect". The two terms are synonymous here, but I agree it'd be safer to not substitute the wording. I changed the draft to use "non-specific effect" alone (without "placebo"); to help the nonexpert reader I also added a wikilink to Non-specific effect (which I have added as a redirect to Placebo).

Eubulides (talk) 06:12, 6 June 2008 (UTC)

"Again, the Bronfort-Ernst controversy you're mentioning is not about cost-effectiveness and so is not relevant to #Cost-effectiveness 2. It is about efficacy, and it is already discussed in Chiropractic #Effectiveness (which cites Bronfort et al.). Bronfort et al. do not address the Ernst paper that #Cost-effectiveness 2 cites." Yes.

Exactly. It is not what we are saying, it is how we are using the sources. We can't use the 2008 review to make a statement about "cost-effectiveness" because it was about "effectiveness" (efficacy), but we can use the sources that it references. I.e. : "Inquiries into the cost-effectiveness for chronic low back pain find one study arguing X, another study concluding Y, and two studies reporting Z." refX,refY,refZ1,refZ2

• From WP:Syn *"Material published by reliable sources can inadvertently be put together in a way that constitutes original research. Synthesizing material occurs when an editor comes to a conclusion by putting together different sources. If the sources cited do not explicitly reach the same conclusion, or if the sources cited are not directly related to the subject of the article, then the editor is engaged in original research. Summarizing source material without changing its meaning is not synthesis; it is good editing. Best practice is to write Wikipedia articles by taking claims made by different reliable sources about a subject and putting those claims in our own words on an article page, with each claim attributable to a source that makes that claim explicitly."

OK, I take your point: Bronfort et al. 2008 (PMID 18164469) didn't make any conclusions about cost-effectiveness; they merely cited 4 sources without comment. So I went back to the well and found a different source: Mootz et al. 2006 (PMID 17142165). This source is older, but it does have the advantage of being more on point, as it has a much longer discussion of cost-effectiveness, and it makes conclusions on its own rather than just citing primary sources. Like Bronfort et al., it is written by chiropractors and fairly represents the pro-chiropractic POV. I removed the text sourced by Bronfort et al. and replaced it with "A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.", citing Mootz et al. Eubulides (talk) 17:43, 6 June 2008 (UTC)

Quoting Canter et al. 2006 (PMID 17173105), Dematt wrote: "Because the specific efficacy of the complementary therapies for these indications remains uncertain, and the studies did not include sham controls, the estimates obtained may represent the cost-effectiveness non-specific effects associated with the complementary therapies.(emphasis mine) See what I mean. He is saying that because efficacy is not certain, they aren't cost effective."

But Canter et al. didn't say efficacy is not certain; they said specific efficacy is uncertain. Specific efficacy is just part of efficacy; it is not the whole thing. Canter et al. are saying that the cost-effectiveness studies aren't separating specific efficacy from overall efficacy. Eubulides (talk) 17:43, 6 June 2008 (UTC)

Dematt wrote "But not cost effectiveness, the last paragraph suggests further research into cost effectiveness." Yes, but surely that is boilerplate. Almost all research papers suggest further research at the end. I'm not sure it's worth saying "more research is needed" here, as the point is already explicitly made about how little is known about cost-effectiveness. Eubulides (talk) 17:43, 6 June 2008 (UTC)

No further comment (other than Dematt's saying he'll check it when he gets to the library in #no agreement for blanking entire sections below), so I installed it. We can fix any wording problems later, once the source is checked by someone other than me. Eubulides (talk) 18:32, 11 June 2008 (UTC)

Cost-benefit

The cost-effectiveness of maintenance chiropractic care is unknown and not well researched. Of the limited quantity of studies found, there is diversity in the findings. Of the various interventions available, the most cost-effective treatment for lower back pain could not be determined because of the lack of more higher quality evaluations. Spinal manipulation appears to be relatively cost-effective for chronic lower back pain. The cost-effectiveness of spinal manipulation therapy has not been demonstrated beyond a reasonable doubt. The data indicates that SMT typically represents an additional cost to conventional treatment. After initial therapy, preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care. Chiropractic managed care may reduce overall health care costs.

When comparing primary care physicians (PCPs) medical management to nonsurgical nonpharmaceutical chiropractic management approaches (CAM-oriented PCPs), a followup study demonstrated with some reservations both a reduction in clinical and cost utilization of in-hospital admissions, hospital days, outpatient surgeries and procedures, and pharmaceutical costs when compared with using conventional medicine IPA performance alone. An initial study found that the benefits of chiropractic care for neck pain seem to outweigh the possible risk. When compared with treatment options such as physiotherapeutic exercise (also performed by a chiropractor), the risk-benefit balance does not favor SMT. In occupational low back pain, the research found that shorter chiropractor care had a benefit for reducing work-disability recurrence and a longer chiropractic care did not show a benefit for preventing work-disability recurrence. SMT helps to reduce time lost due to workplace back pain, and thus employer savings.

Comments on Cost-benefit

Is there anything worth merging into other sections or adding to cost-effectiveness. QuackGuru 18:39, 11 June 2008 (UTC)

I don't see anything that would be useful in other sections of Chiropractic; this stuff is all about cost and Chiropractic #Cost-effectiveness is the only section that is about cost. If we expanded Chiropractic #Scientific research into a subarticle it may be useful to cite some of those primary studies, but even there we'd need considerable caution, as it's better to stick with reliable reviews. Please see the bullet list at the start of #Improving the cost-benefit section for some problems with the primary sources cited in #Cost-benefit. Eubulides (talk) 19:03, 11 June 2008 (UTC)

lead

This isn't a subject I'm particularly familiar with, but I was wondering if the lead was a bit long? Sticky Parkin 19:21, 6 June 2008 (UTC)

A "bit long" is an understatement; the lead is way too long. By my count it has 431 words. By comparison, Coeliac disease, a recent featured article on a medical topic, has 263 words in its lead. Suggestions for improving and trimming down Chiropractic's lead are welcome. Eubulides (talk) 20:11, 6 June 2008 (UTC)

Removed Scientific research on 6/9/2009

I have been bold and am moving this section of Chiropractic to the talk page as it seems to have several synthesis problems and therefore is not appropriate in article space. We can replace sections of this as we fix them. Some have already been discussed and agreed to changes that are not yet in this version. -- Dēmatt (chat) 14:34, 9 June 2008 (UTC)

• That was too bold, I think. It's better to discuss the changes first. I'll follow up in #Questions and #no agreement for blanking entire sections below. Eubulides (talk) 20:01, 9 June 2008 (UTC)

---

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care. Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims. A 2007 survey of Alberta chiropractors found that they do not consistently apply research in practice which may have resulted from a lack of research education and skills. Evidence-based chiropractors possess the ability to apply research in practice. Continued education enhances the scientific knowledge of the practitioner.

Effectiveness (current version)

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective. Chiropractic care, like all medical treatment, benefits from the placebo response. The efficacy of maintenance care in chiropractic is unknown.

