Chiropractic/Archive 21

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Percentage of Musculoskeletal vs. Non-Musculoskeletal conditions treated by chiropractors: a scientific investigation

The argument presented that the treatment of non-musculoskeletal conditions is widespread and common in the average chiropractic practice. Yet, the evidence suggests otherwise. Please add studies below that investigates what percentage (%) of patients seek chiropractic care for musculoskeletal and non-musculoskeletal care.

"Examination of office records for patients' symptoms and diagnoses, however, reveals a near-absence of non-musculoskeletal conditions. "'No nonmusculoskeletal symptom accounted for more than 1 percent of patients' symptoms, and the three most frequently diagnosed nonmusculoskeletal conditions, asthma, otitis media, and migraine headaches, were noted for only about 1 in 200 patients.""'

Hurwitz EL, Coulter ID, Adams AH, Genovese BJ, Shekelle PG. Utilization of chiropractic services in the United States and Canada: 1985-1991. Am J Publ Hlth 1998;88:771-776. CorticoSpinal09:33, 31 May 2008 (UTC)

I am aware of the surveys showing that 90+% of treatment by chiropractors is for back pain and most of the rest for MSK pain or headaches. But, in spite of this, chiropractors, I'm not sure what percentage, seem to make claims that manipulation will help a myriad of non-MSK disorders. "The largest professional associations in the United States and Canada distribute patient brochures that make claims for the clinical art of chiropractic that are not currently justified by available scientific evidence or that are intrinsically untestable. These assertions are self-defeating because they reinforce an image of the chiropractic profession as functioning outside the boundaries of scientific behavior."http://lib.bioinfo.pl/auid:4445043 This is one of the characteristics that get the attention of skeptical 'allopaths' and motivate them to come here, perhaps! Some DCs want to be 'primary care doctors' and treat nearly everything. That philosophy is fringe, but in practice, they are mostly treating back pain...according to the analysis of office records...--CynRN ""'—CynRN""' "" 07:20, 1 June 2008 (UTC)

CynRN makes good points. In response to the original query, there's also Coulter "et al." 2002 (PMID|11805694), a more recent study by the same authors, which gave the following percentages: 41% lower back, 24% neck, 13% extremities, 6% non-musculoskeletal, 4% unspecified MSK, 4% headache, 3% disc, 3% not mentioned, 2% scoliosis, 0.4% other MSK. Eubulides08:39, 2 June 2008 (UTC)

BJD Neck Pain Task Force: Dominated by Chiropractors?

Claim:

""'The Task Force report represents the chiropractic mainstream (although the task force has some MD members, it is dominated by chiropractors). Ernst represents critics of chiropractic, which includes much of the medical mainstream, a far bigger group of people than chiropractors. Both sides make good points, and both should be fairly represented"'.

http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=prevoldid=215228264."

Considering the information below, its clear that this statement is without merit and invalidated. Thus, the argument presented above is debunked. Consequently, TaskForce, as an international, muti-disciplinary source gets more weight than the opinion of Edzard Ernst and we can put this is a FAQ so the next generation of Wikipedians don't have to go through the same dog and pony show. CorticoSpinal19:57, 30 May 2008 (UTC)

The information has merit and is not invalidated. Please see below for details. Eubulides01:08, 31 May 2008 (UTC)

Common sense dictates that indeed, the argument presented that the TaskForce represents mainstream scientific opinion and not mainstream chiropractic opinion, your personal, yet curious interpretation of the matter. CorticoSpinal08:45, 31 May 2008 (UTC)

Again, please see below for details. Eubulides08:39, 2 June 2008 (UTC)

A frequent argument made is that the Neck Pain Task Force is 'dominated by chiropractors' and is a mainstream "'chiropractic"' document. I have argued that no, the TaskForce is a mainstream "'scientific"' document. The dispute is not whether or not the Task Force is reputable and represents mainstream scientific opinion. The dispute is the allegation used by Eubulides et al. that the TaskForce is a dominated by chiropractors. This has tendentiously been pushed for now for 3 months. An analysis into the principal investigators (scientific panel) demonstrates clearly the claim is without merit (which was used to discredit and subvert the findings and weighting of the task force at Chiropractic

A quick look into the matter http://www.nptf.ualberta.ca/ here easily debunks the claim of chiropractors "dominating" the TaskForce. Looking at the advisory, scientific secretariat and admin committees, here is the breakdown, by professional designation of the principal investigators: MD=16, DC=8, DDS=1, PT=1, OT=1, PhD=6. Dual registrants were noted as such. Dominated? No. Debunked? Yes.

PS: This further proves chiropractic medicine is mainstream, btw. The leaders of the admin and scientific committees are DCs and the lead co-ordinator is a DC/MD/PhD. Yet more evidence that supports the argument that chiropractic care is part of mainstream health care. Cheers. CorticoSpinal16:22, 30 May 2008 (UTC)

http://www.nptf.ualberta.ca/ That source shows that top guys in the task force are chiropractors. The president (Haldeman) is a chiropractor. The head of its scientific secretariat (Cassidy) is a chiropractor. If the 1 admin and 1 technical guys are chiropractors, it's a pretty safe bet that the task force in general will be friendly to chiropractors, regardless of whether they have "D.C." after their name.

This can be shown in who's writing the reviews. The most important review for Chiropractic Safety is Hurwitz "et al." 2008 (PMID|18204386). Here, the lead author (Hurwitz) is a chiropractor, and 5 of 12 authors are chiropractors. Again, a chiropractor is running the show, and there is a heavy chiropractic component to the reviewers involved.

I am not at all accusing the task force of being intentionally biased or underhanded or anything like that. It's an extremely strong group and they have done good work. Still, one can't ignore the fact that unintentional biases may well be at work, and that a group with such a heavy chiropractic makeup is less likely to generate a report that is critical of chiropractic.

There are certainly some elements of mainstream medicine that are supportive of chiropractic, just as some elements of mainstream medicine support acupuncture, homeopathy, etc.; but this is not the same thing as saying that chiropractic is mainstream medicine. As we've seen, very few chiropractors agree with that assessment.

Eubulides

01:08, 31 May 2008 (UTC)

You can spin all you want but the fact remains you said it was dominated by chiropractors, which is isn't. Also your are using red herrings again ("there are certainly some elements of mainstream medicine that are supportive of chiropractic, just as some elements of mainstream medicine support acupuncture, homeopathy, etc.; but this is not the same thing as saying that chiropractic is mainstream medicine. As we've seen, very few chiropractors agree with that assessment.) I've asked that you not do that, but I guess it's more IDIDNTHEARTHAT. Besides the obvious diversion, do you have any evidence that suggests the TaskForce is produced by a fringe organization? Because if you're saying that there's a heavy chiropractic component, in an international multidisciplinary, health care document, you might have inadvertently proved my point that chiropractic is more part of mainstream health care than fringe. (PS -I'll kindly remind you again that chiropractic is not part of mainstream "'medicine"'(the profession) but moreso a part of mainstream "'health care"' (the system). It's all in the details. Also, your comment ("...a chiropractor is running the show) proves that the profession is more mainstream than fringe, but it should be noted that Dr. Haldeman a chiropractor, a neurologist (MD), and a scientist (PhD). Bottom line, are you disputing the fact that the Bone and Joint Decade is a mainstream scientific outfit? CorticoSpinal02:13, 31 May 2008 (UTC)

