Talk:Chiropractic/Mediation/Archive 1

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Opening statements[edit]

Please give a brief (under 200 words) statement of what your concerns are for the article and what you would like to achieve through mediation. Also, please give me a top 5 wishlist - if you could change any 5 (specific) things about the article content right now, what would they be? Shell babelfish 18:12, 6 November 2008 (UTC)

Statement by User:Eubulides[edit]

I'd like Chiropractic to become a wp:Featured article. It's already at the quality level of a wp:Good article; the main thing holding it back from formal good-article status has been ongoing edit wars over tags and content. Ideally Chiropractic should go through wp:Peer review in preparation for featured-article status.

All this will take some work. My greatest current concern for the article is that distractions over what should be easily-resolvable issues, such as whether spinal manipulation sources are directly relevant to the article, have prevented making further improvements to the article. We have wasted a large amount of time in circular discussions. My hope is that mediation will help avoid similar time-wasting in the future.

Top-5 wishlist:

  1. Featured-article (or at least good-article) status.
  2. Treatment techniques is by far the weakest section; it's just a list of techniques without much organization or motivation. It should be rewritten give a novice a better feeling for what chiropractors actually do.
  3. The article's organization can be improved. Scope of practice and Education, licensing, and regulation should be combined into a single section, since both sections are about the legal boundaries and enforcement mechanisms. Utilization, satisfaction rates, and third party coverage is a dog's-breakfast section; part of it (credibility and insurance) belongs in the single section described above, and the rest of it belongs in a slimmed down section on utilization and popularity. Vaccination is an odd-man-out section right now; its material also belongs in the merged section, I think, next to the coverage of credibility.
  4. The article needs more images.
  5. Some of the sections are bloated and could use some trimming, with material moved into subarticles. They include the combined section mentioned above, Philosophy, and Evidence basis.

Eubulides (talk) 20:31, 6 November 2008 (UTC)

Statement by User:DigitalC[edit]

I too would like to see Chiropractic reach FA status, although currently there are many obstacles in that path. Chief among those are violations of WP's core policies, including NPOV and OR. I would like to see the evidence basis section trimmed, as there is currently too much weight given to that section. I think the best way to go about this is to go back to general sources on Chiropractic, and look at how much weight they give to such topics - we should be presenting the topic as it is presented in reliable sources. Through mediation I would like to see a resolution of the OR violations, without dismissal of uninvolved editors' opinions. I would like to see the removal of any source that does not explicitly mention the topic of the article, which is Chiropractic - for we cannot assume an authors intentions, and therefore cannot determine ourselves if something is directly related or not unless it mentions the topic.DigitalC (talk) 23:33, 6 November 2008 (UTC)

Statement by User:ScienceApologist[edit]

I think that consensus is being referred to way to often and there is not enough consideration of WP:CCC and WP:CON#Exceptions. There is no way that "consensus" can override WP:V, WP:RS, WP:NPOV, etc. User:QuackGuru has patiently explained rationale. The response, to me, seems to be "I disagree, but I'm going to be silent as to why." This kind of non-communication must stop.

ScienceApologist (talk) 01:04, 7 November 2008 (UTC)

Statement by User:Levine2112[edit]

My major concern with the article should be no surprise. I think the Evidence basis section suffers from rampant WP:NOR violations. This section is ostensibly about the evidence basis of chiropractic, however, for some sources, we are using research which concludes nothing specifically about chiropractic, but rather about spinal manipulation in general. (Example 1, Example 2) By us using such research as the evidence basis of chiropractic constitutes original research because we are making an original application of the research as evidence of chiropractic; an application not necessarily intended by the research author(s).

I would like the article:

  1. to reach GA status, but feel it is impossible with such rampant WP:NOR violations in place.
  2. to become more stable.
  3. to have less violations of WP:OWN.
  4. to conform more with WP:NPOV. Right now it too often presents the critical POV as the major POV and often times neglects the neutral and supportive POVs.
  5. to deal less with minor tangential issues such as Vaccination which would be better dealt with on the tangential article rather than Chiropractic.

-- Levine2112 discuss 19:10, 7 November 2008 (UTC)

Statement by User:Y[edit]

The OR Tag[edit]

Since this seems to be the elephant in the room at the moment, lets talk about the OR tag. For editors who believe the OR tag needs to stay on the section, what are your specific reasons for the tag? Please don't offer a summary of anyone's opinion other than your own. Be very specific and offer a suggested compromise that you would accept to resolve the problem. If anyone makes a general statement like "SM isn't Chiro SM" or "But the studies don't say Chiro specifically" or "SM is related so this stuff is ok" I will immediately remove your statement and ask you to rewrite. Shell babelfish 04:33, 8 November 2008 (UTC)

Since it looks like there may be a number of specific issues we need to go over, I've changed the format a bit (per Fylsee's suggestion) so we can discuss each one on its own merits. I'd like to ask that we hold off on adding any additional sections for the time being and see what we can do to reach a compromise on these three statements. Shell babelfish 21:57, 8 November 2008 (UTC)
Since Levine2112 is proposing solutions below involving total removal and movement of material to the Spinal manipulation article, I suggest that such "solutions" be dealt with in a separate section/RfC, since it is a whole different matter. There is disagreement about whether the chiropractic article should even have an "effectiveness" section, and that matter shouldn't be part of this discussion. Make it a separate RfC. In fact, a solution to that question could make this discussion totally superfluous.
This mediation is about improving the chiropractic article by tweaking and refining content, and this subsection is about the OR tag. How can we tweak/refine the content to make it better suited, without any potential OR issues? Many of us feel there is no OR issue, and others do, but removal isn't the solution. Instead let's fix it. -- Fyslee / talk 21:58, 8 November 2008 (UTC)
@ Fyslee: If you don't agree with Levine's suggestion, you're welcome to post your own review of the situation and an alternate suggestion.
@ Levine: Stating that something should be removed from the article entirely isn't really suggesting a compromise, so perhaps you can review the situation again and find an alternative that you would accept. Shell babelfish 22:40, 8 November 2008 (UTC)
I think the format change of this discussion is a good one. Thanks, Fyslee. And I like the suggestion about just starting out with these first three and see how it goes from there. Too much at once could be overwhelming. Thanks, Shell.
At this time, I am unable to think of another suggested compromise which will eliminate the WP:NOR violation other than removing the offending passages from this article where they are being used out of the context of their sources. I do think these passages still have encyclopedic merit and that is why my suggested compromise is to retain these passages by moving them to an article which more appropriately suits them contextually. This is a compromise from just deleting these passages wholesale. That said, I am always open to considering any and all other suggestions; I just can't think of one at this time which will reconcile the NOR violation. -- Levine2112 discuss 02:01, 9 November 2008 (UTC)
Well then, we could at the least copy this to the Spinal manipulation article as an edit that is independent of these proceedings. As for the matters at hand, we'll still need to discuss them. -- Fyslee / talk 07:20, 9 November 2008 (UTC)

Low Back Pain section of Chiropractic#Effectiveness[edit]

Okay, let's take this one sentence and one source at a time starting with the Low Back Pain section of Chiropractic#Effectiveness.

Sentence 1[edit]

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.

  • Source: Inconsistent Grading of Evidence Across Countries: A Review of Low Back Pain Guidelines, Murphy et al.
  • OR issue(s): While the source does support the statement given, the statement itself is not about the subject of the article (Chiropractic) or more important, not about the subject of the article subsection (The evidence basis of the efficacy of Chiropractic for low back pain). The conclusion which we are summarizing in the article is about evidence basis of the efficacy of Spinal manipulation in general for low back pain and says nothing about chiropractic specifically. When we make the leap and assume that Murphy's conclusions can be applied to discuss the efficacy of chiropractic for low back pain (LBP), we are using the source in a manner which was not intended by the author. So even though our summary is faithful to the source, using it to discuss the efficacy of Chiropractic is to use the source out of context. From WP:OR: Take care, however, not to go beyond what is expressed in the sources or to use them in ways inconsistent with the intent of the source, such as using material out of context.
  • Suggested compromise: As this is a seemingly well summarized statement from a reliable source, we should simply move it from Chiropractic#Effectiveness to the corresponding section in Spinal manipulation where it can exist in proper context.

-- Levine2112 discuss 21:31, 8 November 2008 (UTC)

  • It may not say anything about the profession of chiropractic specifically and directly (it does include chiropractic SM...), but it does say something about "spinal manipulation" specifically and directly, and SM is definitely related to chiropractic. That was covered in the RfC. Therefore I see no specific OR issue here. It is thus related to chiropractic.
  • It is conceivable that some specific SM research, when applied in some particular and very special manner, would not be applicable at all to chiropractic, but we are not attempting to cross that bridge here, so there is still no problem. If that situation arrives here, we can deal with it then. Right now we are dealing with generalities and thus the current situation doesn't involve OR.
  • Considering that we lack sources that contradict the findings of Murphy, then they are fair game, especially since they included chiropractic spinal manipulation. If we had other sources, then we could include them to round out the picture, since the truth of the matter may lie somewhere in between.
  • The danger of OR is ever present and denying that OR is an issue now doesn't mean that it might not be a legitimate concern under the right circumstances in the future, but it's not an issue now.
-- Fyslee / talk 07:51, 9 November 2008 (UTC)
  • This is the line of reasoning which Shell specifically prohibited us from making. "SM is related so this stuff is ok". Further, this is about research and the RfC did not cover whether or not general spinal manipulation research can be applied to chiropractic. In fact, you specifically worded the RfC to not be about that. "This RfC is NOT about "research" (we are discussing that elsewhere), only the "subject" of spinal manipulation and its relation to the chiropractic profession." Perhaps we should consider creating an RfC which specifically asks the question: Can research on spinal manipulation which draws no conclusions about chiropractic be used at Chiropractic to draw conclusions about chiropractic? -- Levine2112 discuss 08:54, 9 November 2008 (UTC)
  • All of the outside editors who commented on the RfCs felt that spinal manipulation belonged in the article and was integral to understanding chiropractic.
  • All but one of the outside editors felt that general spinal manipulation studies were appropriate; a single editor suggested that studies should be specific to chiropractic spinal manipulation.
  • All of the outside editors felt that spinal manipulation should be covered in detail at its own article, but that an overview of pertinent information was necessary in this article as well.
  • In the areas reviewed, none of the outside editors agreed that the use of spinal manipulation studies in this article was original research.
  • There are several involved editors who feel very strongly that material on the efficacy of spinal manipulation is not appropriate for this article and they have argued extensively to this point. However, a review of these many discussions over the past months shows that despite the variety of arguments they have been unable to convince other involved editors, or even those editors who are not so involved. In Wikipedia parlance, this means that a general consensus has developed. So, unless there are additional reasons for the OR tag in the Effectiveness section, it needs to be removed. Shell babelfish 10:47, 9 November 2008 (UTC)
  • It is difficult to reach a compromise when our arguments are ignored or there are ground rules set that don't allow us to voice them. I would suggest the compromise in this instance is to find an additional source that draws the same conclusion, but mentions chiropractic? If such an additional source cannot be found, then can we not decide that this "fact" is not well enough established to warrant inclusion? The use of the word "continuing" in the text would imply other sources should be easy to find. --Surturz (talk) 12:42, 9 November 2008 (UTC)
  • I fully agree with Shell. The OR tag needs to go.
  • To solve the problem mentioned by Surturz, we can just remove the word "continuing" until such a source is found. That's the quickest and easiest solution. The text should follow the sources we are actually using, not any possible sources that exist somewhere else. -- Fyslee / talk 18:18, 9 November 2008 (UTC)
  • Removing the word "continuing" does not change the fact that the article quoted is a guideline for medical doctors and is not really related to chiropractors. If we really must use the reference, then perhaps removal of the 'international guidelines' part would be appropriate since it is irrelevant to chiropractors. suggested compromise "There is conflicting evidence on the efficacy of SMT for nonspecific low back pain". --Surturz (talk) 04:30, 10 November 2008 (UTC)
  • I'm not sure about your point regarding it being for MDs. Mainstream treatment guidelines are generally read and adapted for use by all mainstream professions, regardless of their possibly being originally made for MDs. It's a team effort within the mainstream, and thus all mainstream guidelines are relevant to all team members. (Added later: I assume that most chiropractors who claim to be scientific practitioners will also be following along with advances in knowledge and reading those practice guidelines.) -- Fyslee / talk 05:02, 10 November 2008 (UTC)