Research has focused on spinal manipulation therapy (SMT) in general, rather than specifically on chiropractic SMT. There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks. Many controlled clinical studies of SMT are available, but their results disagree, and they are typically of low quality. It is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect. Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference, a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.

Available evidence covers the following conditions:

Low back pain (current version)

• 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 SMT 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 SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care. A 2007 literature synthesis found good evidence supporting SMT 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 SMT, and a 2004 Cochrane review () stated that SMT or mobilization is no more or less effective than other standard interventions for back pain.

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Research and guidelines (renamed from Effectiveness - work in progress)

Chiropractors may use one or more of several modalities or methods in any combination to treat neuromusculoskeletal (NMS) conditions. They include several types of spinal manipulation(SMT)/mobilization(MOB), flexion/distraction, massage, ice/heat, physiotherapeutics, exercise, and ergonomic type advice. Depending on their training they may also use acupuncture, nutritional advice or other alternative medicine techniques. Some researchers consider that something unique to the doctor-patient encounter common to alternative medicine practitioners plays a role in effectiveness as well. Guidelines are generally consensus statements by experts in the field based on the best available evidence, including meta-analysis and systematic reviews where available.

• Low back pain. Guidelines for the treatment of low back pain divided into 3 categories; acute pain (less than 6 weeks duration), subacute (6 to 12 week) and chronic (more than 12 weeks). The efficacy for the use of any of these modalities varies depending on the category. There is still conflict of opinion concerning the proper frequency and duration of any of the interventions, or whether the guidelines accurately reflect effectiveness. However, most guidelines based on best evidence support the use of SMT for nonspecific (i.e., unknown cause) chronic low back pain (CLBP). A 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail. 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 SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care. A 2007 literature synthesis found good evidence supporting SMT 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 SMT, and a 2004 Cochrane review () stated that SMT or mobilization is no more or less effective than other standard interventions for back pain. Flexion/distraction was determined to be as effective as exercise... Massage was beneficial during the chronic phase but was not effective or recommended during the acute phase. Physiotherapeutics have little support on their own, though may have some benefit when used in combination with other modalities. Exercise is not recommended during the acute phase, though is strongly supported in subacute and chronic phases. Ergonomic advice and pamphlets alone were found to have little effect in any phase.

Low back pain comments

Comment #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.

This is the first statement we make about SMT. As nonspecific low back pain is only one type of low back pain and has different stages; acute, subacute, and chronic that all have different guideline suggestions for SMT, I suggest this is a not the balanced majority view, yet is given the first sentence. It leaves the reader with a negative POV about any of the guidelines. What are the guildeines saying? Which of the guidelines are wrong? All of them? Is one right? Are none right? If we use this sentence at all, we should use it after we have explained the guidelines as well as the controversy and then the doubt will be cast based on the evidence, not because we said so. It's a question of juxtapositioning and NPOV#Neutrality and verifiability. Our first sentence should make a net return statement that is explained with the subsequent information. Something like; "Spinal manipulation/mobilzation is effective to varying degrees for the treatment of low back pain depending on the cause of the pain, duration of the pain, and attitudes of the patient." Then we can go into guidelines if we want and even argue them back and forth if we must. Though guidelines are not really science, they are based on science, but they are usually consensus statements formed by top people in the fields that deal with the problems. Which is one of the reasons we should consider renaming this section.

-- Dēmatt (chat) 14:44, 10 June 2008 (UTC)

• It isn't the first statement made about SMT in Chiropractic#Scientific research. There are several earlier statements. For example: "Many controlled clinical studies of SMT are available, but their results disagree, and they are typically of low quality."
• Earlier sentences in the section already talk about guidelines. Here is one example among several: "The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care."
• The source does not answer questions like "Which of the guidelines are wrong? All of them? Is one right?". We'd all love to know the answers to those questions, but I'm afraid definitive answers are not available.
• There is already an introductory statement saying something along the lines you suggest. Here it is: "The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment."
• I agree that Scientific research is not a good name for the section, and have proposed a different name, but the proposal didn't gain consensus. I don't recall what the name was now, but it was something about being evidence-based. I still think a name like Evidence basis would be better than Scientific research.

Eubulides (talk) 19:43, 10 June 2008 (UTC)

"It isn't the first statement made about SMT in Chiropractic#Scientific research." We're getting back into being pedantic. It is clearly the first sentence in the subsection about low back pain. I agree with Dematt that this section doesn't seem to be NPOV. In fact, to me it reads like a negative POV sandwhich - put in the beginning negative (continuing conflict of opinion on efficy), sandwhich the positive POV in the middle, and then end with negative POV again (of 4 systematic reviews, ONLY 1, AND...). DigitalC (talk) 00:31, 11 June 2008 (UTC)

I apologize for referencing the wrong section, and thank you DigitalC for stating it clearly. -- Dēmatt (chat) 03:02, 11 June 2008 (UTC)

• There is a paragraph about low back pain (not a subsection) that is part of a Chiropractic#Scientific research section and Chiropractic#Effectiveness subsection that clearly establish context for that paragraph. This context applies to all the paragraphs in the subjection: not just low back pain, but also whiplash and other neck pain, headache, etc. It is not "pedantic" to mention prefatory remarks, which are applicable to several paragraphs in the section, as being part of context for that section. Copying this context over and over again into each paragraph would make the article longer, more repetitive, and more boring.
• Furthermore, the paragraph on low back pain is not a simple sandwich. Here's what it does:

• It leads with the fact that there is conflict (neutral).
• It says that this casts doubts on guidelines' reliability (neutral, because since some guidelines favor chiropractic and some don't).
• It mentions the 2007 U.S. guideline (positive).
• It mentions the 2002 Swedish guideline (negative).
• It mentions the 2008 review (positive).
• It mentions the 2007 literature synthesis (positive).
• It briefly summarizes four pre-2006 reviews (negative).

• This isn't a sandwich: it is a smorgasbord, and it is a faithful attempt to write an NPOV summary of high-quality reviews in this area. The order is reverse-chronological within source type (where the types are overviews, guidelines, and reviews). There was no attempt to write a "sandwich", and the resulting order is not that of a "sandwich".

Eubulides (talk) 17:58, 11 June 2008 (UTC)

It is NPOV when we closely follow the sources. If editors do not like Scientific research then my second choice would be Evidence basis. QuackGuru 01:48, 11 June 2008 (UTC)

You added that without consensus again. If we are to continue to work with consensus rules then I would ask that you revert your edit. "Evidence base" does not fit what we have written either. We woud have to edit it differently with a name like that. -- Dēmatt (chat) 03:02, 11 June 2008 (UTC)

Thanks for reverting yourself. How about "Research and guidelines"? -- Dēmatt (chat) 13:26, 11 June 2008 (UTC)

Me thinks something along the lines of Evidence-based medicine and research would be a better name. QuackGuru 17:49, 11 June 2008 (UTC)

Shorter names are better. Eubulides (talk) 17:58, 11 June 2008 (UTC)

Whiplash and neck pain

• Whiplash and other neck pain. There is no overall consensus on manual therapies for neck pain. A 2008 review found evidence that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis. A 2007 review found that SMT and mobilization are effective for neck pain. Of three systematic reviews of SMT published between 2000 and May 2005, one reached a positive conclusion, and a 2004 Cochrane review () found that SMT and mobilization are beneficial only when combined with exercise, the benefits being pain relief, functional improvement, and global perceived effect for subacute/chronic mechanical neck disorder. A 2005 review found limited evidence supporting SMT for whiplash.