It is chaired by a chiropractor, and the primary author of the review in question is a chiropractor. You may not call that "domination", but I do. It's clearly high-quality work and should be cited, but it is not the definitive source in this area; there are other mainstream sources that should be cited as well, and these include Ernst as well as others. Eubulides07:56, 31 May 2008 (UTC)

"it's a pretty safe bet that the task force in general will be friendly to chiropractors, regardless of whether they have "D.C." after their name". To be clear here Eubulides, are you calling into question the scientific integrity of the interdisciplinary panelists of the World Health Organizations Bone and Joint Decade 2000–2010 Task Force on Neck Pain? CS is right on this one, this is a mainstream scientific document, not a mainstream chiropractic document. DigitalC06:30, 31 May 2008 (UTC)

No, I already said "I am not at all accusing the task force of being intentionally biased or underhanded or anything like that". Their review is consonant with mainstream chiropractic, and I would even agree that it is part of mainstream science. However, I do disagree that they represent the definitive mainstream opinion on chiropractic care: they do not. Their review represents one source among many; it is not "the definitive" source versus a bunch of "fringe" sources. Eubulides07:56, 31 May 2008 (UTC)

CS, I'm confused about whcih documents we are talking about. Ernst has several papers. Do you have links to the Task Force document and the Ernst document in question? (The link above does not work, btw). I think if we can see them together, we can better make judgements. -- Dematt Dēmatt 17:21, 30 May 2008 (UTC)

The Task Force document in question is Hurwitz "et al." 2008 (PMID|18204386). It is not freely readable, I'm afraid. It's not clear which Ernst document CorticoSpinal is referring to. Eubulides01:08, 31 May 2008 (UTC)

I'm talking specifically about the Bone and Joint Decade (2000-2010) Neck Pain Task Force. Links to it can be found http://www.boneandjointdecade.org/default.aspx?contid=1923 here and here. I shall save my rebuttal of Ernst for a separate thread, I do not want to conflate the 2 topics. PS -I believe I fixed the link in my previous comment. If you want to open another thread about Ernst (Reliability/Validity of the conclusions of Edzard Ernst regarding spinal manipulation and chiropractic care) I could post the papers and rebuttals there. CorticoSpinal17:41, 30 May 2008 (UTC)

Well, I don't think there is any question that that is a RS. I assume you are asking whether Ernst should carry more weight than the Task Force, is that correct? -- Dematt Dēmatt 17:59, 30 May 2008 (UTC)

Ahh, so the whole issue of FRINGE is whether Ernst carries as much weight as the Task Force... Well, if all things are equal, and both are considered mainstream, then I think the Task Force carries more weight just because Ernst is one person vs an entire multidisciplinary body. However, if the Task Force is fringe, then Ernst would become the mainstream opinion at this time and therefore carry more weight... -- Dematt Dēmatt 18:04, 30 May 2008 (UTC)

Yes, that's right. The question is whether the Task Force document (which is largely supportive of chiropractic care) should carry substantially more weight than critical reviews like Ernst's (which are less supportive). As I understand it, CorticoSpinal argues that the Task Force is mainstream and that Ernst etc. are fringe, hence Ernst etc. are unfairly given too much weight right now. CorticoSpinal's position disagrees with more-neutral measures like Google Scholar citation count, but he disputes that the citation counts are significant. Eubulides01:08, 31 May 2008 (UTC)

I don't think this is a logically sound argument. Regardless of the conclusions we're looking at the quality of the research document. The quality of the document depends on several things, depth, breath, solo author vs. international multidisciplinary experts, notable institutions involved, where the source is published and obviously methodological quality. The strength of the conclusions and, consequently, the weight of the paper are directly dependent on these factors. For example, one review that is written in say 1 week by one reviewer who comes to conclusion 'x' whereas another review is done over a period of 8 years by a variety of scientific experts representing various mainstream health disciplines who comes to conclusions are polar opposite 'y' should logically be weighed differently no? Thus the argument at hand isn't about citation counts, it's about the reliability, validity and the overall quality of the papers in question. The issue at hand is the Neck Pain Task Force paper a stronger paper than the paper by Edzard Ernst. I would argue that the TaskForce not only trumps the Ernst papers (whose conclusions were openly disputed and refuted) but does so rather handily and that we didn't need to waste 4 months proving this point. Your argument comes down to we should weigh a disputed paper by a known critiic with heavy bias whose conclusions are opposed by the majority of the literature equal weight and a google counter to the BJD 2008 TaskForce on Neck Pain, which according to you is fringe because it is a chiropractic document. Are you serious? CorticoSpinal05:43, 31 May 2008 (UTC)

I have never said that the Task Force review is fringe. On the contrary, I've said it's a mainstream work.

You are correct that the Task Force review (Hurwitz "et al." 2008, PMID|18204386) was done by a lot more people who undoubtedly collectively took a lot more time than Ernst 2007 (PMID|17606755). But Ernst had an advantage too: his review focuses entirely on adverse effects of SMT, whereas Hurwitz "et al." is about the much broader topic of the use, effectiveness, and safety of all noninvasive interventions for neck pain etc. If memory serves, Ernst's more-focused review, which is directly on the topic at hand, has more material on SMT safety than Hurwitz's broader review.

Ernst 2007 is not the only high-quality critical source cited on chiropractic safety; there are others, including Vohra "et al." 2007 (PMID|17178922) and Miley "et al." 2008 (PMID|18195663). These are also cited by ChiropracticSafety.

Ernst 2007 was not "refuted"; it was criticized, which is normal and expected in a contentious scientific area like this.

Most of the material in Chiropractic Safety is supported by sources favorable to chiropractic; this includes the http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf WHO guidelines on safety (the single most-heavily cited source), http://www.jcca-online.org/Client/cca/jcca.nsf/objects/jcca-v49-3-158/$file/jcca-v49-3-158.pdf Anderson-Peacock "et al." 2005 (PDF), and Thiel "et al." 2007 (PMID|17906581).

Eubulides

07:56, 31 May 2008 (UTC)

The 'favourable' sources of chiropractic seem to be misrepresented, they selectively choose evidence that brings up safety concerns without addressing any of the benefits as well.

The Ernst source has been disputed and refuted in the literature and therefore, should not be used when non-disputed sources/research are available.

The document is clearly mainstream scientific consensus, not a mainstream chiropractic document. ShirleyTO21:59, 31 May 2008 (UTC)

ChiropracticSafety is about safety, not about benefits, so the sources consulted in that section are consulted only for what they say about safety. For benefits please see ChiropracticEffectiveness and ChiropracticCost-benefit.

Ernst Canter 2006 (PMID|16574972) certainly has been criticized, just as they in turn criticized earlier work. They have not been "refuted". I am not aware of important "non-disputed sources/research" in this contentious area, except for sources published so recently there hasn't been time to publish works on the other side.