(outdent) Chiropractic is clearly described as an alternative medicine system in the article and I don't think anyone disagrees with that. I don't think you can make the case that chiropractic is part of mainstream medicine, and I don't think you'd want to. Therefore, it is right to question the relevance of an article which is aimed at medical doctors and not chiropractors. --Surturz (talk) 05:18, 10 November 2008 (UTC)

I agree that it is correctly classified as alternative, but the progressive portions of the profession are actively following along with modern research, and the chiropractic researchers we have quoted certainly notice practice guidelines and can learn from them, but, as the Mercy Guidelines debacle showed, they have a hard time getting straights to follow them. Chiropractic has for a long time attempted to profile itself to the public as a mainstream, scientific profession. Any chiropractor who claims to be evidence based or who claims to believe in science, should be reading practice guidelines and following them. They should be practicing according to the latest and best evidence. I have added a sentence above to make this clear. -- Fyslee / talk 06:58, 10 November 2008 (UTC)
  • It's incorrect to assert that Murphy et al. 2006 (PMID 16949948) is "aimed at medical doctors and not chiropractors". That article was published in the Journal of Manipulative and Physiological Therapeutics, an official journal of the American Chiropractic Association. The journal's stated goal is "advancement of chiropractic health care" and its audience is primarily chiropractors.
  • It's also incorrect to assert that Murphy et al. is a "guideline". It's not; it's an article about guidelines, not a guideline itself.
  • Surturz's suggested rewording seems to be based on these two incorrect assertions, which leads to obvious problems; perhaps Surturz could rephrase the suggested rewording with the corrections in mind?
  • Fyslee suggested removing the word "continuing". However, the word "continuing" is directly supported by Murphy et al., which talk about "continuing conflict of opinion" regarding efficacy of SMT (emphasis mine). Furthermore, I don't see how removing the word "continuing" would address the point that Surturz raises. Surturz is saying that the Murphy et al. does not mention chiropractic; if that claim is accurate and is a valid concern, then why would trimming a word or two from the summary of Murphy et al. address the point?

Eubulides (talk) 08:10, 10 November 2008 (UTC)

  • If my reasoning is a bit inconsistent it is because I am trying to compromise, and the mediator has prohibited me from talking about non-chiro SM. Like Levine, I don't think the sentence should be in at all, however, I'll tolerate its inclusion if you and Fyslee are willing to compromise on the wording. Despite its provenance, I don't think the article is aimed at chiropractors because I don't think chiropractors set the guidelines that the article is talking about. Defending chiropractic against bad science would be within the journal's stated goal. I agree the article is about guidelines, it is not a guideline itself. So let's go back to my suggested wording: "There is conflicting evidence on the efficacy of SMT for nonspecific low back pain". What's wrong with it? The section is about efficacy, not the accuracy of guidelines, after all. --Surturz (talk) 13:01, 10 November 2008 (UTC)
  • Chiropractors are involved with setting some of the guidelines. They don't write the guidelines all by themselves, of course; they're part of a committee that also includes other professionals. This point is not covered by Murphy et al. 2006 (PMID 16949948), but if you look at Table 3 (p. 2509) of Koes et al. 2001 (PMID 11707719), which Murphy et al. cites heavily, you'll see that chiropractors were involved in writing guidelines for the U.S., the UK, and New Zealand.
  • Even if chiropractors did not help set the gudelines, that wouldn't mean the guidelines would be irrelevant to chiropractic. Guidelines often determine whether chiropractic care will be used or reimbursed. In the UK, for example, the guidelines are shared between GPs, chiropractors, etc.
  • Murphy et al. does not really support the claim "there is conflicting evidence". What it supports is a claim that there is a conflict of opinion about the evidence. For example, on page 579 it talks about a "continuing conflict of opinion" about (among other things) "efficacy of SMT for treatment of nonspecific or uncomplicated LBP. The abstract summarizes this as "there remains a lack of consensus regarding reported efficacy of spinal manipulative therapy for the treatment of nonspecific LBP."
  • Chiropractic #Evidence basis is not just about efficacy; it's also about effectiveness, safety, cost-effectiveness, and guidelines. The section's topic sentence mentions guidelines prominently, and this is followed up at some length in the 2nd sentence. One can easily imagine an alternative organization for Chiropractic, in which guidelines are discussed in a separate section or subsection. A change along those lines might improve the article, but this of course would involve moving text around rather than deleting it.
Eubulides (talk) 01:07, 11 November 2008 (UTC)

Sentence 2a[edit]

A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail...

-- Levine2112 discuss 21:31, 8 November 2008 (UTC)

  • Same reply as above, since the same conditions and arguments are being applied. -- Fyslee / talk 07:54, 9 November 2008 (UTC)
  • This sentence actually misrepresents the article to a significant degree. The recommendation was not weak, the article says that SM is weak-to-moderately efficacious. "nonpregnant" is not relevant, that was merely a parameter of the study. "when ordinary treatments fail" is complete WP:OR - it is implied that these treatments should be considered before drugs or invasive treatments are used. Suggested compromise: "A 2007 U.S. guideline recommended Physicians consider using SM as an effective alternative therapy for chronic or subacute low back pain..." --Surturz (talk) 13:06, 9 November 2008 (UTC)
  • Without commenting on any accuracy or inaccuracy issues, I would like to commend Surturz for making a new contribution that is specific. This is the kind of comment that can lead to further discussion, rather than continuing in the same old circular arguments. -- Fyslee / talk 18:23, 9 November 2008 (UTC)
  • I completely agree and greatly appreciate the efforts to reach an acceptable phrasing that everyone can tolerate. Shell babelfish 19:02, 9 November 2008 (UTC)
  • Surturz is quite right that the text misrepresents the cited source, but that's because the citation is wrong! The text is attempting to cite the 2007 clinical practice guidelines of the American College of Physicians, but it's incorrectly citing the next article in the same journal. I tracked the problem down to this May 15 edit by CorticoSpinal, which introduced the mention of the practice guidelines along with the incorrect citation. Here is the correct citation:
Chou R, Qaseem A, Snow V; et al. (2007). "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society". Ann Intern Med. 147 (7): 478–91. PMID 17909209. 
  • All along I never bothered to check the citation because I was referring directly to the guidelines. Thanks, Surturz, for catching the bug in the citation.
  • Now, to address Surturz's point: Surturz's proposed wording is not supported by the (corrected) source. If you read the guidelines you'll see that current text in Chiropractic summarizes the source's Recommendation 7, which says:
"For patients who do not improve with self-care 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)."
  • The "weak recommendation" of the source supports the "weakly recommended" of Chiropractic.
  • The "when ordinary treatments fail" of Chiropractic is supported by the "For patients who do not improve with self-care options" in the source.
  • The "nonpregnant" of Chiropractic is supported by this quote from the source: "Children or adolescents with low back pain; pregnant women; and patients with low back pain from sources outside the back (nonspinal low back pain), fibromyalgia or other myofascial pain syndromes, and thoracic or cervical back pain are not included."

Eubulides (talk) 08:10, 10 November 2008 (UTC)

  • When the article text doesn't match the reference, you change the reference? :-) I think the "weakly recommended" is misleading because the context is in comparison to pharmaceutical treatment. ie. it is "weakly" recommended because the authors consider drugs to be superior to SMT. In terms of the actual efficacy of SMT itself, both articles say that there is moderate evidence that SMT works for low back pain. Suggested compromise: "There is moderate evidence that spinal manipulation is an effective treatment for low back pain, although it is less effective than treatment with pharmaceuticals". (with both refs) --Surturz (talk) 13:01, 10 November 2008 (UTC)
  • The strength of recommendation being "weak" is independent of whether the evaluators consider drugs to be superior to SMT. What "weak" means that the benefits and risks and burdens are finely balanced for SMT. See Table 1 of the (corrected) source.
  • The suggested compromise evidence is about evidence, not about treatment guidelines, as it is based on PMID 17909210 (the evidence review), not PMID 17909209 (the guideline). As such, I suggest putting it next to the other summaries of systematic reviews of the evidence, a list that is currently in reverse-chronological order.
  • PMID 17909210 doesn't say that SM is less effective than treatment with pharmaceuticals, as it doesn't talk about pharmaceuticals. What it does say is that it found good evidence that SM is moderately effective for chronic or subacute low back pain. So we could add something like this: "A 2007 evidence review found good evidence of moderate efficacy of SM for chronic or subacute low back pain.", citing PMID 17909210. This could be added just before the "Of four systematic reviews" sentence in Chiropractic #Effectiveness. This wouldn't affect Sentence 2a, which is about guidelines.
Eubulides (talk) 01:07, 11 November 2008 (UTC)

Sentence 2b[edit]

...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.

-- Levine2112 discuss 21:31, 8 November 2008 (UTC)

  • Same reply as above, since the same conditions and arguments are being applied. -- Fyslee / talk 07:54, 9 November 2008 (UTC)
  • This is out and out WP:OR and should be deleted, since the sentence is quoting text from the 'results' section of the article; it is not a conclusion of the article, it is a data point. The actual conclusion of the article is:

    Treatment recommendations for nonspecific LBP, particularly spinal manipulation, remain inconclusive. Guideline developers need to consider guidelines in neighboring countries and reach consensus on how evidence is graded and incorporated into guidelines. Guidelines should continue to be regularly updated to incorporate new evidence and methods of grading the evidence.

    I do not think it is good practice to encourage editors to cherry pick data out of studies, according to Wikipedia:MEDRS#Respect_secondary_sources. Pulling data points out of secondary sources is akin to using primary sources to debunk secondary sources. The article actually concludes that there is not enough evidence one way or the other for the authors to be able to recommend a change in guidelines. The current "Swedish" text above implies that there is more recent evidence to indicate that SMT should no longer be recommended. This is completely contrary to the actual conclusion of the article - the article does NOT say whether or not the Swedes did the right thing! --Surturz (talk) 13:20, 9 November 2008 (UTC)
  • The current text is entirely in line with the conclusions of the article. Murphy et al. says that treatment recommendations disagree, and the current text in Chiropractic states this accurately.
  • There is no "cherry picking" here: there is an overall statement in Chiropractic #Effectiveness that guidelines disagree (the main point), along with one (US) example of a guideline recommending SM, and another (Swedish) example of a guideline not recommending SM.
  • It would not be neutral to remove the Swedish example and keep the US example, as the main point here is that guidelines disagree.
  • It would not be helpful to remove both examples, as it's useful and illustrative to give an example of disagreement instead of to merely say that there's disagreement.
  • It might be helpful to add more text, adding the point that Murphy et al. concluded that the evidence is too weak to justify altering either US-style or Swedish-style guidelines.
Eubulides (talk) 08:10, 10 November 2008 (UTC)
  • Absolutely it would be helpful to remove the US and Swedish guideline examples, they are unnecessary. We can simply say the evidence is conflicted, there is no need to exhaustively illustrate the point. The low back section can and should be halved in size. Real scientific evidence is much more important than whether guidelines change; guidelines etc can be beholden to political interests. Delete! Delete! Delete! --Surturz (talk) 13:01, 10 November 2008 (UTC)
"A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,[1] 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.[2]"
  • As I said, I prefer keeping the text here, but it's not that strong a preference. I can go along with this change to Chiropractic, as I share your concern about length. Instead of deleting it from Wikipedia, though, I suggest moving it to Spinal manipulation, along with enough linking text to place it in context.
Eubulides (talk) 01:07, 11 November 2008 (UTC)
  • Second issue, which has been raised before, is reliability of the source. There was no 2002 Swedish Guideline, which I realized through OR. However, because of this, it is clear the Murphy is unreliable on this point. DigitalC (talk) 11:29, 16 November 2008 (UTC)