Headache

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

Other

• Other. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs, and a lack of higher-quality publications supporting chiropractic management of leg conditions. A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine) and no scientific data for idiopathic adolescent scoliosis. A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality; it also found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions. Other reviews have found no evidence of benefit for baby colic, bedwetting, fibromyalgia, or menstrual cramps.

Questions

• What is this section about - is it about effectiveness of chiropractic or is it about effectiveness of SMT. As chiropractors use more than SMT, it would not be NPOV to discuss SMT as if it were chiropractic any more than we would discuss spinal injections as if it were medicine. Medicine may use injections as one option for treatment in the management of low back pain, but that is not all that medicine does, so when the evidence does not support the use of injections, we do not suggest that medicine is not effective, only that injections are not effective. I see that we have three options; either 1) move this to the Spinal manipulation article, or 2) we keep something like this and add details of effectivness of some of the treatment methods that chiropractors use. These would include massage, exercise, nutrition, elctrical muscle stimulation, ultrasound, ice, heat, stretching , trigger point work, acupuncture, etc., etc.. Or 3) we only discuss chiropractic in the general terms and we use the sources appropriately to talk about chiropractic in general without any inferences to any specific treatment modality. Of course any NPOV discussion of chiropractic effectiveness would have to address "compared to what". I think I have seen a few of those sources available. -- Dēmatt (chat) 15:07, 9 June 2008 (UTC)

• The main motivation for Chiropractic #Scientific research is, as User:Delvin Kelvin put it, "answering simple questions that the reader will have in mind" about scientific evidence[47]. He went on to say "Clearly chiropractic has some sort of benefit according to science. But as with all science views they use limitations, delineations and they are critical. Please lets have that information presented so it is clear for the reader..."[48].

Then why aren't we telling Delvin Kelvin that chiropractic uses many approaches and each approach has benefits and limitations? -- Dēmatt (chat) 13:57, 10 June 2008 (UTC)

Chiropractic currently covers several treatment forms; it's not just SMT. I agree that coverage of other treatments could be better. Eubulides (talk) 19:43, 10 June 2008 (UTC)

We agree that we need to cover them better. -- Dēmatt (chat) 02:52, 11 June 2008 (UTC)

• The material in Chiropractic#Scientific research is mostly not suitable for Spinal manipulation. Most of it is about topics other than SMT, and these topics already include exercise, self-care, advice to stay active, and others. If we can find reliable reviews of the other topics we can add them.

Agreed, this material should be under an SMT section of Low back pain, Whiplash, Neck pain, and the various symptoms that chiropractors treat that are not tiny minorities.

The material could also be briefly summarized there as well; but there is still a need to briefly summarize the effectiveness of chiropractic care here, in Chiropractic. Eubulides (talk) 19:43, 10 June 2008 (UTC)

We agree that Chiropractic should be about chiropractic care. IOWs, if we are going to label a section Low back pain, then it needs to address all the things that chiropractors do for low back pain, not just SMT. However, the brief summary should be here while the details should go in the related articles where it doesn't matter who performs them and therefore we don't have to worry about undue weight. -- Dēmatt (chat) 02:52, 11 June 2008 (UTC)

I would favor addressing all the things chiropractors do about low back pain. We need to find reliable sources, though, preferably reviews as reliable as what we have already for SMT. If there are good sources we should summarize them too. If this section gets too long we can summarize it and put it into a subarticle, but we are not there yet. Eubulides (talk) 17:58, 11 June 2008 (UTC)

• A sizeable fraction of Chiropractic#Scientific research is about SMT, but that is appropriate, as SMT is the characteristic treatment of chiropractic.

If we can balance this with everything else that chiropractors use, we might be able to present it without undue weight, but a lot has not been evaluated with reviews, so we might be relegated to primary studies to present it with fairness of tone. How would we handle it on the Physical therapy article? -- Dēmatt (chat) 13:57, 10 June 2008 (UTC)

Sorry, I'm lost. Primary studies about what? The main and most common form of treatment chiropractors use is adjustment. They also routinely encourage patients to change lifestyles, and frequently perform procedures other than adjustment, but these are less common than adjustment. So I don't see how a focus on adjustment in Chiropractic #Scientific research is undue weight. Eubulides (talk) 19:43, 10 June 2008 (UTC)

Because the section is on low back pain, not spinal adjustment. -- Dēmatt (chat) 02:52, 11 June 2008 (UTC)

There are plenty of reliable reviews and treatment guidelines on low back pain; we shouldn't need to reach down into primary sources to discuss treatment modalities. Eubulides (talk) 17:58, 11 June 2008 (UTC)

• Chiropractic #Scientific research obviously has some problems, but its problems are relatively minor compared to the rest of Chiropractic. Any problems with WP:NPOV that it has are dwarfed by the NPOV problems in Chiropractic #History, for example. Any problems it has with WP:OR or with WP:SYN are dwarfed by the OR and SYN problems in Chiropractic #Philosophy. It is not right to focus on the relatively minor problems of Chiropractic #Scientific research and to use them as an excuse to remove the section, while ignoring the larger problems elsewhere.

This article is currently a work in progress. Your opinion is just as valid as mine. As far as I am concerned, you can make whatever changes you want in article space or here. If I disagree, I'll let you know. I expect you to address my biases just as I address yours. That is what makes WP work, though sometimes dysfunctionally. If we all remain rational and reasoned, the tools that WP provides us, NPOV, VER and RS will allow us to end up with something that we are all equally satisfied with. -- Dēmatt (chat) 13:57, 10 June 2008 (UTC)

Fair enough; I'll keep that in mind. Eubulides (talk) 19:43, 10 June 2008 (UTC)

Eubulides (talk) 20:01, 9 June 2008 (UTC)

I am sure that you can understand that when we equate SMT with chiropractic, we inadvertantly equate SMT's limitations as chiropractic's limitations. IOWs, when we say that SMT is not suggested for acute low back pain, we are inadvertantly telling the reader that chiropractic is not suggested for acute low back pain. We are not even attempting to let the reader know that chiropractors are perfectly capable of managing acute low back pain using scientifically validated methods and modalities- and this is verifiable. This entire section is a violation of NPOV for this reason - giving undue weight to this modality and synthesizing it to equate to chiropractic. If we can't fix it then we need to delete it. -- Dēmatt (chat) 13:21, 10 June 2008 (UTC)

I agree that Chiropractic #Scientific research should not attempt to equate SMT with chiropractic care, and that it should make it clear that the two are not the same thing. If the wording can be improved to make this more clear, let's by all means do that. But clarifying this point is not the same as removing the mention of all research about SMT-in-general: it's common among chiropractic sources to cite and rely on such research, even when the research is derived partly from non-chiropractic data, and we should follow the experts' lead in this matter. Eubulides (talk) 19:43, 10 June 2008 (UTC)