If by "the document" you mean Hurwitz "et al." 2008 (PMID|18204386), I agree that it is a mainstream work and that it's appropriate to summarize its comments on chiropractic safety in ChiropracticSafety, which is what is currently being done. I disagree with the implication that it is "the" mainstream consensus; there are other mainstream views, such as Ernst's, which also need to be represented fairly. Eubulides08:39, 2 June 2008 (UTC)

Roughly, thats my interpretation of the matters as well. Also, the Ernst papers have been refuted and rebutted (so they're disputed). We're currently giving a disputed source, whose conclusions are opposed by the majority of the literature, equal weight (if not more) with respect to crucial scientific aspects such as Safety, Efficacy, and Cost-Effectiveness. Essentially it's being used to water down scientific consensus which has consistently demonstrated that SMT/manual therapy and chiropractic care as a safe, effective and cost-effective for back pain (at a minimum) neck pain (generally) and neuromusculoskeletal complaints (globally). It's a pretty big deal. The opinion of one man can subvert and circumvent international scientific consensus at Chiropractic. This is the push Eubulides has been making over the last 4 months, the push I've been resisting for 4 months and we're now seeing it crystallize. In Canada, we'd say this issue is the "TSN Turning Point". Eubulides assessment of the TaskForce has been demonstrated to be false. He has tendentiously pursued this point for months. Hit control-F, type "dominated by chiropractors" to see how often he has used this false argument to discredit the task force and its implications for the article as a whole. CorticoSpinal18:23, 30 May 2008 (UTC) Addendum: The whole issue of FRINGE is whether or not it applies to the chiropractic profession as a whole, and whether or not chiropractic care is moreso mainstream health care or moreso fringe health care. x CorticoSpinal 18:26, 30 May 2008 (UTC)

The Task Force's work is a mainstream chiropractic document, and should be fairly summarized, but it does not represent "the international scientific consensus" nor does it represent the definitive mainstream scientific opinion. It should not be given undue weight over critical mainstream opinion. All sources in this controversial area are disputed to some extent; that is not an argument for not citing them. Eubulides01:08, 31 May 2008 (UTC)

Repeating the same argument does not advance the debate. You have suggested the Task Force was dominated by chiropractors. The evidence has proven this to be incorrect. You have suggested it's a mainstream chiropractic document (despite the fact there is a 2:1 ratio of MD to DC) thats incorrect. It's a "a multidisciplinary, international Task Force led by Prof Scott Haldeman from the University of California in Irvine and in L.A., involved more than 50 researchers based in 9 countries and represented 14 different clinical and scientific disciplines in 8 universities. The group assembled the best international research data on neck pain and related disorders – specifically more than 31,000 research citations with subsequent analysis of over 1,000 studies – making this monumental document one of the most extensive reports on the subject of neck pain ever developed, and offering the most current expert perspective on the evidence related to the treatment of neck pain."http://www.boneandjointdecade.org/default.aspx?contid=1923. So that's incorrect too. It does indeed represent mainstream scientific opinion because its written by mainstream scientific experts as illustrated above. Next, there really is no controversy in this area, besides the fact that you are disputing the weight of the task force and claiming it is mainstream chiro and not mainstream science which is clearly not the case. So, next unless you can provide a reliable source that disputes the conclusions of the TaskForce then all we are left is your protest vote which is more or less a case of IDONTLIKEIT. We do however have reliable sources that disputes Ernst's reviews. So, given that Ernst' reviews are disputed in the literature which suggests his conclusions are invalid, given that he is a one man show vs. an international panel of experts, given that the TaskForce is a mainstream scientific document, I fail to the merit in your argument that the sources should be presented with the same weight. Also, I'd please ask that you not misrepresent my argument, as you have done. Despite the severe bias, methodological flaws and invalidated conclusions I haven't argued against the inclusion of Ernst. I have argued that his conclusions represent the minority view of the literature, that he is rather extremist in his assessment of SMT and chiropractic care, and that there is quite frankly, far better research that disputes his conclusions. So, please explain to me, logically, why Ernst POV=Task Force in terms of weight. Thanks. CorticoSpinal02:04, 31 May 2008 (UTC)

I agree that repeating the same argument does not advance the debate; as this is the only new discussion topic that appears in the above comment, perhaps we can at least agree that the subject is exhausted here? Eubulides07:56, 31 May 2008 (UTC)

No, the subject is not exhausted until we've reached a definite, undisputed consensus that settles the matter once and for all. It's been 4 months of back and forth nonsense over things exactly like this. We will sit hit and get it right and then we will codify it in a FAQ or a chiropractic constitution if we will to make sure these types of tendentious, civil pov pushing arguments that is not scientifically credible nor defensible get the prominence it has here on Chiropractic. So, again, I will ask you directly: Please explain to me, logically, why Ernst POV=TaskForce in terms of weighing and impact? To be clear, please explain why you contend the impact of a disputed paper by 1 author who is known critic of SMT and chiropractic is greater than the impact of a international health document by a panel of expert scientists that has been described as the most authoritative and comprehensive, evidence-based investigation on neck pain? Because that's what this is really about. Weighing Ernst as much and more (as you content) than the TaskForce (which you cite as fringe and being a chiropractic document). CorticoSpinal08:45, 31 May 2008 (UTC)

Again, this is repeating the same argument. It's unlikely we will ever achieve "undisputed consensus"; that is too much to ask for in a controversial topic like this. Eubulides08:39, 2 June 2008 (UTC)

Eubulides, you say that "The Task Force's work is a mainstream chiropractic document, and should be fairly summarized, but it does not represent "the international scientific consensus" nor does it represent the definitive mainstream scientific opinion." and "Ernst represents critics of chiropractic, which includes much of the medical mainstream."

I'm not sure how you know either of these sentences. If you have the sources for them, then you have made your case. But they are statements. What I mean is, statements about scientific opinion and about the medical mainstream should be backed up by sources (I mean if we use that to write the article). In this large of a field, the mainstream opinion will be written somewhere, in peer reviewed articles or other RS sources. I'm just wondering how we know this. If we do know it, then this information is highly relevant. I usually edit in the paranormal, and for instance in Astrology, there is a clear and stated scientific consensus that it is wrong.

I assume you're talking about http://www.ncbi.nlm.nih.gov/pubmed/18204386 this source. This is NIH, correct? So, it was sponsored by NIH? What exactly does this Joint Decade 2000-2010 Task Force on Neck Pain represent? ——"'—— 02:53, 31 May 2008 (UTC)

Consider where the funding for the Task Force came from: http://findarticles.com/p/articles/mi_qa3987/is_200111/ai_n9014691. ScienceApologist07:45, 31 May 2008 (UTC)

The web site Martinphi cites (PMID|18204386) is just the entry in the NIH PUBMED database for the abstract of the paper in question. It has nothing to do with whether the task force was sponsored by the NIH. As ScienceApologist mentions, its funding came from places like the Canadian Chiropractic Protective Assn. and like NCMIC, a chiropractic malpractice insurance company. Eubulides07:56, 31 May 2008 (UTC)

Why shouldn't the CCPA fund it; its an important study to determine the best practices in managing neck pain, a condition treated by every chiropractor. They did this in good faith, yet your comment insinuates that some nefarious action is taken place, like the CCPA can buy off the TaskForce and swing the findings. Talk about grasping for straws. Also, are you suggesting that pharmaceutical companies don't fund the same types of studies? What exactly is your point? That the findings and conclusions of the TaskForce are in disrepute because the CCPA (which I am a proud member, they support research into the methods in chiro care) was a financial contributor to the BJD Task Force? That line of thinking is very fringe. Again, I'm thankful that you're allowing me to contrast our stances, and editing practices on critical issues here at Chiropractic. CorticoSpinal08:58, 31 May 2008 (UTC)

No, I already said "I am not at all accusing the task force of being intentionally biased or underhanded or anything like that". I don't see the relevance of whether pharmaceutical companies are nefarious. Eubulides08:39, 2 June 2008 (UTC)

Disruptive editing?