Combined suggestion 1 + 2a + 2b[edit]

Continuing from the section above, my suggested compromise is to rationalise both sentences to:

"There is moderate evidence that spinal manipulation is an effective treatment for low back pain, although it is less effective than treatment with pharmaceuticals."

and then link all three references we have discussed here (the treatment guidelines, non-pharma and US guideline articles). I feel this is delightfully NPOV. Pro-chiros would enjoy the comparison with drugs, anti-chiros would like the fact that drugs are more effective. --Surturz (talk) 02:45, 11 November 2008 (UTC)

  • I don't see how the sources in question directly support the proposed wording.
  • The proposed wording (which is about evidence) is about a different subject from Sentence 1 (which is about conflicts of opinions and guidelines), so it's not really a replacement for Sentence 1; it's a new point. As discussed above, it's reasonable to remove Sentence 2, but Sentence 1 is a key point and shouldn't be removed.
  • (a minor issue) This new wording would be out of order, as the rest of the reviews are listed in reverse chronological order.
  • As mentioned above, I suggest the following change to Chiropractic instead. The new wording about evidence is in italics; text to be moved to Spinal manipulation is struck out:
"A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,[3] 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.[2] A 2008 review found strong evidence that SM is similar in effect to medical care with exercise, and moderate evidence that SM is similar to physical therapy and other forms of conventional care.[4] A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.[5] A 2007 review found good evidence of moderate efficacy of SM for chronic or subacute low back pain."[6]
  • The italicized addition is directly supported by the following statement from the cited source, which begins the conclusions section of the source's abstract:
"Therapies with good evidence of moderate efficacy for chronic or subacute low back pain are cognitive-behavioral therapy, exercise, spinal manipulation, and interdisciplinary rehabilitation."
Eubulides (talk) 06:48, 11 November 2008 (UTC)
Eubulides could you re-frame your suggestion quoting the old text to be replaced in full and the new, replacement text you are proposing. I am tentatively supportive of your suggestion, but I am unsure as to the fate of the introductory sentence. --Surturz (talk) 00:57, 13 November 2008 (UTC)
The old text is quoted in full, in the above quote: it consists of everything that's struck out along with everything in normal text. The new text is also quoted in full, in the same quote: it consists of everything in normal text, along with everything in italics. The struck-out part would be removed, and the italics converted to normal text, before the change would be installed. Eubulides (talk) 08:47, 13 November 2008 (UTC)

Is there any point continuing mediation?[edit]

Is there any point continuing mediation if the text we are discussing is going to be edited despite the mediation process? [1], Talk:Chiropractic#Two_edit_requests_for_admins I now feel like I am wasting my time here, and this page is all some trick to keep me off the main talk page. Which is a shame, I thought the mediation was going well. --Surturz (talk) 02:52, 11 November 2008 (UTC)

In most cases, articles are not locked during mediation. In the case of the changes requested, one was simply procedural since the template was not updated when the article was changed from move to full protection. The second was due to an editor realizing that they made an error in sourcing when they originally posted a statement - WP:V is one of our key policies, so it was important to make that change for now. Editors participating in the mediation can still decide to change the statement or add additional information covered in the other source or even use the source somewhere entirely different if they think that's best. Shell babelfish 06:00, 11 November 2008 (UTC)
I am unsure about continuing this mediation as well. I feel that Shell came into this with an opinion about an illusionary consensus which has biased her ability to effectively mediate here. I honestly feel that the best way to proceed here is to create a direct RfC which is intended only for outside comments. No one who has given their opinions on this matter thus far should make the slightest peep on the RfC as there is a tendency for self-sabotage once one of us comes in and tries to "clarify" a point or "discuss" an editors' commentary. The RfC should use the three examples above, state that none of them discuss chiropractic specifcally in their conclusions whatsoever, state that there is no agreement in the scientific community about whether or not all SM research can be directly applied to chiropractic and then ask the question: "Is it OR to use such sources at Chiropractic to discuss chiropractic (even though that is not clearly the intent of the sources)?" I honestly feel that this is the only way to proceed. The well here is too poisoned and this mediation has failed before it started, in my opinion. If the mediator wasn't going to let one side discuss their cheif concern on the outset, then what is the point of mediation? -- Levine2112 discuss 18:02, 11 November 2008 (UTC)
If you still have concerns with my reading of the consensus, you are welcome to ask for a second opinion from another admin, just as you could have with the close of the RfC. This is why I cross posted the information to the main Chiropractic page where again, no one has seen fit to disagree. I know its difficult to put down the stick since you feel so strongly about the topic, but its time to move on and find ways to work together on the article.
There are quite a number of editors who are willing to try to find a way to cooperate and they are already discovering possible solutions. This is completely voluntary, so if you're not interested in this type of collaboration, you won't be penalized for not participating except for losing the ability to have input into these suggestions and compromises. Working on a mediation means accepting that you're not going to be thrilled with every solution; there will be many times that the best we can do is find a suggestion we can all tolerate. Shell babelfish 00:08, 12 November 2008 (UTC)
I think we've made some progress so far in the mediation, with what I hope will be consensus for trimming Chiropractic #Evidence basis, a trim that should improve the article. My hope is that we can continue the process. It will take considerable work to go through the section sentence by sentence to do this, but we've got time and there's no rush. I doubt whether an RfC along the suggested lines would help to either improve the article or achieve consensus. For one thing, we've already had many RfCs and we're suffering from RfC exhaustion on this topic; for another, it's likely that an RfC written in a biased way as described above, with the other side not allowed to comment, would lead to an biased result. Eubulides (talk) 18:58, 11 November 2008 (UTC)
Me thinks a good compromise would be to trim the section a bit. Do editors agree with this suggested compromise? QuackGuru 19:34, 11 November 2008 (UTC)
Make a proposal in a new section. -- Fyslee / talk 20:50, 11 November 2008 (UTC)

Proposed compromise[edit]

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

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

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

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

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

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

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

Admirable solution Coppertwig, but we have died-in-the-wool anti-chiro POV pushers here, and rather than try and change them (which won't happen) I think a better solution would be try something else. I had an idea this morning, perhaps we can have a "enmilitarized" zone here on the mediation page that allows limited edit-warring. What I am thinking is that we have a proposed version of the text which it is permissible to edit war upon, and if/when the "EMZ" becomes stable, it is incorporated into the article. I think some common sense ground rules for the EMZ would be "no reversions or repetitions" (ie. you must always change the EMZ text to a new version) and a good faith assumption by all EMZ participants that they are aiming for stable text. Just trying some lateral thinking here, because we have a group of editors that have been editing this article for quite a while and they have so far been unable to establish a useful working relationship. --Surturz (talk) 00:54, 13 November 2008 (UTC)
I actually kind of like Coppertwig's proposal here. I am open to exploring it further if other editors are aboard. -- Levine2112 discuss 01:33, 13 November 2008 (UTC)
I SAID this on the talk page. At least I remember saying it (: This isn't a compromise, it's as you say the basic solution to these kinds of things we're supposed to seek. ——Martinphi Ψ~Φ—— 01:59, 13 November 2008 (UTC)
"Some researchers..." is a violation of WP:ASF. Some researchers implies that there are researchers that disagree. "Chiropractors, on the other hand, assert that spinal manipulation by chiropractors is essentially different..." is completely unsourced and a WP:FRINGE view. It would help if references were provided with the proposed text to better evaluate the proposal. QuackGuru 02:22, 13 November 2008 (UTC)
Don't shoot the messenger? Coppertwig was clear that references would be necessary to implement this idea. I'd suggest QuackGuru, if you're interested in participating in the mediation that instead of discounting possible solutions, you do a bit of the leg work yourself to shore up the sourcing. Shell babelfish 02:32, 13 November 2008 (UTC)
A 2002 review of randomized clinical trials of SM[35] was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular;[91] however the review's authors stated that they did not consider this difference to be a significant point as research on SM is equally useful regardless of which practitioner provides it.[90]
Here is the current version in the article that is referenced. Here are a few additional references.[2][3][4][5]
The second part of proposal was: ...which don't mention chiropractic, but only if such studies have been cited by other reliable sources as sources of conclusions about chiropractic. That would essentially delete many reliable refs from the article. I think we should keep the references in the article because they are directly related to the topic of the article per WP:OR. QuackGuru 02:55, 13 November 2008 (UTC)
(outdent) See this is the problem we've been having. We have now expended over 6000 words discussing changes to two sentences. As usual it starts off going well and then someone suggests a completely new version of the text, which prompts everyone else to put in their version, and no consensus is reached. I'm going to try the limited edit war idea... --Surturz (talk) 05:09, 13 November 2008 (UTC)
  • Coppertwig's skeleton draft at first sounds like it would be a good one. But it has some problems. The most important problem is that approach taken by the skeleton draft has already been tried, and is embodied in Chiropractic now, but it obviously has not defused the situation. The embodiment in Chiropractic is in the following sentence, already quoted by QuackGuru:
"A 2002 review of randomized clinical trials of SM[7] was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular;[8] however the review's authors stated that they did not consider this difference to be a significant point as research on SM is equally useful regardless of which practitioner provides it.[9]"
  • This embodiment doesn't exactly match Coppertwig's draft wording, of course, but it is the same basic idea, and it's the closest that we have been able to approach Coppertwig's draft wording under the constraint of supporting each claim by a reliable source.
  • As for Coppertwig's proposal that we not cite source X unless we can find another source Y that cites X: there are some downsides to this proposal, which may not be immediately obvious. For example, it would make Chiropractic more out-of-date, since it would exclude sources that are too recent to have been cited by other sources.
  • I am unaware of any precedent for this sort of restriction on Wikipedia editing. I'd be more comfortable if I knew of other articles where the strategy "you can't cite X unless you can also find a Y that cites X" has been tried and has worked.
  • It might help to try out this proposal on a real example. Let's take Murphy et al. 2006 (PMID 16949948), which some editors have argued is not directly relevant to Chiropractic. Murphy et al. is cited by the following reliable source, which clearly is about chiropractic:
Wilkey A, Gregory M, Byfield D, McCarthy PW (2008). "A comparison between chiropractic management and pain clinic management for chronic low-back pain in a national health service outpatient clinic". J Altern Complement Med. 14 (5): 465–73. doi:10.1089/acm.2007.0796. PMID 18564952. 
  • The citation to Murphy et al. appears at the end of the following sentence in Wilkey et al.: "Treatment that is available for patients suffering with CLBP [chronic low back pain] appears almost inexhaustible, although the evidence for the effectiveness of many of these therapies is questionable and as such, national guidelines that have been produced vary widely with regard to the timing and type of interventions that are advised." The sentence also cites 8 other sources.
  • This citation to Murphy et al. demonstrates that it has "been cited by other reliable sources as sources of conclusions about chiropractic".
  • But let me stop now and double-check: is this the sort of procedure that is being proposed for removing some sources from Chiropractic?