We agree on this. -- Dēmatt (chat) 02:52, 11 June 2008 (UTC)

"Chiropractic #Scientific research obviously has some problems, but its problems are relatively minor compared to the rest of Chiropractic. Any problems with WP:NPOV that it has are dwarfed by the NPOV problems in Chiropractic #History, for example." WP:OTHERCRAPEXISTS. Just because there are problems with other sections, does not mean that we should not be dealing with this section. Consensus was not reached on this section before someone inserted it, and therefore it should be removed until we can reach such consensus - otherwise editors will continue to insert large edits without consensus. I noticed several editors voicing support for effectiveness 3C, yet that seemed to be ignored. There is a major WP:SYN violation here that has been brought up several times, and ignored several times. DigitalC (talk) 00:38, 11 June 2008 (UTC)

We agree on this. -- Dēmatt (chat) 02:52, 11 June 2008 (UTC)

• I agree with the WP:OTHERCRAPEXISTS point: I do not object to attempts to improve coverage of effectiveness. What I objected to was the procedure of removing everything until a consensus can be reached. That is a recipe for removing nearly everything in Chiropractic, my point about Chiropractic#History was merely that blanking sections is not a reasonable way to fix NPOV problems like this.
• We have a continuing problem with people inserting changes without consensus, a problem that predates my involvement with Chiropractic, and a problem that will persist indefinitely unless we figure out some way to fix it. I suspect formal mediation will be the next step in that process.
• There is some support for 3C, but also much opposition. I do not favor 3C, since it arbitrarily excludes research on SMT-in-general, even though we have reliable sources (e.g., Meeker & Haldeman) saying such research should not be excluded.

Eubulides (talk) 17:58, 11 June 2008 (UTC)

Scientific evaluation of methods 2

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which treatments are legitimate and perhaps reimbursable under managed care.

Effectiveness

Many medical procedures have not been rigorously proven to be effective, including many of the methods that chiropractors use. This does not infer that they are not effective for some conditions under certain conditions, only that their effectivenss has not been adequately studied. Particularly, though many chiropractors suggest maintenance care, the effectiveness of this type care is unknown.

Comments on "Scientific evaluation of methods 2"

Is #Scientific evaluation of methods 2 a draft of a replacement for Chiropractic #Scientific research? It's just a stub and would need much work to be an adequate replacement. Eubulides (talk) 20:01, 9 June 2008 (UTC)

Yes, Eubilides, I was just working, then got interrupted, but, no, this is not the replacement - a work in progress. -- Dēmatt (chat)

no agreement for blanking entire sections

Sections have been blanked. There is no agreement for blanking entire sections. QuackGuru 19:25, 9 June 2008 (UTC)

I agree.

• It's quite unhelpful to remove Chiropractic #Scientific research because of perceived NPOV problems. There are NPOV problems with several sections of Chiropractic. Currently Chiropractic #History is by far the worst, as it presents chiropractic as a profession attacked by mainstream medicine, and it presents mainstream medicine as being essentially clueless about disease, without fairly presenting the mainstream side. Despite these NPOV problems, which are much worse than any POV problems in Chiropractic #Scientific investigation, nobody has simply removed Chiropractic #History.
• If one could remove an entire section simply because it "has problems and no consensus"[49], then all the sections in Chiropractic could be removed. They all have problems. There is not a universal consensus for any of the sections.
• Removing Chiropractic #Scientific research also turned several citations into red links; this is a relatively minor problem but it's another reason changes like these should be discussed first.
• Removing all discussion of effectiveness is an even bigger, and to my mind more-controversial, change than QuackGuru's controversial edit of last month (which I also opposed). This is not the right way to edit this article. Effectiveness, safety, and cost-effectiveness are valid and important topics that should be covered in Chiropractic.
• Again, let's discuss major controversial changes like this before installing the change. I have put my discussion of the content (as opposed to the procedure) in #Questions above.

Eubulides (talk) 20:01, 9 June 2008 (UTC)

It hasn't been blanked. It has been moved to the talk page. I think that is better than replacing it with the version that was there previously, which I was happy with but others were not. Nothing says that we have to leave something in that has no consensus and has issues concerning NPOV and OR that we need to correct. -- Dēmatt (chat) 20:05, 9 June 2008 (UTC)

This doesn't address the above bullet points. Other sections have major POV problems and lack full consensus; should they be removed as well? Removal is an extreme step and requires better justification than a terse comment about "issues concerning NPOV and OR". Please reconsider the removal in the light of the discussion above and in #Questions. Eubulides (talk) 20:37, 9 June 2008 (UTC)

I didn't realize a conversation was going on here about this, and I rarely participate in long, tendentious discussions on controversial articles, but I undid the blanking of content. Dematt is a regular, so he doesn't deserve a template, but if I had seen this with someone I didn't know, I'd have given them a Level 2 or 3 warning about deleting content. Whatever you feel about QC's additions, a simple deletion is undeserved. OrangeMarlin ^{Talk• Contributions} 21:01, 9 June 2008 (UTC)

I think you all have misunderstood what I am doing. I am not reverting anyone's edits. I am not replacing it with anything that is controversial, I am only moving it here to the talk page till we do reach consensus. Unfortunately, I have to work in spurts and can't react to all of your issues as fast as you like, but AGF.-- Dēmatt (chat) 21:36, 9 June 2008 (UTC)

• I see; but from the point of view of the article, this was a big deletion, and big deletions can be controversial and can lack consensus too. I realize that the text being deleted is controversial, but still I'd feel more comfortable discussing an improved version here first than simply deleting the old version (leaving a big hole in the article) and waiting (for quite some time, most likely) for a new consensus. The newer version wouldn't have to be perfect; just better than what is there now.
• #Cost-effectiveness 2 contains a draft replacement for Chiropractic #Cost-benefit, the last subsection of the deleted-then-restored text. I hope this proposal addresses some of the concerns raised. This draft was proposed five days ago, discussed quite a bit in #Cost-effectiveness 2 comments, and revised in response to the discussion; no comment has been made since then. Perhaps it's time to install it? Again, it doesn't have to be perfect; just better than what's in there now. We can discuss and improve it further later.