QuackGuru has gone ahead and unilaterally removed the protection tag to unilatearlly put in his preferred version of education that was against majority consensus. This is the 4th time he's gone ahead and done something similar to this during the last 4 weeks. Can someone please comment on the appropriateness of such actions? Common now, skeptics are trying to crucify me for being disruptive and completely ignore the actions of QG? Sigh. CorticoSpinal17:44, 31 May 2008 (UTC)

If you are referring to http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=216101499oldid=216101135 this, then notice that the protection expired on 17:58, 30 May 2008, see http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=prevoldid=215319080 the protection edit and http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=215319128oldid=215319080 the protected template addition --Enric Naval13:47, 1 June 2008 (UTC)

That does not negate the fact that making large wholesale changes to the page without discussing such changes first is a disruptive editing tactic, and that such edits often result in edit wars on this article. DigitalC00:37, 2 June 2008 (UTC)

CS, come on, your constant badgering of QG is getting a little old. If you're to make a comment, how about being specific. 01:39, 2 June 2008 (UTC)

POV tag

I replaced the POV tag that Martinphi placed and QuackGuru removed. This article still has significant NPOV issues in science, education and safety to say the least, but glad to say we are working our way through them. -- Dematt Dēmatt 21:04, 2 June 2008 (UTC)

Following up on that: since the entire article now has a POV tag, I http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=216708061oldid=216704405 removed the POV-section tag from Chiropractic Medical opposition, as it is now redundant (there's no point marking each section as POV if the whole article is marked as POV). At the same time I changed the date on the article's POV tag from May (Martinphi's placement) back to February, since the article has had some sort of POV tag on it continuously since February. Eubulides21:20, 2 June 2008 (UTC)

I agree with that. -- Dematt Dēmatt 21:36, 2 June 2008 (UTC)

Education, licensing, and regulation 1

This draft I wrote and now deleted is obsolete. QuackGuru19:33, 2 June 2008 (UTC)

Education, Licensing, Regulation 2

The first school of chiropractic was opened in 1896 in Davenport, Iowa, USA.http://www.chiro.org/Plus/History/Persons/PalmerDD/PalmerDD's-Lifeline-chrono.pdf Chiropractic education is unique in the United States that it is divided into straight or mixer (progressive) educational curriculums depending on the philosophy of the institution.cite web|url=http://www.ed.gov/about/offices/list/ous/international/usnei/us/edlite-professional-studies.html|title=First Professional Studies|publisher=United States Department of Education|accessdate=2008-05-27 In the United States, all but one of the chiropractic colleges are privately funded, but the colleges in Australia, South Africa, Denmark, one in Canada, and two in Great Britain are located in government-sponsored universities and colleges.DeVocht JW (2006). "History and overview of theories and methods of chiropractic: a counterpoint". Clin Orthop Relat Res 444: 243–9. doi:10.1097/01.blo.0000203460.89887.8d. PMID|16523145.. In 1971, National College of Chiropractic (now known as National University of Health Sciences) became the first federally recognized and accredited college by the United States Department of Education. This led the way to important grants in federal funding for research as well as grants and loans to chiropractic schools and prospective chiropractic students.Peterson Wiese. Chiropractic: An Illustrated History (1994). Mosby, 528 pages. ISBN|0801677351

Most commonly, chiropractors obtain a first professional degree in Chiropractic medicine. In North America, typically a 3 year university undergraduate education is required to apply for the chiropractic degree.http://www.ac-fpeh.com/PDF/academic/Chiropractic.pdfhttp://www.ccachiro.org/Client/cca/cca.nsf/web/Chiropractic%20Education?OpenDocument In general, there are 3 major educational paths involving full‐time chiropractic education across the globecite paper |author= World Health Organization |date=2005 |title= WHO guidelines on basic training and safety in chiropractic |url=http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf |format=PDF |accessdate=2008-03-03:

A four‐year full‐time programme within specifically designated colleges or universities, with suitable pre-requisite training in basic sciences at university level;

A five‐year bachelor integrated chiropractic degree programme offered within a public or private university

A two or three‐year pre‐professional Masters programme following the satisfactory completion of a specifically designed bachelor degree programme in chiropractic or a suitably adapted health science degree.

Regardless of the model of education utilized, prospective chiropractors without relevant prior health care education or experience, must spend no less than 4200 student/teacher contact hours (or the equivalent) in four years of full‐time education. This includes a minimum of 1000 hours of supervised clinical training. cite paper |author= World Health Organization |date=2005 |title= WHO guidelines on basic training and safety in chiropractic |url=http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf |format=PDF |accessdate=2008-03-03 Health professionals with advanced clinical degrees, such as medical doctors, can can meet the educational and clinical requirements to practice as a chiropractor in 2200 hours, which is most commonly done in countries where the profession is in its infancy. http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf Upon meeting all clinical and didactic requirements of chiropractic school, a degree in chiropractic medicine is granted. However, in order to legally practice, chiropractors, like all self regulated health care professionals, must be licensed.

Regulatory colleges are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.cite web |url=http://www.ccachiro.org/Client/cca/cca.nsf/web/Facts%20%26%20FAQs |title=Facts FAQs |accessdate=2008-05-08 |publisher=Canadian Chiropractic Association Today, there are 15 accredited Doctor of Chiropractic programs in 18 locations in the USA and 2 in Canada,cite news |title=Accredited Doctor of Chiropractic Programs |url=http://www.cce-usa.org/adcp.php |publisher=The Council on Chiropractic Education |accessdate=2008-02-22 and an estimated 70,000 chiropractors in the USA, 6500 in Canada, 2500 in Australia, 2,381 in the UK, and smaller numbers in about 80 other countries.cite web |url=http://www.wfc.org/website/WFC/website.nsf/WebPage/Introduction?OpenDocument |title=Introduction |publisher=World Federation of Chiropractic |accessdate=2008-05-09 |last= |first=

Education, licensing, and regulation 4

This draft I wrote and now deleted is obsolete. QuackGuru19:35, 2 June 2008 (UTC)

Comments on Education, licensing, and regulation 4

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

First, its a misnomer to call this section 2. Dematt and myself have also already made alternate drafts. Although I do think yours is a good attempt, I still prefer Dematts though we could integrate bits of yours that reads well. It misses the degrees granted and incorrectly ascribes straight vs. mixer programs worldwide (this is primarily a US phenomenon). It also does omits the brief history info which was well sourced and relevant to the section. CorticoSpinal04:06, 28 May 2008 (UTC)

I changed it from "2" to "4" to help to avoid confusion with 2 or 3 versions. This draft is the best of the lot so far. Thanks! Undoubtedly it could still use improvements but I will let others comment for now. Eubulides09:05, 28 May 2008 (UTC)

I have made a few more improvements. QuackGuru09:36, 28 May 2008 (UTC)

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

Education, licensing, and regulation 5

This draft I wrote and now deleted is obsolete. QuackGuru19:36, 2 June 2008 (UTC)

Comments on Education, licensing, and regulation 5

Here is another variation for Wikipedians to review. QuackGuru19:31, 28 May 2008 (UTC)