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

It think that's close but the caveat of "you can't cite X unless you can also find a Y that cites X" is that Y must cite X in relation to the subject of the article. In this case, Y needs to discuss chiropractic and be citing X in the context of such a discussiion. And then, we can only cite information from X which was related to chiropractic by Y. So your example above is of Murphy cited by Wilkey. Even though Wilkey is about chiropractic, it does not necessarily mean that what it is citing of Murphy has anything to do with chiropractic. However, if we decide that in fact it does have something to do with chiropractic, then that will mean that we can cite Murphy only in the context that it is related to chiropractic by Wilkey. Just because Wilkey might correlate one aspect of Murphy with chiropractic, it doesn't make Murphy in its entirity related to chiropractic.
Maybe that's an overly strict way to go with Coppertwig's proposal, but I think that is the best way to ensure that our Wikipedia article is most reliable in its coverage of the subject. That we are not making any assumptions which could introduce misleading information into our article is of the highest importance in terms of reliability. In the end (figuratively... there is no end, right?), I feel that this will make our article as reliable and up-to-date as the sources allow us to be -- Levine2112 discuss 09:15, 13 November 2008 (UTC)
In that case it sounds like Coppertwig's proposal may have a problem, as it can be interpreted to exclude Murphy et al. even with Wilkey et al. citing Murphy. By the way, Murphy does mention chiropractic, as most of Murphy's evidence comes from chiropractic studies, so it isn't a good example of Coppertwig's proposal (which is only about "studies which don't mention chiropractic"). Still, there is something odd about an interpretation that would exclude Murphy even though chiropractic researchers publishing in a peer-reviewed journal seem to have no qualms about citing Murphy and sources similar to Murphy. Perhaps we can see whether other editors agree with this interpretation of Coppertwig's proposal. Eubulides (talk) 09:47, 13 November 2008 (UTC)
Question to Levine please, you make this above comment "However, if we decide that in fact it does have something to do with chiropractic, then that will mean that we can cite Murphy only in the context that it is related to chiropractic by Wilkey. Just because Wilkey might correlate one aspect of Murphy with chiropractic, it doesn't make Murphy in its entirity related to chiropractic.". From how I read this, it sounds like you are either contradicting yourself, Wilkey might correlate on aspect of Murphy with chiropractic, it doesn't make Murphey in it's entirity related to chiropractic, or cherry picking what should be used or you are using this to state that the ref is no good because it doesn't use the word chiropractic throughout. To me this doesn't make sense, sorry, could you explain this thought clearer for someone like me who is pretty much just trying to watch and help out with this? I read them to be usable for the chiropractic article together as stated by Eubulides and Fyslee at this point. I am having trouble understanding why this is such an issue still after so many outside opinions have agreed that this is exceptable to policy and not a violation as has been continually been stated. I will of course admit I do not understand all the medical terminologies going on here so I am basing my opinions on my own personal limited knowledge of this. (I hope what I am saying is clear enough to answer, it is a little disorganized but I couldn't find a better way of stating my question, sorry if this is a problem in advance.) Thanks for listening, --CrohnieGalTalk 13:49, 13 November 2008 (UTC)
Clarity is hard to acheive and I apologize for the confusion. I assure you that there no cherry-picking or contradiction there however. I am not sure how you can be getting confused by medical terminology as we really aren't using any and it sounds like you have a richer background in medical terminology than I do. I'm really just a layman here. It's pretty simple really.
  • Scenario 1: We have source X which doesn't mention chiropractic in its results, discussions or conclusions. Though it relied on some amount of chiropractic evidence to form its results, discussions and conclusions, the author is not stating anything specifically about chiropractic there. Can we cite the results, discussions or conclusions in our Wikipedia article to discuss chiropractic? I'd say no. It wasn't the intent of the author to discuss chiropractic (or at least we cannot assume that was his/her intent), so for us to go and use such a source as a means to discuss chiropractic, we would clearly be violating WP:NOR.
  • Scenario 2: We have the same source X from Scenario 1, only now we also have a source Y which in fact directly discusses chiropractic. And in this discussion, source Y cites source X. So what does that mean? Can we cite source Y in our article about chiropractic? Most certainly. Can we cite source X in terms of how source Y related it chiropractic? Yes, with proper attribution. Can we now cite any part of source X, even those results, discussions or conclusions not specifically correlated to chiropractic by source Y? No. Just because one aspect of source X has been related to chiropractic by source Y, does not mean that every aspect of source X is therefore related to chiropractic.
  • Scenario 3: This is when it gets a little complicated, so hopefully you are still with me. Okay, similar to Scenario 2, only now we have a source Y which only partially discusses chiropractic. Source Y discusses a couple of things, but not chiropractic exclusively. And in its discussion of one of these other topics, source Y cites source X. Can we cite source X to discuss chiropractic in terms of source Y? No. Why? Because source Y doesn't use source X to discuss chiropractic, so neither can we.
The simplest formulation for us to look at here is given to us by our own WP:NOR policy when it talks about context: Take care, however, not to go beyond what is expressed in the sources or to use them in ways inconsistent with the intent of the source, such as using material out of context. That really says it all. Just because Murphy used some chiropractic evidence -- the amount is hardly important, though Eubulides is wrong when he says, "...most of Murphy's evidence comes from chiropractic studies". Only 2 of the 21 studies looked at were about chiropractic specifically. But even if 21 of the 21 studies were about chiropractic -- it does not mean that Murphy's intent is to discuss chiropractic. And by looking at the Results, Discussion and Conclusion sections of Murphy we can see that the authors are not discussing chiropractic whatsoever. Therefore, for us to use Murphy's results, discussion and/or conclusions to discusss chiropractic goes beyond what is expressed in the source and is inconsistent with the intent of the source. But if we find some source Y which cites one of Murphy's conclusions in a discussion about chiropractic, then the intent of source Y is clearly to use the one conclusion of Murphy to discuss chiropractic and therefore we can cite that one conclusion of Murphy to discuss chiropractic in our Wikipedia article (with proper attibution to source Y, of course).
I hope this clarifies my thoughts on Coppertwig's proposal and why I feel that this will result in us writing the most reliable article about chiropractic that we can source. -- Levine2112 discuss 17:51, 13 November 2008 (UTC)
Question for Levine2112: suppose we keep Sentence 1, but give as its source Wilkey et al. (a source that we agree is about chiropractic) rather than Murphy et al. Would that fix the problem you perceive? Eubulides (talk) 18:57, 13 November 2008 (UTC)
Here is sentence 1: There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability.
The question is: Does Wilkey relate this non-chiropractic statement to chiropractic? I don't believe so because Wilkey's use of Murphy is not to say anything specific about chiropractic: Treatment that is available for patients suffering with CLBP [chronic low back pain] appears almost inexhaustible, although the evidence for the effectiveness of many of these therapies is questionable and as such, national guidelines that have been produced vary widely with regard to the timing and type of interventions that are advised. This source would however be good for the Low back pain article. I may be mistaken and Wilkey could be sourcing Murphy to say something specifically about chiropractic. If this is the case, please provide the text from Wilkey. Seemingly, however, Wilkey disagrees with sentence 1 in part (in term of applying it to chiropractic), for Wilkey's conclusions are along the lines of suggesting that chiropractic is effective at treating low back pain and related disability.
I am going to be out of the loop for awhile, but feel free to continue this discussion without me. I will be checking in, but probably won't have access to edit for the next few days. -- Levine2112 discuss 19:15, 13 November 2008 (UTC)

(outdent)

  • Wilkey et al. is a primary study about the effectiveness of chiropractic treatment, with an "Introduction" section that talks about related work and which cites Murphy et al. as noted above. Wilkey et al. has no explicit statement saying "Murphy et al. is relevant to chiropractic", or anything like that, nor would one normally expect such a statement: it's normally understood that when one source X cites another source Y, the authors of X considered Y to be directly relevant to X's topic.
  • Let's take another example, just to make sure I understand Levine2112's interpretation. Ernst 2008 (PMID 18280103), "Chiropractic: a critical evaluation", says this (p. 8):
"Table 3 gives an overview of the most up-to-date systematic reviews by indication. These systematic reviews usually include trials of spinal manipulation regardless of who administered it. Thus, they are not exclusively an evaluation of chiropractic. Collectively, their results fail to demonstrate that spinal manipulation is effective. The only possible exception is back pain. For this condition, manipulation may be as effective (or ineffective) as standard therapy."
  • Ernst's Table 3 is of 8 recent systematic reviews of spinal manipulation. 2 of those reviews were of chiropractic SM, and 6 were of any type of SM (mostly chiropractic SM, but non-chiro SM was included). As I understand it, Levine2112's interpretation would also exclude citing this part of Ernst 2008, because this part of Ernst 2008 is not exclusively about chiropractic. Am I correct?

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

Take a good look at the second sentence here, with a special eye for the way the words "not exclusively" are used:
  • "These systematic reviews usually include trials of spinal manipulation regardless of who administered it. Thus, they are not exclusively an evaluation of chiropractic."
This whole discussion has really led us into a bizarre situation, having painted us into a corner where even a study that is "an evaluation of chiropractic" gets excluded because it is "not exclusively an evaluation of chiropractic." Yes, even though it is "an evaluation of chiropractic", it isn't "exclusively" about what is most fundamental to chiropractic, namely spinal manipulation, because it is an evaluation of more than chiropractic by virtue of the fact that it includes a few studies about spinal manipulation performed by non-DCs, IOW it comments on chiropractic and "more" than it. It's conclusions most certainly deal with chiropractic's main method, and even deal with all spinal manipulation. It's really bizarre that common sense can't even get a foot in the door here because it is being disallowed by wikilawyering over a supposed OR violation. -- Fyslee / talk 05:11, 14 November 2008 (UTC)
Honestly, I would say that "common sense" sides with my position here. If a source is not exclusively evaluating chiropractic, then we cannot use such a source to exclusively evaluate chiropractic (as we are doing currently in the Chiropractic article). If it is exclusively an evaluation of spinal manipulation, common sense would dictate that the source is perfectly suitable for the Spinal manipulation article.
And one man's "wikilawyering" is another man's rational discussion of the proper adherence to Wikipedia policies. -- Levine2112 discuss 04:47, 19 November 2008 (UTC)
Let's not revisit the chiropractic SM versus general SM debate, please. Eubulides (talk) 06:11, 19 November 2008 (UTC)
It's not a matter of revisiting the debate as the debate is still ongoing. -- Levine2112 discuss 01:58, 21 November 2008 (UTC)
If I understood correctly the mediator said that the debate of this is done and a consenses reached even though a couple of you want to continue the debate further. Please correct me if I am incorrect about this Shell if you wouild, thanks, --CrohnieGalTalk 13:16, 21 November 2008 (UTC)
Levine thanks for the lengthy response, very much appreciated. I understand what you are saying but I have to disagree. Oh and for the record I too am a layman here with no medical background other than the researches I do for myself and my family for personal health reasons. The major problem I am having is that you state the refs don't mention chiropractic or only mention it a little. I've never seen the kind of arguments being made here to keep information out with the reasoning being shown. I think the closest I've seen to this type of argument was at the Stephen Barrett and Quackwatch articles and putting in or keeping out that he was not certified. Then consenses agreed that certification wasn't necessary during the time he practiced medicine. So just because a referrence does state throughout that it is about chiropractic treatments or adds other non-chiropractors in it doesn't make it unusuable to me by any policy. Just follow the refs and state what the refs state. If one ref refers to another one then put them next to each other to show what is being said. I see this argument continuing but I honestly don't see a reason to keep it out. I really think with all the outside comments and the comments that have been made throughout this long debate should end already. It is really time to allow editors to start to work on upgrading the article and to let this go. Sorry, this is just my outside opinion on the matter. I say outside opinion because other than minor comments like this and a revert or two, I don't think I have actually given any major input towards this articles. Thanks again, --CrohnieGalTalk 13:29, 19 November 2008 (UTC)
So let me get this straight, Crohnie. You are saying that this debate is similar to the "Stephen Barrett is not Board Certified" debate? In that debate, you kept the "lack of board certification" information out of the article because you said it was based on WP:OR. But here you seem to be doing a 180; flip-flopping. You want to keep the non-chiropractic SM information in the article despite the WP:OR violation. Hmmm. -- Levine2112 discuss 01:58, 21 November 2008 (UTC)