Eubulides (talk) 23:14, 9 June 2008 (UTC)

I didn't remove the Chiropractic #Cost-benefit section, just the intro and the Effectiveness section of Scientific evaluation. I am encouraged that you changed the sourcing of first sentence, but am waiting to get to the library for that source before I comment further. Let me take a better look at both versions again before replacing them to avoid the perception of "consensus versioning" again, making it impossible for anyone to change anything. I am also ready for education 3 to go in as well if it works for you. -- Dēmatt (chat) 11:45, 10 June 2008 (UTC)

We can fix any problems in wording once you've gotten to the library and checked the citation. In the meantime there doesn't seem to be any serious objection to #Cost-effectiveness 2 and there's been no further comment on it for several days, so I installed it. Eubulides (talk) 18:32, 11 June 2008 (UTC)

Okay, I'll put in Education 3 as well since everyone but QG seems okay with that version. We can work on any other issues that aren't perfect from there. It will be good to get some of these under our belts. -- Dēmatt (chat) 03:48, 12 June 2008 (UTC)

Ah, sorry, I didn't notice that you did not remove the Safety and Cost-benefit subsections. I support either education 3 or education 7 as improvements over what's in Chiropractic now. Eubulides (talk) 19:43, 10 June 2008 (UTC)

(unindent) I've tagged several of the issues with {{Syn}} until we can fix them. I stopped after the first two paragraphs so it wouldn't look quite so bad. -- Dēmatt (chat) 15:54, 11 June 2008 (UTC)

• I don't think those tags were appropriate. Each single statement in Chiropractic#Effectiveness is directly supported by material in the corresponding section; that is, the cited sources explicitly reach the same conclusion that is summarized in the statement. So there is no WP:SYN problem at the statement level.
• I don't see any WP:SYN problem in Chiropractic#Effectiveness; but if there is one, it must be something about the overall section, a gestalt if you will, and it therefore is not a property of any single statement.
• I see now that QuackGuru removed the individual tags and kept the tag for the whole section, and I agree with that removal.

Eubulides (talk) 17:58, 11 June 2008 (UTC)

Well, the whole reason for the {{Syn}} template was to be specific about which sentences I considered needing work and remind us and motivate us to fix it since bringing it to the talk page caused some upset. But, as long as we work them through quickly and get them fixed quickly, I'll leave them off and instead work on them above again. -- Dēmatt (chat) 04:10, 12 June 2008 (UTC)

Dematt and QuackGuru (and everyone else), please don`t make significant changes without prior discussion, whether blanking sections or adding new material. Small changes such as fixing grammatical errors may not require discussion.

Eubulides, re "then all the sections of chiropractic could be removed": LOL, that reminds me of this comment by Jakew at Circumcision: "...or b) have no material whatsoever in the lead. Since the latter outcome is absurd, ..." ☺ Coppertwig (talk) 01:01, 13 June 2008 (UTC)

The problem is that we have changes that lack consensus, violate WP:NPOV and WP:SYN, that have been boldly railroaded into the article. Per WP:BRD, we should be reverting those changes, and THEN discussing it on the talk page. However, we also have an agreement by most of the editors here not to install major changes into the article without consensus, and to NOT use the BRD editing cycle, as it results in edit wars. Until EVERYONE abides by this editing style though, it won't work, and we will have to revert the significant changes that are installed into mainspace without consensus. DigitalC (talk) 04:32, 13 June 2008 (UTC)

I support the reverting of major changes installed without consensus. ☺ Coppertwig (talk) 00:53, 14 June 2008 (UTC)

I have always, in many articles, supported reverting to the version before nonconsensus edits began. Then build consensus from there. This not only upholds the principle of consensus, it makes edit warring useless, and thus eliminates one of the main problems. ——Martin^phi ☎ Ψ Φ—— 01:13, 14 June 2008 (UTC)

• Alas, for Chiropractic there is no "version before nonconsensus edits began". You can go back as far as you like: you'll never find a consensus version.
• I opposed QuackGuru's May 14 edits on procedural grounds. But on content grounds, the edits were a clear improvement over what came before. The pre-May-14 version (a version that also suffered from nonconsensus edits) had severe POV problems. Every single one of the effectiveness sources it cited were strongly pro-chiropractic, dated, low-quality, primary studies; the overall effect was astonishingly biased in favor of chiropractic. In contrast, the current Chiropractic#Effectiveness cites both supportive and critical sources, and uses recent high-quality reviews. As far as quality of sources go, it's night and day compared to the low-quality stuff that was in the older version. The new version is also less biased. It's not perfect; far from it. But it's much better than the pre-May-14 version was.
• In short, we should not go back to the pre-May-14 version; it's much worse than what we have now. We should work on improving what we have now.

Eubulides (talk) 09:23, 14 June 2008 (UTC)

"Like many other medical procedures"

I'm not sure it's fair to say that "Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective.[18] Chiropractic care, like all medical treatment, benefits from the placebo response." Mainstream medical procedures, do, in principle, need to be justified by a reasonably solid evidence base. Similarly, I think that the second sentence may be misleading because the allegation is that chiropractic may have no efficacy beyond the placebo effect. David Mestel^(Talk) 18:30, 10 June 2008 (UTC)

• Sorry, I don't follow the first point. It's true that mainstream medical procedures should be justified by a solid evidence base. But Chiropractic doesn't disagree with that; it merely says that many medical procedures have not been rigorously proven. Is your point that the wording should be changed to say that chiropractic lacks a reasonably solid evidence base? If so, what wording should be used and what reliable source would justify such a claim? Eubulides (talk) 19:43, 10 June 2008 (UTC)

• I don't follow the second point either, alas. Are you suggesting that text be added saying that it's alleged that chiropractic has no efficacy beyond the placebo? If so, could you be specific about the wording (and ideally, supply a source)? Thanks. Eubulides (talk) 19:43, 10 June 2008 (UTC)

• Sorry if I wasn't clear. What I meant to say was the allegation that "many" medical procedures haven't been proven to be effective is probably something that needs a source if it's to be included (I can obviously only see the abstract of this, but it doesn't seem really to be saying that). Wrt the second point, I think that that misleadingly implies that much medical treatment is not effective beyond the placebo effect. My proposed wording would be something like, "Opinions differ as to the efficacy of chiropractic treatment,[18] beyond the proven placebo effect.[98]". How does that sound? David Mestel^(Talk) 16:04, 11 June 2008 (UTC)

• The allegation that many medical procedures haven't been rigorously proven to be effective is made by the cited source. For quotes from the source and more discussion about this allegation, please see #Continued discussion of Scientific investigation 3C and #"Rigorously proven" above.
• I'm afraid that "Opinions differ as to the efficacy of chiropractic treatment,[18] beyond the proven placebo effect.[98]" would be WP:SYN unless we can find a single source that says that. For example, reference [98] (Kaptchuk 2002, PMID 12044130) doesn't actually say that chiropractic treatment has a proven placebo effect.
• I disagree that Chiropractic#Effectiveness's claim "Chiropractic care, like all medical treatment, benefits from the placebo response." implies that much medical treatment is not effective beyond the placebo effect. The claim merely says that treatment benefits from placebo response, which is a far cry from saying that there is no effect beyond the placebo response. That being said, if you can suggest a better wording that reflects the source while avoiding this unwanted implication, please do so.