Which versions are viable candidates now? I see both "5" and "3" in your recent edits. There are a lot of drafts now and I don't want to waste time reviewing ones that are no longer active. Eubulides21:19, 28 May 2008 (UTC)

I still think 3 is the best. -- Levine211202:00, 29 May 2008 (UTC)

I agree with Levine here. 3seems to be the best candidate. DigitalC05:46, 29 May 2008 (UTC)

Dematts (3) proposal is the best thus far as well. CorticoSpinal21:34, 30 May 2008 (UTC)

Education, licensing, and regulation 6

I deleted this obsolete version. For the improved NPOV version. See the chiropractic article history. QuackGuru03:12, 1 June 2008 (UTC)

Comments on Education, licensing, and regulation 6

Here is yet another variation for Wikipedians to review. There may be some low levels details that can be condensed and unnecessary refs can be removed. Thanks. QuackGuru05:55, 29 May 2008 (UTC)

I commend you on a good attempt QG, and there's some good stuff in your draft that can definitely go into the subarticle Chiropractic education. That being said, I believe Dematts proposal is the best thus far and is more succint. CorticoSpinal17:44, 29 May 2008 (UTC)

No specific objections have been made regarding draft six. Dematt's proposal is http://en.wikipedia.org/w/index.php?title=Talk%3AChiropracticdiff=215792177oldid=215778921 controversial. QuackGuru19:09, 29 May 2008 (UTC)

"In both cases, this includes a minimum of 1000 hours of supervised clinical training." What does in both cases mean? DigitalC07:20, 30 May 2008 (UTC)

*That quote isn't present in the current version of Education, licensing, and regulation 6, so I assume this comment is obsolete? Eubulides11:39, 30 May 2008 (UTC)

**No specific objections have been made to number 6. So I added it to the article along with some improvements. QuackGuru09:09, 31 May 2008 (UTC)

***Why would you do such a thing? Consensus clearly does not exist, as evidenced by the current support for draft number 3. With everything happening so quickly on this talk page, I haven't even had a chance to fully review this draft yet. I don't understand why you won't wait for consensus BEFORE making major changes to an article. DigitalC09:22, 31 May 2008 (UTC)

***"Chiropractic education is divided into straight or mixer (progressive) educational curriculums depending on the philosophy of the institution." - Given that this website is talking about the structure of US Education, this statement should be modified to represent that it is talking about American education curriculums. DigitalC09:31, 31 May 2008 (UTC)

***You may also want to read through Talk:ChiropracticEducation_3_improvement_suggestions, as some of the suggestions affect this draft as well, as the wording is identical. (Eg: FCLB oversight) DigitalC09:41, 31 May 2008 (UTC)

****DigitalC has acknowledged he has not reviewed the material and therefore this http://en.wikipedia.org/w/index.php?title=Chiropracticcurid=7738diff=216153763oldid=216152052 edit was a blanket revert. No specific objections have been made at the time of my edit and my improvements have been ignored. What I added to the article was different than draft six. QuackGuru09:47, 31 May 2008 (UTC)

******Please do not misrepresent my statements. I did not say I had not reviewed the material, I said I had not had a chance to review the material in its entirety. There are still significant problems with both the version you implemented into mainspace, draft 6, and other drafts. Again, I will quote the sign at the top of the page for clarity. "This is a controversial topic that may be under dispute. Please read this page and discuss substantial changes here before making them." The edit which you made was a substantial change, was not discussed, and did not have consensus. In addition, there were problems with the version you implemented, such as "In Canada, typically a 3 year university undergraduate education is suggested before applying for a chiropractic college". A 3 year undergraduate education is the minimum needed to apply for CMCC, but is NOT suggested as a prerequisite to UQTR. DigitalC10:14, 31 May 2008 (UTC)

*******If it is just a minor wording that you think needs to be fixed then you could of just fixed it. Reverting an improvement to an entire section is clearly an NPOV violation. QuackGuru10:35, 31 May 2008 (UTC)

********No, it is not a NPOV violation. Please refactor your above comment where you misrepresented me. Any further discussion about these edits should take place on my talk page, as they don't relate to improving the article. DigitalC12:17, 31 May 2008 (UTC)

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

I agree on both points: it was premature to add either draft 3 or draft 6, and mediation might be worthwhile. We already tried informal mediation, and it was a complete bust, so formal mediation would be the way to go. That will take some work, though.... Eubulides08:39, 2 June 2008 (UTC)

Comments concerning all education, licensing and regulation drafts

They are all missing components such as National Board examinations, State Board examinations, and the accredidation body; Council on Chiropractic Education, and FCER (education and research)and FSLB (state licensing regulation). -- Dematt Dēmatt 13:33, 28 May 2008 (UTC)

They are missing specialization such as DACBO (chiropractic orthopedist), DACBR (chiropractic radiology), DABCN (chiropractic neurology), etc..

They are missing the distinction between straight and mixer educational curriculums. It's notable enough for the US Dept of Education to note it's good enough to note for chiropractic. The US is the only jurisdiction in the world that actually separates the chiropractic educational system this way. Every other country in whole world, with the exception of New Zealand is exclusively mixer. This is a significant detail. Practice styles and belief systems are associated with the school matriculation. There's sources that proves this such as McDonald (2003). CorticoSpinal06:01, 29 May 2008 (UTC)

Chiropractic is Fringe: The rebuttal

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

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

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

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

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

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

If Filll could provide any evidence of any measure that experts in the field suggest that chiropractic (SMT?) is fringe treatment that would be helpful. Because the vast majority of the literature disagrees with you. And you say you represent the mainstream? Lol! CorticoSpinal00:45, 28 May 2008 (UTC)

Chiropractic is a FRINGE alternative medical practice by many different measures. First, it is mainly prevalent in the US, and to a lesser extent in Canada and Australia. Although it is present in other countries, it is far less common in these. Even in the US, where it is most common, there are only 53,000 chiropracters http://stats.bls.gov/oco/ocos071.htm compared to 633,000 physicians and surgeons http://www.bls.gov/oco/ocos074.htm. When considered on a worldwide basis, this is a very very minor treatment option. Even in the US, over their entire lives, only 1/5 of the US population has ever had an encounter with a chiropracter. And this in spite of their much cheaper cost and the problems with US healthcare costs. On a dollar basis, chiropractic is minor indeed.