(Outdent)No, I have not done a 180. I don't appreciate your stating this at all. The debate over at Barrett was not because of WP:OR It was because it didn't matter during the time that the dr. did his practice, it was considered trivial. This is totally different in that respect. You claim that because a ref doesn't specifically use the word chiropractor then it's an WP:OR and WP:NOR problem. I disagree, as does the majority here. You beat to death the certification of Dr. Barrett even after it was shown with refs that most dr's of his time didn't have certifications. From what I understand about what is being said here, the refs compliment each other and thus are referring to chiroprators. I am showing you the difference with Dr. Barrett to this because it seems you are doing the same thing, ignoring what the other editors state and believing totally that you are right so you will argue it until finally someone says enough already. It is time to stop this already. So this argument is for naught IMHO and my main concern is that this has held up this article from going forward now for months. Sorry I am done with this for now. I don't like being told I am doing 180 on my reasoning like this when it is not true and I take great offense by it so it's time for me to move on because I don't edit in places where I find this kind of behavior that I feel is deceptive. Good luck to you all, --CrohnieGalTalk 13:16, 21 November 2008 (UTC)

Sure the debate at Barrett was over WP:OR. We had several sources - including Barrett himself - stating that in fact he failed his Board Certification exam and never retook it. But then, using original research, we found out that it wasn't common for doctors to be board certified at that time. Thus, using original research, some editors (like you) decided that it is not okay to include information in the article. Here, you are doing the exact opposite. We have spinal manipulation studies which were not intended to be applied to chiropractic, then through original research we have found some sources which say that it is okay to apply this kind of research to chiropractic. Thus, using original research, you decided that it is okay to include information in the article. Hence, you have flip-flopped. I am sorry that this upsets you. That is not my intent. I am merely showing an inconsistency in the application of Wikipedia policies. I am not commenting on you personally, so there is no need to get upset. I value your input and that is why I am takling the time to foster this conversation with you. But if you feel too emotional about it, we don't have to continue. Thanks for your input thus far. -- Levine2112 discuss 17:07, 21 November 2008 (UTC)
This page is not the right place to talk about old QuackWatch disputes. Please take up this discussion elsewhere. Also, again, this page is not the place to talk about the SM-is-OR dispute. Eubulides (talk) 20:24, 21 November 2008 (UTC)
Again, let's please not re-raise the spinal-manipulation-is-OR debate here. Eubulides (talk) 06:11, 19 November 2008 (UTC)
It's not a matter of "re"-raising the debate. It is on-going. "Re"-raising is redundant as it is raised and continues to happen. -- Levine2112 discuss 07:06, 21 November 2008 (UTC)
As I said above, I thought this issue was already taken care of except by the few who continue to bring it up. Again, Shell can you clarify? Sorry I am very annoyed right now so I am going to go. --CrohnieGalTalk 13:16, 21 November 2008 (UTC)
What? I thought the primary purpose of this page was to try to find a compromise on the SM-is-OR dispute. If not, what is this page for? How did you think it was taken care of, Crohnie? Coppertwig(talk) 00:38, 22 November 2008 (UTC)
It has been taken care of when editors have been informed that SM is related to chiropractic. QuackGuru 03:35, 22 November 2008 (UTC)
The primary purpose of this page is not to rehash the SM-is-OR dispute. It is to address the question "What specifically needs to be changed to facilitate removing the OR tag?"; see Talk:Chiropractic #Disruptive tag reverts without discussion. It is unlikely that we'll see universal agreement over an answer to that question, but we may gain consensus. The more time we spend on the SM-is-OR dispute, the less time we'll spend on gaining consensus. Eubulides (talk) 06:58, 22 November 2008 (UTC)

Arbitrary break[edit]

Hi Coppertwig, I see others have shown you links but what I went by for saying this discussion is closed is This Shell breaks down all the discussions quite well to me and gives her conclusions about it. Though the same editors are debating this conclusion still, it is still the mediators conclusions to me, thus it should end this part of the discussion.

I'd like to also add that in my opinion Levine in misrepresenting what happened with the prior debate about Barrett but more important is that back then he use policy incorrectly then as he is now. You are right when you said you had Barrett as a source but wiki linking to Barrett's comments is not allowed by policy. It's not WP:OR to check and see if the subject being discussed happened during the time span that the debate was arguing that it was needed. If I remember correctly a large amount of editors told you about a slew of policies that made the information you were pushing incorrect for the article at that time. But as has been said this isn't the place to talk about this. What I am saying is that this conversation has been going in circles now for months, with the same arguments no matter who says it should be in as the link I provide shows with Shell's nicely formed comments with all the conversations difs shown and the conclusions they come to. --CrohnieGalTalk 12:42, 22 November 2008 (UTC)

Oh, thanks for the link, Crohnie. OK, the situation seems to be this: that some regular editors of the page believe that it's OR to cite general SM results in a chiropractic effectiveness section, but that a broader consensus (or at least rough consensus) of the general community is that it's not OR and belongs in the article. I apologize, Shell, for not having noticed that conclusion earlier; I was away from this article for a period of time. If that's the situation, couldn't we agree to leave the OR tag off?
However, even in the absense of the OR tag, I think that we should not just ignore the concerns of some editors, but should strive to modify the text so that, although it may regrettably contain some citations that some editors believe to constitute OR in this context, it also contains some words that attempt to moderate that effect by placing the citations in context (e.g. ...was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular..., and perhaps other phrases along those lines, perhaps sprinkled among the paragraphs about different parts of the body, as I suggested.)
Martinphi: if you were the one to propose such a compromise first, you certainly deserve credit for it; I'm sorry I didn't remember.
Eubulides: re not citing X unless another source Y cites X: First of all, this is not very different from the WP:MEDRS idea of using secondary sources in preference to primary sources (although it's not exactly the same thing, either). What I meant was: if X mentions chiropractic, then X can be cited. If X doesn't mention chiropractic, but Y cites X while mentioning chiropractic, (e.g. Y states that X shows something about chiropractic), then according to my suggested compromise, X can be cited. I also suggested that except in those two cases, X not be cited. Eubulides, you said that Murphy mentions chiropractic and that most of Murphy's evidence comes from chiropractic studies; in that case, according to this suggestion, (and per WP:SYN, and as a secondary source), Murphy can be cited.
Oh, I think I see your point, Eubulides (9:37, 13 November) if Wilkes is generally talking about chiropractic and cites Murphy without specifically mentioning chiropractic in the same sentence as citing Murphy, then why can't we do the same?
Levine, I think you misunderstood my suggested compromise as being merely a restatement of your own position. No, it's a compromise, requiring concessions from both sides. I'm saying that if source Y mentions chiropractic while citing source X, then we can cite source X directly, even stating details from source X that were not specifically mentioned by source Y. Of course, all of this has to be done within a context of discussion and common sense, not taking things to extremes.
Fyslee and Levine: Ernst is quoted as saying, "Thus, they are not exclusively an evaluation of chiropractic." Ah, this implies that they are an evaluation of chiropractic! (Just not an "exclusive" evaluation.) I think that's Fyslee's point. So they're relevant to this article. I don't think there's anything in WP:SYNTH requiring that information be "exclusively" about the topic. Coppertwig(talk) 15:18, 22 November 2008 (UTC)
Completely my fault - I archived the discussion from here because I thought we'd actually moved past it ;) There's still a lot of room for discussion about how to handle the section best (for example, there's been a lot of good suggestions and edits below on the Low back pain section) but in general, we're trying to move past the perennial discussion about SM studies blanketly being OR in the Chiro article. Shell babelfish 19:08, 22 November 2008 (UTC)
Coppertwig, you understand my point exactly. -- Fyslee / talk 21:45, 22 November 2008 (UTC)

Limited Edit War on Chiropractic#Low back pain[edit]

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

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

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

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

  • 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.[2] A 2007 U.S. guideline weakly recommended SM as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,[10] 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.[2] A 2008 review found strong evidence that SM is similar in effect to medical care with exercise, and moderate evidence that SM is similar to physical therapy and other forms of conventional care.[4] A 2007 literature synthesis found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.[5] Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review[11] stated that SM or mobilization is no more or less effective than other standard interventions for back pain.[12] A 2008 systematic review found insufficient evidence to make any recommendations concerning medicine-assisted manipulation for chronic low back pain.[13] A 2005 systematic review found that exercise appears to be slightly effective for chronic low back pain, and that it is no more effective than no treatment or other conservative treatments for acute low back pain.[14]

Proposed text (previous version before it was substantially shortened)[edit]

  • Low back pain. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the reliability of the guidelines' recommendations.[2] A 2008 review found strong evidence that SM is similar in effect to medical care with exercise.[4] A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks;[15] a 2007 literature synthesis found good evidence supporting SM for low back pain regardless of duration, and supporting exercise for low back pain lasting more than 12 weeks.[5] Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review[16] stated that SM or mobilization is no more or less effective than other standard interventions for back pain.[12] A 2008 systematic review found insufficient evidence to make any recommendations concerning medicine-assisted manipulation for chronic low back pain.[13] A 2005 systematic review found that exercise appears to be slightly effective for chronic low back pain, and that it is no more effective than no treatment or other conservative treatments for acute low back pain.[17]

Proposed text (drastically shortened, limited to chiropractic source)[edit]

  • Low back pain. A 2007 literature synthesis found good evidence supporting chiropractic SM for low back pain regardless of duration.[5]

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

  • Low back pain. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain.[2] A 2008 review found strong evidence that SM is similar in effect to medical care with exercise.[4] A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks;[18] a 2008 literature synthesis found good evidence supporting SM for low back pain regardless of duration.[19] Of four systematic reviews published between 2000 and May 2005, only one recommended SM, and a 2004 Cochrane review[20] found that SM or mobilization is no more or less effective than other standard interventions for back pain.[12] Methods for formulating treatment guidelines for low back pain differ significantly between countries, casting some doubt on their reliability.[2]

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

Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist.[13]

to this:

Medicine-assisted manipulation, such as manipulation under anesthesia, involves sedation or local anesthetic and is done by a team that includes an anesthesiologist; a 2008 systematic review did not find enough evidence to make recommendations about its use for chronic low back pain.[21]

Discussion[edit]