Eubulides (talk) 17:58, 11 June 2008 (UTC)

• Fair enough; as you can imagine, it's pretty difficult working from just the abstracts.
• Ditto: I assumed from the abstract that it did.
• Hmmm. I shall think on this some more. David Mestel^(Talk) 11:30, 12 June 2008 (UTC)

History improvements

#History 2 is a draft replacement for Chiropractic #History. Please add comments in #Comments on History 2 below. Eubulides (talk) 17:22, 12 June 2008 (UTC)

History 2

Main article: Chiropractic history

File:Ddpalmer3.jpg

D.D. Palmer

Chiropractic was founded in the 1890s by Daniel David (D.D.) Palmer in Davenport, Iowa. Palmer, a magnetic healer with no formal education, hypothesized that manual manipulation of the spine could cure disease. Although initially keeping the theory a trade secret, in 1898 he began teaching it to a few students at his new Palmer School of Chiropractic. One student, his 21-year-old son Bartlett Joshua (B.J.) Palmer, became committed to promoting chiropractic, gained control of the Palmer School in 1906, and rapidly expanded its enrollment. Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a vital nervous energy or life force that represented God's presence in man; chiropractic leaders often invoked religious imagery and moral traditions, and B.J. seriously considered declaring chiropractic a religion, deciding against it partly to avoid confusion with Christian Science. Early chiropractors also tapped into the Populist movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and trusts, and accusing the American Medical Association (AMA) of trying to create a monopoly.

File:BJPalmer2.jpg

B.J. Palmer

B.J. helped shift chiropractic from craft to profession, by emphasizing formal education, establishing a professional journal in 1904, and founding a professional organization in 1906. Although most early chiropractors were "straight" and disdained scientific instruments, a minority, which B.J. scornfully called "mixers", advocated their use. In 1910 B.J. changed course and endorsed the use of X-rays for diagnosis; this resulted in a significant exodus from Palmer of more-conservative faculty and students. At the same time the mixer camp grew until by 1924 B.J. estimated that only 3,000 of the U.S.'s 25,000 chiropractors remained straight. That year, B.J. began promoting a new patented temperature-sensing device, the neurocalometer; although highly controversial among B.J.'s fellow straights, this was another sign of chiropractic's gradual acceptance of medical technology. Despite heavy opposition by organized medicine, by the 1930s chiropractic was the largest alternative healing profession in the U.S. The longstanding feud between chiropractors and medical doctors continued for decades. Until 1983, the AMA labeled chiropractic "an unscientific cult" and held that it was unethical for medical doctors to associate with an "unscientific practitioner". This culminated in a landmark 1987 decision, Wilk v. AMA, in which the court found that the the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic.

In recent decades chiropractic gained legitimacy and greater acceptance by physicians and health plans, and enjoyed a strong political base and sustained demand for services; like other forms of complementary and alternative medicine, chiropractic became more integrated into mainstream medicine. However, its future seemed uncertain: as the number of practitioners grew, evidence-based medicine insisted on treatments with demonstrated value, managed care restricted payment, and competition grew from massage therapists and other health professions. The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into alternative medicine and primary care.

Comments on History improvements

Me thinks these two sections (Medical opposition and Movement toward science) requires further improvements and can be shortened. Feel free to edit both sections. QuackGuru 18:55, 11 June 2008 (UTC)

It's not just those two subsections of Chiropractic #History. The entire History section requires further improvements and should be shortened. The section should be about three paragraphs total, and should use standard WP:SUMMARY style to summarize Chiropractic history. Relatively-minor details should be moved into Chiropractic history (if they're not there already). You can see an example of this in the way that Biology #History summarizes History of biology, or in the way that Mathematics #History summarizes History of mathematics. Eubulides (talk) 19:27, 11 June 2008 (UTC)

Chiropractic has a long history. We would loose a lot of interesting facts if we shortened the entire history section. QuackGuru 19:37, 11 June 2008 (UTC)

We would not lose any facts, any more than Biology #History loses facts with its summary of History of biology, or Mathematics #History loses facts with its summary of History of mathematics. All the less-important details would be in Chiropractic history. This is standard Wikipedia style; see WP:SUMMARY. Eubulides (talk) 19:50, 11 June 2008 (UTC)

Well, some information may be minor while other information may be important. I would like to see WP:BOLD editing on the above sections. QuackGuru 21:05, 11 June 2008 (UTC)

Chiropractic history already includes everything that is here. All we have to do is prune this one. -- Dēmatt (chat) 04:13, 12 June 2008 (UTC)

Comments on History 2

OK, I drafted a pruned version above. It still needs work (particularly, it needs coverage of the recent evidence-based and managed-care revolution), but I hope you get the idea of the desirable length anyway. Eubulides (talk) 17:18, 12 June 2008 (UTC)

I added material about the recent evidenced-based and managed-care changes, and pruned some of the older text. #History 2 is now ready to be reviewed with the idea of putting it into the article. Please note that, like #Education, licensing, and regulation, this draft contains some material not in its subarticle; the intent is to migrate this new material into the subarticle as well. Eubulides (talk) 06:36, 13 June 2008 (UTC)

When mentioning the Manga Report, put a footnote to the actual Manga Report, since that's what the reader will want to see. Also, in the text mention the jurisdiction (Ministry of Health of where?). "its future seemed uncertain" does not seem NPOV to me. Perhaps the sentence could be re-phrased beginning something like "In response to pressure from ...". ☺ Coppertwig (talk) 13:33, 13 June 2008 (UTC)

Thanks for the comment. To respond to your two points:

• Manga report. The stuff about the Manga report was inserted without comment by QuackGuru, along with a bunch of other stuff. I disagree that this level of detail belongs in a brief summary of over a century chiropractic history. Certainly citing the Manga report directly would be a mistake: we should be citing secondary sources (high-level summaries of chiropractic history), not primary documents. Also, we should not be citing documents from websites of defunct organizations to highlight their minor contributions to a big field. This detail should be moved to Chiropractic history; it should not be here. I've removed the unnecessary detail, removing any need to cite the Manga report.
• Future seemed uncertain. The cited source (Cooper & McKee 2003, PMID 12669653) says this in its introduction, after the first paragraph which talks about its successes:

"Even so, chiropractic's future seems uncertain. Recent expansions of chiropractic colleges are swelling the ranks of practitioners while managed care is restricting payment for what chiropractors do and evidence-based medicine is demanding that what they do must have demonstratable value. At the same time, chiropractors are experiencing greater competition from acupuncturists and massage therapists, whose ranks also are growing."

Several other reliable sources indicate that chiropractic's future seemed uncertain. See, for example, Phillips 2005 (PMC 1840027), Nelson et al. 2005 (PMID 16000175), the 2005 IAF report, and the debate between DeVocht 2006 (PMID 16523145) and Homola 2006 (PMID 16446588). I don't know of any reliable source saying that chiropractic's future seemed or seems certain.