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

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

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

:Lets play with your numbers to see if they are a valid argument. Do you consider optometry "fringe"? There are roughly 33,000 optometrists in the US (BLS data), and 53,000 Chiropractors (BLS data). There are 15 Optometry schools in the US, 2 in Canada, and 3 in Australia. There are 18 Chiropractic colleges in the US, 2 in Canada, and 3 in Australia. You say that in the "US, over their entire lives only 1/5 of the US population" sampled has seen a Chiropractor. In the province of Alberta, 1/5 of the population (sampled) had seen a Chiropractor within the last year. As for Palmer theory, you are now talking about a minority of Chiropractors. As far as I know, subluxation, as a hypothetical construct has not been "shown to not even exist", however I know that many Chiropractors reject the use of the word subluxation. DigitalC01:09, 29 May 2008 (UTC)

:If one may offer a more succinct arguement: There is what is called "mainstream medicine". Chiropractic is not a part of it. What is not mainstream, is fringe. QED. Jefffire20:28, 28 May 2008 (UTC)

It's not that simple. Some elements of chiropractic are fringe: e.g., http://jvsr.com/abstracts/index.asp?id=345 using spinal adjustments to treat autism, something for which there is zero scientific evidence). Some elements are not fringe, even if there is controversy about them: e.g., using SMT to treat lower back pain, as even Ernst, a sharp critic, says that this may help in a subgroup of patients (Ernst 2008, PMID|18280103). It is certainly true that the medical establishment has not yet fully accepted chiropractic as mainstream (e.g., see Meeker Haldeman 2002, PMID|11827498), so in that sense it is not mainstream. But this does not mean that chiropractic is entirely fringe either. It is a bit of a hybrid: a profession at the crossroads, as it were. Eubulides21:19, 28 May 2008 (UTC)

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

http://www.schubberesch.com/pdf/081206A.pdf Once fringe, chiropractic care now gets mainstream acceptance

http://www.washingtondiplomat.com/January%202008/a8_01_08.html Chiropractic Care Moving From Fringe to Mainstream

http://www.chiropracticresearch.org/NEWS_chiropractic_joins_the_mainstrea.htm chiropractic joins the medical mainstream

http://www.mja.com.au/public/issues/176_08_150402/iti_150402.pdf Chiropractic itself can no longer be considered a fringe therapy

http://www.washingtonpost.com/wp-dyn/content/article/2007/07/13/AR2007071301836.html Mainstream Makes Adjustments

https://www.nydailynews.com/archives/lifestyle/2002/04/01/2002-04-01_the_conventional_alternative.html Once on the fringe, chiropractic joins the medical mainstream

Accordingly it does seem that the popular belief nowadays is that chiropractic - though once considered fringe - is not not considered as such by the mainstream based on the growing scientific support. After all, what is fringe? Our own Wikipedia defines fringe as ideas viewed as marginal or extremist by the mainstream. Well, since the mainstream apparently doesn't think chiropractic is fringe, the only thing fringe around here are the ideas of those still maintaining that chiropractic is still fringe! ;-) -- Levine211221:39, 28 May 2008 (UTC)

I think that there are some REDFLAG issues with the "evidence" you cite. Many of them are obviously chiropractic websites with the goal of making themselves look more mainstream than they are. Others are mainstream news articles which are notoriously bad for determining what is the opinion of the experts. Why not get some references from the organizations of medical doctors and scientists who are able to best evaluate the subject to back up your claims? ScienceApologist22:09, 28 May 2008 (UTC)

Incorrect. And your "one bad apple spoils the bunch" tactics don't fly here. -- Levine211200:48, 29 May 2008 (UTC)

How about the only apple in the bunch of lemons is spoiled? ScienceApologist08:41, 31 May 2008 (UTC)

Please look closer. We have a medical journal in Australia, mainstream newspapers, magazine. The one chiropractic source is actually just a reprint of the New York Daily News article. No ref flags. Sorry, that argument holds no water. The sources above demonstrate that the mainstream media and science no longer consider chiropractic "fringe". Thus, the belief that chiropractic is fringe is ironically a fringe belief. -- Levine211222:30, 28 May 2008 (UTC)

The article in MJA contends that chiropractic is not mainstream medicine, rather it claims that because a large minority uses chiropractic it has to be examined closely. The no longer considered "fringe" comment is a red herring extraordinaire: googled for and ripped from the context of the actual article http://www.mja.com.au/public/issues/176_08_150402/bre10066_fm.html. You obviously didn't read REDFLAG carefully. Get some better sources and stop misconstruing the ones you do find. ScienceApologist22:41, 28 May 2008 (UTC)

Incorrect. And your "one bad apple spoils the bunch" tactics don't fly here. -- Levine211200:48, 29 May 2008 (UTC)

No. You've established that chiropractic true believers think that chiropractic is mainstream and not fringe. That's quite different. ScienceApologist19:38, 29 May 2008 (UTC)

The 'true believer' label is a red-herring and straw man attack. We could apply the same logic and call ScienceApologist a 'true denier' of chiropractic. It's the same thing. Most importantly, It has nothing to do with the the topic at hand: "'Namely, there is strong evidence, from high impact mainstream, peer-reviewed journals that supports the claim that chiropractic is not fringe but rather mainstream health care in 2008"'. (Or far closer to it in a sliding scale context than it is to fringe and comparisons to 'alien abductions Flat Earth, Creationism, AIDS Denialism, and other nonsense. There is also evidence of this in verifiable, reliable and reputable lay sources such as the New York Times and many other distinguished and notable papers. You have presented nothing that supports your claim that chiropractic is fringe, nor have you produced any evidence that disputes the sources presented. In short, you have produced nothing but hot air on this topic. You have, however presented, rather tendentiously I might add, your personal opinion that chiropractic is fringe and a pseudoscience. Given your track record, SA, I'd be careful to how much you civilly push your POV. CorticoSpinal03:54, 30 May 2008 (UTC)

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

No one is arguing that we shouldn't report true believer POVs in here: that's what the article is ostensibly about anyway. We are only arguing that we should simply characterize it as such. The claim that "true denier" POV exists can also be attributed to true believers. However, there is a group of people hoping to write the entire article from a true-believer perspective that heralds chiropractic as the new fountain of youth that will invigorate all of medicine. This kind of ridiculous posturing needs to be resisted. ScienceApologist08:41, 31 May 2008 (UTC)

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

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

The problem is that chiropractic has "both". Its fringe element is not history; it is still quite active among a large fraction of chiropractors, and still promotes chiropractic care for conditions like high blood pressure for which there is zero scientific evidence. (See, for example: cite journal |journal= Skept Inq |date=2008 |volume=32 |issue=1 |title= A skeptical consumer's look at chiropractic claims: flimflam in Florida? |author= Thyer B, Whittenberger G |url=http://csicop.org/si/2008-01/thyer.html) Conversely, there is some scientific support for some treatment forms; even Ernst, a critic, says that spinal manipulation might be effective for some patients with low back pain, with the implication that more research is needed. (See Ernst 2008, PMID|18280103.) One cannot dismiss chiropractic as being entirely fringe; nor can one accept it as being entirely mainstream. It has strong elements of both. Eubulides08:39, 2 June 2008 (UTC)

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

Please see 10% straight? below. Eubulides06:34, 3 June 2008 (UTC)

10% straight?

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

For more about this, please see McDonald "et al." 2003 (ISBN|0972805559, doi|10.1016/j.sigm.2004.07.002, http://chiroweb.com/archives/21/12/19.html lay summary). This survey of North American chiropractors reported that nearly 90% of surveyed chiropractors wanted to retain the term "vertical subluxation complex" and opposed having adjustments be "limited to musculoskeletal conditions"; when asked to estimate the percent of visceral (i.e., non-musculoskeletal) ailments in which subluxation is a "significant contributing factor", the mean response was over 60%. These are all "straight" positions. Also, a high percentage of chiropractors espoused fringe theories like homeopathy (supported by over 80% of surveyed chiropractors).