  • Incorporated Eubulides suggested text as a start. --Surturz (talk) 05:29, 13 November 2008 (UTC)
  • Altered the proposal to match what I actually proposed here. The proposal was to leave the initial and final parts of the paragraph alone, and change just the middle. Eubulides (talk) 01:45, 14 November 2008 (UTC)
  • Sanctioned by mediator Shell, moved to mediation page. --Surturz (talk) 03:51, 15 November 2008 (UTC)
  • Coppertwig removed the text "casting some doubt on the guidelines' reliability", saying "I didn't find this in the source (maybe I missed it)". However, the cited source (p. 579) says, "The most surprising finding, and a factor that casts some doubt on the reliability of the recommendations made, was that the levels of evidence and/or grades of recommendation used for formulating treatment recommendations varied so significantly between countries." The recommendations in question are the recommendations made by the guidelines. I am restoring the text to "casting some doubt on the reliability of the guidelines' recommendations", which hews to the original more closely, even though I prefer the brevity of the original. Eubulides (talk) 21:06, 15 November 2008 (UTC)
  • Surturz merged the discussion of Meeker et al. 2007 (PDF) and Chou et al. 2007 into the single phrase "Two 2007 reviews found good evidence supporting SM and mobilization for low back pain and exercise for chronic low back pain". But this isn't an accurate summary of Chou et al.: it did not mention mobilization and (unlike Meeker et al.) it did not find good evidence supporting SM for acute low back pain. Chou et al. did find good evidence for subacute or chronic low back pain, but not for acute. If we're going to trim, I suggest trimming the lower-quality evidence from Meeker et al., as it's arguably not worth mentioning here. This will let us remove the phrase "one of which also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain". Similarly, we can also remove the lower-quality evidence from Bronfort et al. 2008 (PMID 18164469). This will let us remove the phrase "and moderate evidence that SM is similar to physical therapy and other forms of conventional care". We can merge the two reviews more carefully, and explain the "subacute" and "chronic", using the following wording: "A 2007 review found good evidence that SM is moderately effective for low back pain lasting more than 4 weeks; a 2007 literature synthesis found good evidence supporting SM for low back pain regardless of duration, and supporting exercise for low back pain lasting more than 12 weeks." I've made the changes suggested in this bullet. Eubulides (talk) 06:31, 16 November 2008 (UTC)
  • I'm holding off editing for the moment to let others have a go, but I'm not sure why we are going into so much pedantic detail. This is an encyclopedia article, not a literature review. The key points are that there is a fair bit of evidence that SM works for low back pain, although there are some contrary views. I'm not sure why the medicine assisted manipulation sentence is included (since it doesn't conclude anything), nor am I entirely sure why there is a sentence talking about exercise (while I am sure some chiros would prescribe exercise, I'm sure many doctors would too, so I don't think it warrants inclusion). I think the discussion about guidelines should be moved to the end, because the source article is really talking about how the guidelines are formulated, not about accuracy of the guidelines themselves (as is stated in the current text). --Surturz (talk) 03:15, 17 November 2008 (UTC)
  • This section has been substantially trimmed. It is much shorter compared to the previous version. A lot of text has been deleted. I think it is short enough. QuackGuru 06:36, 17 November 2008 (UTC)
  • While I'm fine with the way the section has been trimmed, I'm also willing to explore Surturz's suggestions for further trimming in Chiropractic; my assumption, which I think we all share, is that the deleted text can be moved to Spinal manipulation or other such article where the extra detail can be useful. (Good comments from Surturz, by the way; thanks.) The medicine-assisted-manipulation (MAM) comment is there only because there was consensus a while back that MAM should be covered in Chiropractic. Personally I don't care one way or another, but if MAM is covered, a brief note about effectiveness is in order; perhaps it'd be best to fold this into the earlier mention of MAM rather than to mention MAM again here. Removing discussion of exercise is reasonable, in the interest of brevity. Moving the guideline discussion to the end is fine too. I've made edits along these lines to the draft above. Eubulides (talk) 06:46, 17 November 2008 (UTC)
  • I added the previous version to make it easier for editors to compare both versions. QuackGuru 17:46, 17 November 2008 (UTC)
  • Why? The shorter version is the current proposal. Introducing a previous proposal confuses things. Why don't you just change the current proposed version according to the rules that have been endorsed by the mediator? --Surturz (talk) 23:29, 17 November 2008 (UTC)
  • We have a difference of opinion. I propose the medium short version is the best proposal. QuackGuru 00:38, 18 November 2008 (UTC)
  • The shorter version is still evolving; let's see where it goes before deciding. Eubulides (talk) 03:07, 18 November 2008 (UTC)
  • I apologize for removing the "casting some doubt" bit. I should have looked more thoroughly for it in the source. Coppertwig(talk) 00:55, 18 November 2008 (UTC)
  • No problem. I see Surturz went back to the shorter version. Short is good. Eubulides (talk) 03:07, 18 November 2008 (UTC)
  • Coppertwig inserted the text "Some researchers contend that research results about the efficacy of SMT in general are indicative of the efficacy of chiropractic treatment.[citation needed]" (fact tag added by Coppertwig). This text has two problems. First, the inserted claim is about efficacy of SMT in general, and therefore belongs in the paragraph that talks about that subject, not in this paragraph (which is merely about low back pain). Second, the inserted claim is unsourced. As a general rule in this area it's better to find reliable sources first, and summarize what they say, rather than summarize first and find the sources to match the summary. I took the liberty of undoing that insertion for now. Eubulides (talk) 03:07, 18 November 2008 (UTC)
  • Well, this is the whole chiro vs non-chiro SM issue, isn't it? The section purports to explain the efficacy of chiropractic of low back pain, yet we are only describing the effectiveness of general SMT on low back pain. I don't blame Coppertwig for wanting the distinction to be made. --Surturz (talk) 04:39, 18 November 2008 (UTC)
  • The low-back-pain effectiveness bullet is parallel to other bullets, one on whiplash and other neck pain, one on headache, and one on "other". SM is discussed in each of the other bullets. Concerns about chiro vs non-chiro are not specific to the low-back-pain bullet; they apply equally well to the other bullets. A much better place for such concerns is in the intro to the bullets, i.e., the first paragraph of Chiropractic #Effectiveness. The last two sentences of that paragraph are already about this issue; and Coppertwig's proposed sentence would be appropriate as a rewrite of or addition to those last two sentences. Those two sentences are well-sourced, though, whereas Coppertwig's addition is not. For reference, here are the two sentences in question: "Most research has focused on spinal manipulation (SM) in general,[9] rather than solely on chiropractic SM.[22] A 2002 review of randomized clinical trials of SM[7] was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular;[23] however the review's authors stated that they did not consider this difference to be a significant point as research on SM is equally useful regardless of which practitioner provides it.[9]" Eubulides (talk) 04:49, 18 November 2008 (UTC)
  • While I agree that a trimmed version is much better than what is currently in the article, this section does not mention chiropractic, and does not mention any other treatment modalities other than SM. As such, it is clearly much better suited for the spinal manipulation article. This article on chiropractic should not discuss the efficacy of SM any more than any other (NPOV) article on chiropractic does, or we would have a WP:UNDUE violation. DigitalC (talk) 22:49, 18 November 2008 (UTC)
  • Please see #What weight to give to effectiveness? below. Eubulides (talk) 02:02, 19 November 2008 (UTC)
  • Some may hate it, but I removed several statements from sources which are not explicitly about chiropractic, but rather spinal manipulation in general. The way this was reading before was something which was clearly suited for Spinal manipulation and was only tangentially (at best) related to Chiropractic. -- Levine2112 discuss 04:43, 19 November 2008 (UTC)
  • Using that argument, one should remove all the sources, as all the statements, even the statements supported by Meeker et al. 2007,[5] are statements about spinal manipulation in general. It wouldn't be reasonable to do that. Nor is it reasonable keep only the lowest-quality source we have on the topic, the only source that is not published in a peer-reviewed journal, merely because that source happens to be sponsored by chiropractors with the word "chiropractic" in the title. We should be using the stronger sources, not the weaker ones. I restored the more-reliable sources and the claim they support. It would be reasonable, I suppose, to remove the lowest-quality source, but I didn't take that step. Also, I ask again not to resurrect the argument about chiropractic SM versus general SM; rearguing that is not likely to lead to consensus. Eubulides (talk) 06:11, 19 November 2008 (UTC)
  • While I agree with Levine that the chiro SM vs non-chiro SM is a suppurating sore in this section, can we lower our expectations and aim for text which is merely better than the extant text. At this stage, can everyone ask themself, "would I prefer the proposed text to the current text?". If we can get everyone to answer "yes" to that question, we have consensus for a change. If we are unable to achieve that, the editorial dysfunction will continue. --Surturz (talk) 23:47, 19 November 2008 (UTC)
  • QuackGuru seems insistent that we install the current proposal into the article. Does anyone oppose its installation? ie. does anyone think it is worse than the current article text? --Surturz (talk) 07:18, 20 November 2008 (UTC)
  • It's better than what is there now for sure. Why? Because it contains less WP:OR. Yes, it still contains OR violations, but at least there is less in this version. Currently, there is only one source used in the prose which is directly related to chiropractic. The others are not. Therefore including them at Chiropractic still violated WP:NOR. -- Levine2112 discuss 01:37, 21 November 2008 (UTC)
  • There is an unreliable reference in the section per WP:MEDRS. QuackGuru 02:31, 21 November 2008 (UTC)
  • Accompanying the above comment, QuackGuru added a {{vc}} tag to the text sourced by Meeker et al. 2007.[5] I wouldn't object to removing that text and the source, so I did so. That makes the text shorter, which is an advantage. In response to "QuackGuru seems insistent that we install the current proposal into the article", I think QuackGuru has stated a preference for Talk:Chiropractic #Proposed text for low back pain; it's not clear whether QuackGuru would find the current draft acceptable. Eubulides (talk) 06:06, 21 November 2008 (UTC)
  • Congratulations. The version now contains absolutely no references that are directly related to chiropractic. The version as it stands from this edit would be perfect for the Spinal manipulation article but to try to apply these non-chiropractic sources to Chiropractic would be a violation of WP:NOR. As such I have tagged this version. I think we are misuses WP:MEDRS here. I mean a pper-reviewed, review of literature performed by the top medical researcher in the world published in the New England Journal of Medicine and studying the effects of Coca Cola on the body is actually a worse source for this article than a non-peer reviewed case study published in the Journal of Magical Thinking which looked at chiropractic's effects on the body. You guys are opting to use higher quality sources that are not directly related to the subject of this article over lower quality (but perfectly acceptable) sources which are directly related to chiropractic. In the section just below, Eubulides listed out several peer reviewed studies specifically dealing with the efficacy of chiropractic. We should be opting for those sources over sources which are not directly related to the subject at hand. I know for a fact that I can double the sources below in terms of finding other pieces of research which specifically deal with chiropractic. -- Levine2112 discuss 07:06, 21 November 2008 (UTC)
  • Again, let's not bring up the "SM-is-OR" dispute here, as it's likely to get in the way of consensus. I am removing the {{OR}} tag for that reason. If you prefer restoring the source and text that QuackGuru tagged, please do so; it was the weakest source we had, but it's still a reliable (mainstream chiropractic) source, and it's just as reasonable to include it; that is, I don't have a strong feeling about it one way or the other. Eubulides (talk) 08:12, 21 November 2008 (UTC)
  • That is the second time you have reverted my edits, Eubulides, despite the very first rule of this "Edit War" stating that there is to be no reversions. -- Levine2112 discuss 17:09, 21 November 2008 (UTC)
  • Sorry, but merely tagging the draft was not a constructive edit. Nor was deleting almost all of the draft and substituting one brief sentence supported by our weakest (non-peer-reviewed) source. I am restoring the previous version of the draft (with some minor rewording to make it shorter), and am putting the one-brief-sentence version into a new section #Proposed text (drastically shortened, limited to chiropractic source) for others to comment on as they find appropriate. In the future I will try to remember all the versions we've ever generated, and to generate a new one that differs from all the previous versions, but at some point in the not-too-distant future that rule will become a hindrance rather than a help to coming up with a compromise version. Eubulides (talk) 20:24, 21 November 2008 (UTC)
  • The last sentence beginning with 'Methods for formulating treatment guidelines" seems out of place. It would make more sense if it were put after the first sentence. The section is exteremly short and can be expanded a bit. At this point, we need to be careful to avoid adding in any references that fail to pass WP:MEDRS guidelines. Complying with WP:MEDRS will limit the use of unreliable references arguing with higher quality reviews. QuackGuru 08:01, 21 November 2008 (UTC)
  • Surturz suggested above to move that last sentence to the end. I don't have a strong feeling one way or the other; I don't think the location of that last sentence should prevent consensus. Eubulides (talk) 08:12, 21 November 2008 (UTC)
  • This edit by QuackGuru replaced "strong evidence" with "good evidence". But the cited source (Bronfort et al. 2008, PMID 18164469) says "strong evidence", not "good evidence". That paper has a specific formal meaning for "strong evidence", and we can't simply replace the "strong" with "good" ourselves. The edit also replaced "low back pain of unknown cause" by "nonspecific (i.e., unknown cause) low back pain"; it's not clear to me why we need to educate the reader about what the medical jargon "nonspecific" means here. Clearly the "good" must be changed back to "strong", but according to the ground rules I'm not allowed to make that change, as that would revert the wording back to an earlier state that it's already head. Nor can I simply revert QuackGuru's edit, for the same reason. So I made a slightly different change to fix the problem and change some other wording in an unimportant way. I hope this helps to explain why the EMZ ground rules are starting to not make sense. Eubulides (talk) 06:58, 22 November 2008 (UTC)
    • You're absolutely right, there are some changes which aren't going to make sense under the rules. My suggestion would be to start a discussion about it down here and see if there's a general consensus that strong is the proper word to use there. The rules about not reverting are really to prevent edit wars - in cases where most editors agree on an older version or want to change a certain thing back, there's no reason that can't be done. Shell babelfish 18:24, 22 November 2008 (UTC)