Eubulides (talk) 17:20, 13 June 2008 (UTC)

Me thinks the history rewrite is a bit too short. So I expanded it a bit. QuackGuru 17:54, 13 June 2008 (UTC)

That expansion is more than just "a bit". It grows the length of the summary by about 40%. It adds material that is poorly sourced compared to what's already in there. The new material cites primary sources, which is undesirable. Let's stick with what high-level reviews say rather than telling the history of chiropractic directly from primary sources in in our own idiosyncratic way; that will help us maintain perspective and avoid bias. I am not opposed to a brief mention of further conflicts among chiropractic, or a brief expansion of evidence-based medicine, so long as they are both supported by reliable general-chiropractic-history sources. But that's not what this "a bit" change does. I am reverting it for now. If, despite these comments, you continue to prefer the much-longer version, I ask that you generate a new one and call it "History 3". Eubulides (talk) 18:42, 13 June 2008 (UTC)

History 3 improvements

Main article: Chiropractic history

File:Ddpalmer3.jpg

D.D. Palmer

Chiropractic was founded in the 1890s by Daniel David (D.D.) Palmer in Davenport, Iowa. Palmer, a magnetic healer with no formal education, hypothesized that manual manipulation of the spine could cure disease. Although initially keeping the theory a trade secret, in 1898 he began teaching it to a few students at his new Palmer School of Chiropractic. One student, his 21-year-old son Bartlett Joshua (B.J.) Palmer, became committed to promoting chiropractic, gained control of the Palmer School in 1906, and rapidly expanded its enrollment. Early chiropractors believed that all disease was caused by interruptions in the flow of innate intelligence, a vital nervous energy or life force that represented God's presence in man; chiropractic leaders often invoked religious imagery and moral traditions, and B.J. seriously considered declaring chiropractic a religion, deciding against it partly to avoid confusion with Christian Science. Early chiropractors also tapped into the Populist movement, emphasizing craft, hard work, competition, and advertisement, aligning themselves with the common man against intellectuals and trusts, and accusing the American Medical Association (AMA) of trying to create a monopoly.

File:BJPalmer2.jpg

B.J. Palmer

B.J. helped shift chiropractic from craft to profession, by emphasizing formal education, establishing a professional journal in 1904, and founding a professional organization in 1906. Although most early chiropractors were "straight" and disdained scientific instruments, a minority, which B.J. scornfully called "mixers", advocated their use. In 1910 B.J. changed course and endorsed the use of X-rays for diagnosis; this resulted in a significant exodus from Palmer of more-conservative faculty and students. At the same time the mixer camp grew until by 1924 B.J. estimated that only 3,000 of the U.S.'s 25,000 chiropractors remained straight. That year, B.J. began promoting a new patented temperature-sensing device, the neurocalometer; although controversial, this was another sign of chiropractic's gradual acceptance of medical technology. Despite heavy opposition by organized medicine, by the 1930s chiropractic was the largest alternative healing profession in the U.S. The longstanding feud between chiropractors and medical doctors continued for decades. Until 1983, the AMA labeled chiropractic "an unscientific cult" and held that it was unethical for medical doctors to associate with an "unscientific practitioner". This culminated in a landmark 1987 decision, Wilk v. AMA, in which the court found that the the AMA had engaged in unreasonable restraint of trade and conspiracy, and which ended the AMA's de facto boycott of chiropractic. Objective Straight chiropractors, who were an off-shoot of straights, only focused on the correction of chiropractic vertebral subluxations while traditional straights claimed that chiropractic adjustments are a plausible treatment for a wide range of diseases. Reform chiropractors were an evidence-based off-shoot of mixers who rejected traditional Palmer philosophy and tended not to use alternative medicine methods. Conflicts between straights and mixers have also continued to this day.

In the first 50 years of chiropractic, there was a lack of research. The terms science and research were often used as marketing tools. Several decades would pass before research and an interest in science became evident in chiropractic. In the early 1990s there was little scientific research into chiropractic. In 1993, the Manga report funded by the Ministry of Health in Ontario strongly supported chiropractic care for lower back pain that "caused ripples throughout the traditional medical community." A 2001 study stated "The Manga report was not a controlled clinical trial but a review of the literature that offered an opinion."

In recent decades chiropractic gained legitimacy and greater acceptance by physicians and health plans, and enjoyed a strong political base and sustained demand for services; like other forms of complementary and alternative medicine, chiropractic became more integrated into mainstream medicine. However, its future seemed uncertain: evidence-based medicine insisted on treatments with demonstrated value, managed care restricted payment, and competition grew from massage therapists and other health professions. The profession responded by marketing natural products and devices more aggressively, and by reaching deeper into alternative medicine and primary care.

Comments on History 3 improvements

Here is another choice for editors to review. The history of chiropractic should tell a story. For example, the landmark Manga report is part of the story. This draft 3 could be a good replacement for Chiropractic #History. Feel free make suggestions and edit the above draft 3. QuackGuru 19:50, 13 June 2008 (UTC)

• I agree that the history should tell a story. But the Manga report is not nearly so important that it deserves to be mentioned at this level, much less emphasized. The Manga report is just one of dozens of similar reports and is a small part of a long overall debate about the effectiveness and cost-effectiveness of chiropractic. For example, Cooper & McKee 2003 (PMID 12669653), a general survey that is of high quality, has about eight pages summarizing the history of evidence-based investigation of chiropractic. It cites the Manga report as one of five citations suppporting the phrase "In the early 1990s, reviews and metanalyses of more than 30 such trials concluded that SMT was safe and effective" and then goes on at considerable length (about three pages, with dozens of citations) for what happened after that, with respect to effectiveness and cost-effectiveness. The word "Manga" never appears in the discussion; it appears only in the abovementioned citation to one of 5 sources.
• Chiropractic #History should be summarizing the likes of Cooper & McKee 2003; it should not be reaching down and emphasizing one of Cooper & McKee's dozens of citations, far more than Cooper & McKee themselves do. I am not saying that we have to follow Cooper & McKee weightings slavishly, of course; what I am saying is that Cooper & McKee's coverage of Manga suggest that #History 3's emphasis of Manga is way out of line compared to the weighting given by reliable sources.
• The Manga report is not the only problem with #History 3. It also greatly overemphasizes the "objective straight" and "reform" movements, which had a relatively minor effect on the history of chiropractic. This overemphasis, again, is not supported by reliable historical surveys of chiropractic. Cooper & McKee, for example, mention neither objective straights nor reforms in their 32-page paper (despite spending about half a page on straights and mixers).
• This exhausts the main set of differences between #History 2 and #History 3; I see no reason, supported by reliable high-level sources, to prefer #History 3 to #History 2.

Eubulides (talk) 20:28, 13 June 2008 (UTC)

• "It's future seemed uncertain" is taken out of context. I suggest restoring the context by including the following words right after it: "the ranks of practitioners swelled,".
• I think the activator is far more notable than the neurocalometer, and is not mentioned anywhere in the article. (I did a few web searches (e.g. "activator chiropractic" in google scholar) and got many times the hits for activator than for neurocalometer.) I suggest stating somewhere in the article the date of invention of the activator and the name of the inventor. E.g. this link has that info.
• I agree with Eubulides that there's too much material on straights and mixers or whatever. The Wilks thingy works well as the end of the paragraph; the other stuff coming after it seems out of place.
• I'd like to see some info on the spread of chiropractic to countries other than the U.S., and the pattern of chiropractic schools, e.g. if there was a particular time period when a lot of new schools opened; the link given above also mentions a lot of schools closing at one point. ☺ Coppertwig (talk) 00:53, 14 June 2008 (UTC)

Thanks for your comments. Here's what I did:

• In #History 2 I added "as the number of practitioners grew" after "future seemed uncertain". This is a bit less poetic than "swelled", but I thought the "swelled" would be a bit confusing for non-native English readers.
• In #History 2 I removed moved the "other stuff coming after it".

and here are some other thoughts:

• The activator is more notable in the current practice of chiropractic (and this explains your Google Scholar results), but the neurocalometer is far more notable as far as the history of chiropractic goes. See, for example, Chiropractic history: a primer, which gives a couple of sentences to the activator while giving a page and a half to the neurocalometer.
• I don't know of any good source (i.e., a high-quality recent review) for the recent (as opposed to pre-1930) history of the education of chiropractic. It's not clear to me that it's worth mentioning at this level. The above-cited chiro history primer doesn't mention it.
• Nor do I know of a good source for the expansion of chiropractic to countries other than the U.S. Again, the chiro history primer doesn't mention it.