Even though I don't have hard evidence, I agree with you that more chiropractors would call themselves "mixers" than "straights". However, the survey suggests that this doesn't mean that they're entirely off the hook as far as FRINGE goes. Eubulides06:34, 3 June 2008 (UTC)

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

These two arguments make assumptions that vertebral subluxation equates to fringe. We need to understand that VS is just what chiropractors call the lesion that they treat. Other types of therapists treat these lesions as well and are well within mainstream thought. They just call it something different. IOWs, VS has at least 5 components (http://www.chiro.org/LINKS/FULL/The_VSC_1.shtml take a quick look) when describing a vertebral joint problem; 1)misalignment and/or fixation, 2)compressed or irritated nerve, 3)muscle spams/weakness/or atrophy (around the involved joint), 4)local inflammation (at the joint), 5)pathological changes at the site (arthritic changes) and global loss of homeostasis (effects on the body). A VS can involve ONE or ALL of the above, so when you ask a chiropractor in a chiropractic survey if he/she "believes" in subluxation, he/she may be thinking what 90% of physical therapists are thinking when asked if they believe in fixated joints, or orthopedists if they believe in ruptured discs (this is a combination of misaligned, inflammed and irritated nerve). So just because a chiropractor thinks that "vertebral subluxation" exists, doesn't make him nuts, only that he is not speaking your language. The only fringe in chiropractic are those that think they can "'cure"' cancer, polio, or things like diabetes. Notice that this does not mean that chiropractors who treat these patients are fringe, only the ones that think they are "curing" it or an alternative to medical treatment for it. That group is surely less than 10%. And not all of them are straights. -- Dematt Dēmatt 13:05, 3 June 2008 (UTC)

Point taken on the term "subluxation", but the other two points remain: in that same survey 90% of chiropractors opposed having adjustments be "limited to musculoskeletal conditions", and when asked to estimate the percent of visceral (i.e., non-musculoskeletal) ailments in which subluxation is a "significant contributing factor", the mean response was over 60%. That latter response is uncomfortably close to saying that adjustments have a role in "curing" ailments like diabetes etc. It's just one survey, of course, but other surveys also show that a large fraction of chiropractors hold important non-mainstream views. Colley Haas 1994 (PMID|7884327) reported that of surveyed chiropractors "One-third agree that there is no scientific proof that immunization prevents disease, that vaccinations cause more disease than they prevent, and that contracting an infectious disease is safer than immunization." More-recent Canadian surveys reported 27.2% and 29% of chiropractors being antivaccination (http://jmptonline.org/article/S0161-4754(05)00111-9/fulltext?articleId=S0899-3467%2807%2960081-0 Busse "et al." 2005, PMID|15965414). It's hard to call opinions like these anything but "fringe". In other words, the "10% straight" claim (which so far has no supporting evidence), even if it were true for some definition of "straight", doesn't by itself resolve the question as to how much "fringeness" is in chiropractic practice. Eubulides16:50, 3 June 2008 (UTC)

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

I agree with almost everything you said—except for the number. I don't agree that "90% of chiropractors treat only neuromusculoskeletal problems". I don't know of any source for that number, and I think the percentage is much smaller than that. It could well be that 90% of the "visits" are for NMS problems, but that is not the same thing as saying that 90% of "chiropractors" treat only NMS. For a recent source on this topic, please see: cite journal |journal= Skept Inq |date=2008 |volume=32 |issue=1 |title= A skeptical consumer’s look at chiropractic claims: flimflam in Florida? |author= Thyer B, Whittenberger G |url=http://csicop.org/si/2008-01/thyer.html This source found that three-fourths of the office representatives of surveyed chiropractors in Tallahassee said that chiropractors could treat high blood pressure, arthritis, or both, even though there's no scientific evidence that chiropractic care is effective for these conditions. The paper also reports on another case in Ontario where 72% of surveyed chiropractors said that they could help with chronic ear infections in a two-year-old child. Eubulides21:27, 3 June 2008 (UTC)

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

Again, I agree with what you say about chiropractic ≠ SMT, diet, exercise, etc., but… the Ontario story was about chronic ear infections; and the problem isn't the wait-and-see attitude, it's that chiropractors advocate using SMT (in particular, upper-cervical manipulation) to treat chronic ear infections. See, for example, http://www.amerchiro.org/content_css.cfm?CID=69 the ACA's web page on the subject. There isn't any scientific evidence that SMT is effective for chronic ear infection, so in that sense it is not a mainstream treatment. Eubulides07:24, 4 June 2008 (UTC)

Is chiropractic &quot;alternative&quot;?

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

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

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

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

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

Do you think this has to do with the fact that the American Medical Association was found guilty of an anti-trust and anti-competition lawsuit by the United States Supreme Court and that the AMA's policy until 1990 was to "contain and eliminate" chiropractic? and may have http://findarticles.com/p/articles/mi_qa3987/is_200606/ai_n17182863 resumed its practices again?

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

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

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

Out of curiosity, Filll, could you provide evidence that

Palmer Theory is being used today by the mainstream of the profession

Subluxations/joint dysfunction (manipulable lesion) has been found not to exist and

That the use of the word subluxation proves that the article is in terrible shape.

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

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

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

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

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

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

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

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

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

So, considering that your arguments fail the litmus test, perhaps you can bring new arguments (not riddled with fallacies either) that I can debunk. It's been a pleasure providing you with some (badly needed) continuing education. Also, your opinions are not congruent with the majority on SMT and chiropractic care. Please refrain from continuing this civil POV push which suggests that SMT and chiropractic is fringe (similar to Flat Earth, Creationism and Homeopathy. Last time I checked none of those topics were covered at the World Health Organization. CorticoSpinal21:59, 28 May 2008 (UTC)

It is quite clear that close textual analysis of CS's citations that are to actual experts do not argue that Chiropractic is mainstream medicine, just that millions of people use it. Well, millions of people use a lot of fringe things (look at homeopathy, creation science, UFOs, etc.) Whether people use it or not does not determine whether it is fringe or not. Expert evaluation does, and expert evaluation is pretty clear that there isn't much that can be said that chiropractic has been shown to medically benefit. A number of the other sources are obvious REDFLAGs. ScienceApologist22:09, 28 May 2008 (UTC)

I think the larger picture here reveals that fringe and mainstream are not an either/or set of demarcation. Rather, is is a sliding scale. Like black and white with all shades of gray in between. That's the problem with labeling based on narrow-thinking and bias - some people want so badly for something to be labeled one thing, that they fail to realize what kind of scale they are dealing with. Currently, based on modern sources, chiropractic slides much more towards mainstream than it does toward fringe. -- Levine211222:35, 28 May 2008 (UTC)

You're right about everything but the last sentence. You have yet to provide us with the high-quality sources needed to establish that chiropractic is mainstream medicine. ScienceApologist22:44, 28 May 2008 (UTC)

Incorrect. All I set out to do was to show that Chiropractic is not fringe. I have demonstrated that clearly with reliable mainstream sources. -- Levine211200:50, 29 May 2008 (UTC)

Yet, you failed to adhere to the standards outlined in REDFLAG. ScienceApologist08:41, 31 May 2008 (UTC)

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

Again, is optometry fringe? Is dentistry fringe? Is podiatry fringe? Is chiropody fringe? Where is the optometrist general? The dentist general? The podiatrist general? Why would we want half of the healthcare practitioners in the US to be specialized in focusing on NMS disorders? Your arguments are flawed and do not contribute to enhancing this article, nor to the encyclopedia. DigitalC01:40, 29 May 2008 (UTC)

Is it your position that chiropractors are "specialists"? In what anatomical or physiological sense are they specialists? Are they spinal doctors? ScienceApologist19:38, 29 May 2008 (UTC)