How come the proposed text doesn't mention chiropractic at all? which article is this written for? I am against this version.TheDoctorIsIn (talk) 17:56, 23 November 2008 (UTC)

The proposed text, like the text it replaces, is about spinal manipulation, the core aspect of chiropractic. Let's please not re-raise the discussion about whether it's WP:OR to discuss spinal manipulation in Chiropractic. Eubulides (talk) 06:35, 24 November 2008 (UTC)
talk, just to clarify... you prefer to retain the current version rather than replace it with the proposed version? --Surturz (talk) 05:03, 26 November 2008 (UTC)
  • Discussion seems to have died down. How about if we declare this bullet (on low back pain) done, install the current version into Chiropractic (moving some of the old text to Spinal manipulation etc. of course), and move on to the next bullet? Eubulides (talk) 06:54, 26 November 2008 (UTC)

No way. . I am still against this version because it does not seem to be about chiropractic. . . of course, neither does the current version. . . why do people here refuse to address this detrimental issue? We should make this about chiropractic. . . just change the language to say so. . . but make sure the sources support what we say.TheDoctorIsIn (talk) 01:23, 27 November 2008 (UTC)

  • This comment again raises the spinal-manipulation-is-OR argument, which I'd rather not discuss here. It sounds like it doesn't matter to you whether the current (longer) or proposed (shorter) version is used. If that's correct, then there's no reason not to install the shorter version; on the contrary, decreasing the amount of text should be a win, assuming you dislike the text either way. But if you prefer the longer version, could you please explain why? Eubulides (talk) 05:27, 27 November 2008 (UTC)
  • A week ago I removed the phrase "a 2007 literature synthesis found good evidence supporting SM for low back pain regardless of duration" because QuackGuru tagged the source (Meeker et al. 2007) as not being peer-reviewed. As it happens, that source has now been published in a peer-reviewed journal, as Lawrence et al. 2008 (PMID 19028250), with only relatively minor editorial changes that do not affect our summary of it. Since lack of peer review was the only objection to the source and phrase, I've restored the phrase (changing "2007" to "2008") and cited the new version of the source. Eubulides (talk) 06:25, 28 November 2008 (UTC)

We can install the shorter version. . . sure. . . but we should continue the talks on this. . . keep working to make it about chiropractic. . . not about a more general topic. I think this is why we have OR here. . . trying to associate research about spinal manipulation to chiropractic is most definitely original research.TheDoctorIsIn (talk) 17:59, 28 November 2008 (UTC)

  • Of course we can have further discussion, but it seems there is a working consensus that we can install this draft for now and then move on. I'll wait for a short while and then mention this on Talk:Chiropractic. Eubulides (talk) 18:22, 28 November 2008 (UTC)
    • Absolutely - the idea here was to edit this section until just about everyone could at least stomach it. If this shorter section is put in the article, its not a rubber stamp, nor is it an indication that this is the best that can be done, its simply that we've reached a point where everyone can at least tolerate the text and then have in-depth discussions about additional ideas for changes. If we can work through the more problematic sections this way, we can keep the article more stable and get to the point of addressing the more delicate tweaking needed. Shell babelfish 01:37, 29 November 2008 (UTC)

What weight to give to effectiveness?[edit]

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

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

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

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

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

  • I think you've misunderstood the issue. The issue is that the section currently equates "effectiveness of SM" with "effectiveness of chiropractic". Not only that, it equates "efficacy of all SM" with "efficacy of chiro SM". Chiropractors adjust more than just the spine. Also, I'm not sure that treatments such as SOT "blocking" would count as SM. They also provide non-manipulative therapies such as prescribing orthotics to fix gait, etc. That said, I don't think this article should be exhaustive in answering the question of efficacy. The basic problem is that, at the moment, we are not answering the question "does chiropractic work?", we are answering the more narrow and different question "Does generic spinal manipulation work?" --Surturz (talk) 03:15, 19 November 2008 (UTC)
  • Of course, we have seen problems with using google scholar previously. In addition, as Surturz states, the question "Does chiropractic work" (chiropractic efficacy) is different than "does spinal manipulation work" (SMT efficacy). If we do a google scholar search for chiropractic, 84,700 articles come up. Of these, only 12,900 mention the terms effectiveness or efficacy, which works out to about 15%, slightly less than the 18% you suggest we currently devote to coverage of effectiveness here. However, that still leaves the question of whether they are discussing the efficacy of chiropractic, or the efficacy of spinal manipulation. If we search google scholar for articles that contain Chiropractic, "spinal manipulation" or "spinal manipulative" AND "efficacy" or "effectiveness", only around 2,500 articles show up. That works out to be around 3%. Certainly, none of this suggests that the coverage of effectiveness should be strengthened. DigitalC (talk) 03:46, 19 November 2008 (UTC)
  • The query I did emphasized the highest-quality articles, the ones with the most citations. The queries DigitalC covered all articles, even though that only glancingly mentioned chiropractic; this is a less reliable way to estimate the most important topic in highly-referenced scholarly sources. You can see a similar effect by searching for "homeopathy" in Google Scholar; at a quick glance, all the top-10-cited articles are about effectiveness, even though less than half the articles that mention "homeopathy" also mention either "effectiveness" or "efficacy". At this point I'd rather not rediscuss the issue of chiropractic SM versus general SM. Eubulides (talk) 04:47, 19 November 2008 (UTC)
  • I don't know why the straw man impossible question "Does chiropractic work?" is now resurfacing. It's an absurd question that can't be answered. We have therefore chosen to focus on its primary method, the one and only thing upon which all chiropractors agree, and the method by which the professsion is known - spinal manipulation. That's why a discussion of its effectiveness is related to chiropractic, and why it is included in this article. -- Fyslee / talk 05:21, 19 November 2008 (UTC)
I can see how you feel that "Does chiropractic work" is a straw man, in that it is a profession, and not a treatment. However, we should only discuss chiropractic effectiveness the way sources on Chiropractic (in general) discuss effectiveness. Respectfully, I submit that we are not allowed to chose to focus on its primary method - we have to follow the sources. We have to look back to sources on Chiropractic (again, in general) to determine what weight they give to discussing the effectiveness of Chiropractic. DigitalC (talk) 00:29, 20 November 2008 (UTC)
Fyslee raises a good point. Why do we have an evidence basis/effectiveness section in the chiropractic article at all, when discussions about the evidence/effectiveness of chiropractic are "impossible"? For comparison, the article on Medicine has no evidence basis/effectiveness section. --Surturz (talk) 11:27, 22 November 2008 (UTC)
This misreads Fyslee's point. His comment concluded that a discussion of SM's effectiveness is related to chiropractic, and should be included in this article. The point is that "Does chiropractic work?" is the wrong question, for definitional reasons. A better question is "Do the treatments used by chiropractors work?"; this is the question investigated by such a large fraction of the scholarly literature on chiropractic. Eubulides (talk) 15:24, 22 November 2008 (UTC)
Surturz, we have to follow the sources. As Eubulides has shown, sources discussing chiropractic spend a fair amount of time addressing the question of effectiveness, and examine this effectiveness by examining the effectiveness of SMT. So it would violate WP:UNDUE to leave that material out. Nothing analogous is done in a major way in the sources about medicine. Coppertwig(talk) 15:37, 22 November 2008 (UTC)
Eubulides understands. My point was that we should discuss what is really meant when discussing chiropractic's effectiveness (which nearly always refers to SM), which is reworded quite nicely by Eubulides. We should adopt his wording in some manner in the article and here. Right now we have this heading:
  • Effectiveness, and the beginning of its first sentence:
Opinions differ as to the efficacy of chiropractic treatment;...
We should tweak that heading to something like:
  • Effectiveness of treatment methods, and add the word "methods" to the end of the phrase:
Opinions differ as to the efficacy of chiropractic treatment methods;...
-- Fyslee / talk 22:16, 22 November 2008 (UTC)
  • Thanks, I like your idea of adding the word "treatment" to the section header, and have some further suggestions for improvement.
  • I'm not sure what adding the word "methods" buys us. The cited source (DeVocht 2006, PMID 16523145) doesn't use the word "method" in the quote that sources the "opinions differ" claim. Here's its wording: "Nevertheless, there are different views concerning the efficacy of chiropractic treatment, which is not surprising."
  • Shorter section heads are better. If we change Effectiveness to Effectiveness of treatment methods, then for consistency we'd also need to change Safety to Safety of treatment methods, and change Cost-effectiveness to Cost-effectiveness of treatment methods, no? This would bloat the table of contents without corresponding real advantage to the reader.
  • How about this idea instead? Let's rename Evidence basis to Evidence basis for treatment. That way we can get the "treatment" in the parent node of the table of contents.
Eubulides (talk) 06:35, 24 November 2008 (UTC)
That sounds good to me. -- Fyslee / talk 06:47, 24 November 2008 (UTC)
I'm not misreading Fyslee at all, both of us agree that the current 'evidence" text only talks about spinal manipulation, it doesn't talk about the efficacy of the chiropractic profession. So why is it necessary to have a evidence/effectiveness section in the Chiropractic article, when there isn't a similar section in the Medicine article? For medical treatments, the effectiveness is discussed in the articles on the treatments themselves. So for chiropractic, if we are solely going to discuss the effectiveness of Spinal manipulation, why don't we put the evidence basis stuff in the Spinal manipulation article, rather than the chiropractic article? What is the difference between the Chiropractic and Medicine articles? --Surturz (talk) 10:37, 23 November 2008 (UTC)
You are bringing another matter into this debate, and it's not appropriate here. I have suggested the same thing many times, but it has long since been rejected as a solution. We both agree that it would be better to deal with the specific effectiveness of various treatment methods (no matter what method or profession) in the specific article, but the community has rejected that solution in this case. (It can still be done in the articles.) I have therefore not continued to beat that dead horse and have allowed consensus to form and move on. You need to do the same.
Why is it especially important to make an exception in this case? Likely because no other profession is so intimately defined by one treatment method to treat one illusory "ailment". The historical (and to some degree current) nature of chiropractic's intimate relationship to a "one cause, one cure" philosophy[24] is too strong to ignore. It would be wrong to ignore this fact, so it's getting discussed in the chiropractic article. There are myriad sources to back up this way of dealing with it, because spinal manipulation is so directly related and relevant to chiropractic. Medicine has no such relationship to any one method or philosophy. Therefore I have chosen to back out of the discussion of whether to deal with it here or only in the SM article. If someone wants to raise an RfC on the matter, I will make my voice heard, but even though I have suggested it be done several times, no one has done it, and at this point in time it would be very disruptive to do so. We are making progress, and such disruption would be improper. In fact it would be so improper that I would express that point in such an RfC.
It's time to drop the stick and back slowly away from the dead horse. Levine2112, you, other chiropractic supporters, and several SPAs and meatpuppets have been beating this dead horse for far too long, in fact way beyond the point where tendentious editing normally gets sanctioned with blocks and page bans. Just drop it and stop it. If you keep this up (ONE SINGLE MENTION MORE IS ONE TOO MANY), a topic ban for every chiropractic-related article is way overdue for each one of you. -- Fyslee / talk 18:42, 23 November 2008 (UTC)
Fyslee, your threats really are becoming tiresome. None of the rest of us feel it is necessary to threaten editors with a different viewpoint, I don't know why you think it is acceptable behaviour. Threats of administration (are you even an administrator with a right to make such threats?) do nothing to promote a harmonious editing environment. Quite the opposite. When I first started editing this article you immediately accused me of being a sockpuppet and a vandal, in violation of WP:AGF. This sort of behaviour is just going to entrench the discord on this article, as you force new editors to take sides. --Surturz (talk) 00:59, 24 November 2008 (UTC)
I am not an admin, and have no such ambitions. I'm just a concerned Wikipedian. Yes, I have used strong, but civil, language, but it's a warning, not a threat. Keep in mind that Levine2112 has just received a one week ban from Chiropractic and related talk pages, so I'm just warning that others who support him can suffer the same fate. If I didn't care about your fate, I wouldn't provide a needed warning akin to the ones provided by the admins who are watching this dispute. This continued disruption is obviously trying my patience, and as I have pointed out, it is trying the patience of the community, and the brave admins who are watching this situation have my full support in their continued efforts to calm the waters and keep disruptive elements from continually disturbing them. Only then can we make progress. -- Fyslee / talk 06:29, 24 November 2008 (UTC)