Eubulides (talk) 09:23, 14 June 2008 (UTC)

Egads! Structure!

I am having difficulty following this talk page, and I don't think I'm alone (at least I really hope not :-p). There appears to be about 10 disputes happening all at once, and I'm having trouble following them. I'm hoping this discussion can be centralized a bit more for the sake of our collective sanity. Might this be why there is difficulty moving forward? Xavexgoem (talk) 19:05, 13 June 2008 (UTC)

What would it mean for the discussion to be "centralized"? Would it mean someone would write a brief summary of open topics, and keep it up-to-date as new topics emerged? That sounds like a lot of work, but if someone (perhaps you?) would volunteer to write and maintain such a summary, I'm sure it'd be welcome here. Eubulides (talk) 20:40, 13 June 2008 (UTC)

I'm not entirely sure. Everyone is all over the talk page. It might help to collapse (with {{collapse}} templates) or remove/archive some of the stuff from talk. But I don't know what's still disputed and what's been dealt with (I see many of the drafts have been blanked), so I'd need a quick summary (which could be used to write the summary you suggested). But right now, I'm just aiming to keep everything more compacted :-) Xavexgoem (talk) 21:03, 13 June 2008 (UTC)

• We are currently automatically archiving all threads with no activity for 10 days (recently shortened from 14 days). We could shorten the interval to 7 days, I suppose, but at some point if we keep shortening that interval it will become too short.
• I'm afraid that pretty much everything in Talk:Chiropractic is part of a dispute that is currently live. It's a contentious article, alas.

Eubulides (talk) 21:37, 13 June 2008 (UTC)

OK. I was initially thinking of collapsing some of the older headers (particularly the blanked drafts). I should probably ask for QuackGuru's input on that, though (or leave it the way it is). I think reorganizing will help a lot here. Or is communication relatively OK? Xavexgoem (talk) 22:50, 13 June 2008 (UTC)

I don't know. I am a regular commenter here and I took two weeks off. I came back today to get caught up and it is pretty unorganized. Too many versions of suggested rewrites floating around. If everything could be re-arranged and each topic of discussion somehow grouped together that would be helpful. Is it unusual/disallowed to have sub-pages for discussing particular issues (i.e. Could we create a Talk:Chiropractic/History page where we can solely discuss the proposed rewrites of the History section?) -- Levine2112 ^discuss 23:00, 13 June 2008 (UTC)

Certainly allowed, albeit a little unusual. Although it might be best to simply focus on one thing at a time for now :-) Xavexgoem (talk) 23:06, 13 June 2008 (UTC)

For examples of such pages, see Talk:Abortion/First paragraph and Wikipedia:Attribution/Role of truth. I think it's probably a good idea, at least for a few of the most active discussions. Perhaps ideally a draft would be on a subpage of its own: one advantage would be that the page history would be easier to follow. (OK, starting now I'll try to follow Eubulides' example in combining many comments in a single edit, though that also causes problems in trying to refer back to one of those comments.) A disadvantage of subpages, though, is that people might not notice them or might not take the time to go there to participate. We would need some sort of prominent template informing people of the existence of such subpages. ☺Coppertwig (talk) 00:53, 14 June 2008 (UTC)

That's my main concern: sub-pages tend to go unnoticed, and discussion tends to lag (although I'm positive this can be mitigated, but one step at a time...). I know that nearly the entire contents of this article are under dispute, but what do you (or anyone) think is the most important thing that needs discussion? I think we need a starting point :-) Xavexgoem (talk) 01:03, 14 June 2008 (UTC)

Lead rewrite

Chiropractic (from Greek chiro- χειρο- "hand-" + praktikós πρακτικός "concerned with action") is a complementary and alternative medicine health care profession that focuses on diagnosis, treatment and prevention of mechanical disorders of the musculoskeletal system and the effects of these disorders on the functions of the nervous system and general health. It emphasizes manual therapy including spinal adjustment and other joint and soft-tissue manipulation. Traditionally, it is based on the premise that a vertebral subluxation or spinal joint dysfunction can interfere with the nervous system and result in many different conditions of diminished health. Today, this alternative form of therapy examines the relationship between structure and function and its impact on neurological mechanisms in both health and disease.

Chiropractors usually obtain one of the following equivalent first professional degrees in chiropractic medicine (D.C. or D.C.M. or B.Chiro or M.Chiro). Chiropractors use a combination of treatments that are predicated on the specific needs of the individual patient. A chiropractor can develop and carry out a comprehensive treatment and management plan that can include spinal adjustments, soft tissue therapy, prescription of exercises, and health and lifestyle counseling.

Chiropractic was founded in 1895 by D. D. Palmer in the USA, and is practiced in more than 100 countries. Since its inception, chiropractic has been controversial, both within the profession and in the medical and scientific community, particularly regarding the metaphysical approach espoused by its founders and advocated by "straight" chiropractors. This same criticism may have been the catalyst that allowed some within the profession to emphasize primarily a neuromusculoskeletal approach in their educational curriculum, leading them away from the original metaphysical explanations of their predecessors towards more scientific ones.

Chiropractors have historically fallen into two main groups, "straights" and "mixers"; both have had off-shoots. Significant differences regarding scope of practice, claims made about spinal manipulation, and beliefs regarding professional integration, differentiate the various schools of thought and practice styles held within the profession. There have been internal conflicts that exist to this day. Traditional and evidence-based chiropractic beliefs range from vitalism to materialism.

The utilization of chiropractic has increased in popularity. The profession has remained unified with a continuous commitment to clinical care. Chiropractic's greatest contribution to health care may be its patient-physician relationship and hands-on treatment. Patients are usually satisfied with the treatment they received.

The principles of evidence-based medicine has grown in prominence and have been used to review research studies and generate practice guidelines. The efficacy of chiropractic treatment has not been rigorously proven. Chiropractic care is generally safe when employed skillfully and appropriately. The cost-effectiveness of maintenance chiropractic care is unknown. Vaccination remains controversial within the chiropractic community.

Comments on lead rewrite

The lead is a bit long and some parts of the lead may need a rewrite to match the changing article. Feel free to edit the above draft. Any thoughts? QuackGuru 20:33, 13 June 2008 (UTC)

References