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

The effectiveness-related sources are not nearly as good as the sources already used in Chiropractic #Effectiveness. They are older primary sources, and as per WP:MEDRS and WP:RS more-recent reviews (secondary sources) should be used. Let's take as an example Cherkin et al. 1998 (PMID 9761803), the most-cited source above; it is an older primary study that is reviewed (along with 38 other randomized controlled trials) by Assendelft et al. 2004 (PMID 14973958), a Cochrane Collaboration review. Eubulides (talk) 04:20, 20 November 2008 (UTC)
Then some of the reviews are reviewing some studies that mention chiropractic specifically, even if the review itself doesn't mention chiropractic?
Good work on the scholar search, Eubulides, to establish due weight for effectiveness. And thanks for explaining about why the sentences are where they are. I had been wondering why the sentences about general vs. chiropractic SM were so far away from the paragraphs discussing the therapies. Now I get it. It's because those sentences apply to a number of different subsections (paragraphs) on different parts of the body. I had wanted to move the sentences closer to where various conclusions are stated, but now I see that that would be difficult. Well, instead, I wonder whether it would be possible to sprinkle some words and phrases here and there among the various conclusions, to hearken back to those two sentences. Things like "general SMT", "a study of chiropractors and physiotherapists", "No studies specifically of chiropractic SM exist for this", "Although this study also included some practitioners of SM other than chiropractors", etc.
Surturz, I like your suggestion to just get some kind of improvement. I'm mostly just trying to help form compromises in this discussion, and I'm busy with other things so I can't spend much time here, so don't wait for me to comment before deciding you have consensus on something. Coppertwig(talk) 01:50, 21 November 2008 (UTC)
  • Assendelft et al. is primarily about spinal manipulation; it mentions chiropractic when it lists the characteristics of included studies, but it doesn't focus on chiropractic.
  • The ordinary meaning of "Spinal manipulation" is that it refers to the therapy regardless of practitioner. The sentence "Most research has focused on spinal manipulation (SM) in general, rather than solely on chiropractic SM.", already in Chiropractic #Effectiveness, attempts to make this clear; but if that wording could be made clearer, that would be fine.
  • I don't think the article should use the phrase "general spinal manipulation" or "general SM", as those phrases are not commonly used in the literature. The literature uses the phrase "spinal manipulation" to talk about spinal manipulation in general, and so should Chiropractic.
  • I don't know where the phrase "a study of chiropractors and physiotherapists" could be inserted into the existing text (is there any such study cited?). Nor do I know of any reliable source that would support the phrase "No studies specifically of chiropractic SM exist for this". The phrase "Although this study also included some practitioners of SM other than chiropractors" sounds too much like arguing with the source. So far, we do have the well-sourced text "A 2002 review of randomized clinical trials of SM was criticized for not distinguishing between studies of SM in general, and studies on chiropractic SM in particular", which does raise the point; if the point could be made more clearly, while still remaining well-sourced, that would be fine.
Eubulides (talk) 06:06, 21 November 2008 (UTC)
Good answer, Eubulides. I don't know whether I can easily access the text of Assendelft, but I wonder whether the article could place more emphasis on the bits in Assendelft that mention chiropractic. Coppertwig(talk) 00:50, 22 November 2008 (UTC)
I'm afraid not. The bits that mention chiropractic are scattered throughout the paper, in multiple tables and bits of discussion. Gluing the bits together ourselves would constitute wp:OR. Mentioning a few bits separately would be little better than citing the primary studies ourselves. Eubulides (talk) 06:58, 22 November 2008 (UTC)

Is "strong" the proper word?[edit]

As mentioned in #Discussion above, this edit by QuackGuru replaced "strong evidence" with "good evidence". But the cited source (Bronfort et al. 2008, PMID 18164469) says "strong evidence", not "good evidence". Table 6 (p. 219) of the source defines four levels of evidence, "strong", "moderate", "limited", and "inconclusive/conflicting"; "strong" evidence is two or more randomized controlled trials with validity score at least 50, and with statistically significant results. The validity score is how well the RCT meets eight well-defined criteria, described in Table 1 (p. 216). Given all this formal machinery behind the word "strong", I'm reluctant to change it to another word like "good", unless there's a compelling reason I don't know about. Eubulides (talk) 06:35, 24 November 2008 (UTC)

Strong is proper in this situation. -- Fyslee / talk 06:48, 24 November 2008 (UTC)
I would agree that strong is better than good, in that it matches the source. DigitalC (talk) 23:56, 24 November 2008 (UTC)
I don't think it matters much to the lay reader. Personally I think it is better to match the source, but if we can get better consensus (ie. get QuackGuru on board) by using the word 'good' then so be it. We need to let go of the culture of winners/losers in editing this article. I'd like to hear from QuackGuru if he is particularly attached to the use of the word "good" rather than "strong" --Surturz (talk) 01:09, 25 November 2008 (UTC)
I am not attached to the word good. QuackGuru 01:40, 25 November 2008 (UTC)

References[edit]

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

(The following resolve otherwise-dangling references: [2] [7] [9] [13] [12] [22] )

  1. ^ Chou R, Huffman LH; American Pain Society; American College of Physicians (2007). "Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline". Ann Intern Med. 147 (7): 492–504. doi:10.1001/archinte.147.3.492. PMID 17909210. 
  2. ^ a b c d e f g h Murphy AYMT, van Teijlingen ER, Gobbi MO (2006). "Inconsistent grading of evidence across countries: a review of low back pain guidelines". J Manipulative Physiol Ther. 29 (7): 576–81, 581.e1–2. doi:10.1016/j.jmpt.2006.07.005. PMID 16949948. 
  3. ^ Chou R, Qaseem A, Snow V; et al. (2007). "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society". Ann Intern Med. 147 (7): 478–91. PMID 17909209. 
  4. ^ a b c d Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S (2008). "Evidence-informed management of chronic low back pain with spinal manipulation and mobilization". Spine J. 8 (1): 213–25. doi:10.1016/j.spinee.2007.10.023. PMID 18164469. 
  5. ^ a b c d e f Meeker W, Branson R, Bronfort G; et al. (2007). "Chiropractic management of low back pain and low back related leg complaints" (PDF). Council on Chiropractic Guidelines and Practice Parameters. Retrieved 2008-03-13. 
  6. ^ Chou R, Huffman LH; American Pain Society; American College of Physicians (2007). "Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline". Ann Intern Med. 147 (7): 492–504. PMID 17909210. 
  7. ^ a b c Meeker WC, Haldeman S (2002). "Chiropractic: a profession at the crossroads of mainstream and alternative medicine" (PDF). Ann Intern Med. 136 (3): 216–27. PMID 11827498. 
  8. ^ Ernst E (2002). "Chiropractic" (PDF). Ann Intern Med. 137 (8): 701. PMID 12379081. 
  9. ^ a b c d Meeker WC, Haldeman S (2002). "Chiropractic: in response" (PDF). Ann Intern Med. 137 (8): 702. 
  10. ^ Chou R, Qaseem A, Snow V; et al. (2007). "Diagnosis and treatment of low back pain: a joint clinical practice guideline from the American College of Physicians and the American Pain Society". Ann Intern Med. 147 (7): 478–91. PMID 17909209. 
  11. ^ Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004). "Spinal manipulative therapy for low back pain". Cochrane Database Syst Rev (1): CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958. 
  12. ^ a b c d Ernst E, Canter PH (2006). "A systematic review of systematic reviews of spinal manipulation". J R Soc Med. 99 (4): 192–6. doi:10.1258/jrsm.99.4.192. PMID 16574972. 
  13. ^ a b c d Dagenais S, Mayer J, Wooley JR, Haldeman S (2008). "Evidence-informed management of chronic low back pain with medicine-assisted manipulation". Spine J. 8 (1): 142–9. doi:10.1016/j.spinee.2007.09.010. PMID 18164462. 
  14. ^ Hayden JA, van Tulder MW, Malmivaara A, Koes BW (2005). "Exercise therapy for treatment of non-specific low back pain". Cochrane Database Syst Rev (3): CD000335. doi:10.1002/14651858.CD000335.pub2. PMID 16034851. 
  15. ^ Chou R, Huffman LH; American Pain Society; American College of Physicians (2007). "Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline". Ann Intern Med. 147 (7): 492–504. PMID 17909210. 
  16. ^ Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004). "Spinal manipulative therapy for low back pain". Cochrane Database Syst Rev (1): CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958. 
  17. ^ Hayden JA, van Tulder MW, Malmivaara A, Koes BW (2005). "Exercise therapy for treatment of non-specific low back pain". Cochrane Database Syst Rev (3): CD000335. doi:10.1002/14651858.CD000335.pub2. PMID 16034851. 
  18. ^ Chou R, Huffman LH; American Pain Society; American College of Physicians (2007). "Nonpharmacologic therapies for acute and chronic low back pain: a review of the evidence for an American Pain Society/American College of Physicians clinical practice guideline". Ann Intern Med. 147 (7): 492–504. PMID 17909210. 
  19. ^ Lawrence DJ, Meeker W, Branson R; et al. (2008). "Chiropractic management of low back pain and low back-related leg complaints: a literature synthesis". J Manipulative Physiol Ther. 31 (9): 659–74. doi:10.1016/j.jmpt.2008.10.007. PMID 19028250.  An earlier, freely readable version is in: Meeker W, Branson R, Bronfort G; et al. (2007). "Chiropractic management of low back pain and low back related leg complaints" (PDF). Council on Chiropractic Guidelines and Practice Parameters. Retrieved 2008-11-28. 
  20. ^ Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG (2004). "Spinal manipulative therapy for low back pain". Cochrane Database Syst Rev (1): CD000447. doi:10.1002/14651858.CD000447.pub2. PMID 14973958. 
  21. ^ Dagenais S, Mayer J, Wooley JR, Haldeman S (2008). "Evidence-informed management of chronic low back pain with medicine-assisted manipulation". Spine J. 8 (1): 142–9. doi:10.1016/j.spinee.2007.09.010. PMID 18164462. 
  22. ^ a b Villanueva-Russell Y (2005). "Evidence-based medicine and its implications for the profession of chiropractic". Soc Sci Med. 60 (3): 545–61. doi:10.1016/j.socscimed.2004.05.017. PMID 15550303. 
  23. ^ Ernst E (2002). "Chiropractic" (PDF). Ann Intern Med. 137 (8): 701. PMID 12379081. 
  24. ^ Joseph C. Keating, Jr., PhD. Commentary: The Meanings of Innate. J Can Chiropr Assoc 2002; 46(1)