There ARE problems with the word 'specialist' (for instance, to see many specialists, one needs a referal from an MD ie: to see a dermatologist). However, I would assert that chiropractors focus on NMS issues. Why you ignored that above, and then asked if they are "spinal doctors", I don't know. Again, if you look at the research, aside from asthma, infantile colic, and cervicogenic headache, there isn't adequate evidence for non-musculoskeletal conditions - as such, an evidence based chiropractor would not be treating non-NMS conditions. DigitalC01:10, 30 May 2008 (UTC)

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

The official identity of Chiropractic medicine and chiropractors are indeed http://www.wfc.org/website/WFC/website.nsf/WebPage/IdentityConsultation the spinal health care experts in the health care system. Why the anti-chiropractic editors dispute this is beyond me. CorticoSpinal04:02, 30 May 2008 (UTC)

That quote is the brand platform promoted by the World Federation of Chiropractic's position. But that doesn't mean it's the mainstream medical position. The WFC's definition is also controversial among chiropractors. One chiropractor criticized the WFC's definition for its failure to place proper limits on chorpractors who treat general health problems, saying that the WFC's definition is "plunging the profession deeper into pseudoscience and away from establishing an identity for chiropractors as back-pain specialists". See: cite journal |journal= Skept Inq |date=2008 |volume=32 |issue=1 |title= Chiropractic: a profession seeking identity |author= Homola S |url=http://csicop.org/si/2008-01/homola.html Eubulides01:08, 31 May 2008 (UTC)

Are you suggesting, Eubulides, that the WFC is a fringe organization that deserves to be doubted? The organization that represents the chiropractic profession globally. The organization that is recognized by the World Health Organization. Bingo. Not fringe anymore. So, given that it is a legitimate (mainstream) organization that represents the chiropractic profession globally with Dr. Haldeman as the lead scientitst in the Research division, we shouldn't argue with the experts, just as you've always said. The opinion of mainstream allopathic (conventional) medicine is irrelevant. Chiropractic defines itself, not the medical profession. This is the critical difference between FRINGE and mainstream. The mainstream gets to define itself. Mainstream medicine has tried to kill chiropractic. So, what are we left with: the opinion of one man, (Samuel Homola who edits at Quackwatch with Stephen Barrett and who's previous papers have been rebuked; this time he writes in a non-indexed, biased, non-peer-reviewed magazine that is trying to trump, subvert and cast doubt on the reputability of the identity agreed by WFC and by extension the WHO? Weren't you the has said close to 150 times (I've counted) that "we shouldn't reach down into primary sources". And you bring a skeptical inquirer article to the table to discredit the WFC? You are falsifying any real controversy, but rather trying to create one by suggesting that the opinion of disputed, critic of chiropractic who has zero weight in the scientific arena somehow should be seriously taken with weight to dispute the obvious? Homola's personal opinion that has zero evidence to support his theory that chiro will go fringe by adopting the Identity Paper has got to be one of the more ridiculous claims I've seen yet since editing here. So now you dispute the official, verifiable and reliably sourced identity of chiropractic by the WFC with a hit-piece article in the skeptical inquirer. I guess to determine the weight and determine which source should be included we need to determine if the Skeptical Inquirer carries more weight than the World Health Organization, for it is the WHO admitted the WFC into the fold 1997 who and has represented the chiropractic profession at WHO since that time.http://www.wfc.org/website/WFC/Website.nsf/WebPage/HistoryMain?OpenDocumentppos=2spos=1rsn=y. At least the contrast in our arguments and editing practices at chiropractic has become abundantly clear. CorticoSpinal08:29, 31 May 2008 (UTC)

I did not say the WFC is fringe. I said only that its position does not represent mainstream medical opinion. This is not a black-and-white situation, where something must be either entirely fringe or entirely mainstream. Also, I disagree that the opinion of conventional medicine is irrelevant; it's quite important. Eubulides08:39, 2 June 2008 (UTC)

For the record, Samuel Homola has not been a Chiropractor since 2000, as far as I know. DigitalC07:32, 31 May 2008 (UTC)

Yes, Homola is a retired chiropractor. Eubulides07:56, 31 May 2008 (UTC)

Let the Surgeon general http://video.google.com/videoplay?docid=5509287796420413890 speak for himself. You're being owned, Filll. Go get a napkin and wipe that egg off your face. Until then... CorticoSpinal22:06, 28 May 2008 (UTC)

I removed a personal attack perpetrated by CS above. Also, Filll's point is well-taken. The title itself speaks to the fact that surgery is mainstream while chiropractic is not. Even the video you cite indicates that chiropractic is not part of mainstream medicine. Ergo it is fringe. ScienceApologist22:09, 28 May 2008 (UTC)

Restored the http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=prevoldid=215598680 evidence. -- Fyslee / 17:10, 31 May 2008 (UTC)

Comments on Chiropractic is Fringe: The rebuttal Section 3

This section seems to be devoted to debating whether "chiropractic" is "fringe". Would someone please explain to me why this is being debated on this talk page? I just re-read FRINGE and don't see what part of it this thread might be concerned with. Feel free to reply on my talk page if this is something everybody else around here already understands. I can see how it may be useful at a page such as Asthma to decide whether the chiropractic theory of treatment of asthma is "fringe" and not notable enough to be mentioned in that article, but I don't see how a decision as to whether "chiropractic" (the profession? a theory of?) is "fringe" or not would have any bearing on the content of this article: either way, the article will be based in a balanced way on the reliable sources.☺ Coppertwig01:01, 30 May 2008 (UTC)

The survey indicates that the vast majority of chiropractors do not consider chiropractic to be mainstream medicine. This is true independently of the old antipathy between the fields. And the survey's results are not contradicted by any other source presented on this talk page.

I see some quibbling as to whether chiropractic is "mainstream medicine" versus "mainstream health care". But one can easily find sources saying that chiropractic is not mainstream health care as well. For example, Langworthy Cambron 2007 (PMID|17693332) write, "As the chiropractic profession in the United States (US) and United Kingdom (UK) continues in its efforts for full recognition in mainstream health care,..." indicating that the authors do not believe that chiropractic is mainstream health care yet. Another example: the title of Hirschkorn Bourgeault 2004 (PMID|15847969), which is "Conceptualizing mainstream health care providers' behaviours in relation to complementary and alternative medicine", indicates that the authors do not consider chiropractic to be mainstream health care. I don't see any evidence that the distinction between "mainstream medicine" and "mainstream health care" is a huge one in practice, in this regard.

The effectiveness of chiropractic care is a topic under genuine dispute. In some cases (treatment of low back pain, at least for some categories of patients) the evidence is relatively strong, and chiropractic supporters are not fringe, nor are the skeptics fringe (as the evidence is not overwhelming). In other cases (for example, treatment of autism) the scientific evidence is nonexistent, and it's fair to say chiropractic is fringe. And there are some gray areas in between, where some evidence does exist but it's low quality; this is where things get tricky.

Eubulides

01:08, 31 May 2008 (UTC)

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

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

Proponents of chiropractic care who make the valid argument that chiropractic is at a minimum much more part of the mainstream (health care) than fringe, if not already part of it. It completely changes the dynamics of editing. Evidence (with much, much more available) from reliable, non-disputed sources have supported the claim the chiropractic medicine is part of mainstream health care (and not to be conflated with mainstream allopathic medicine, the specific profession) and no evidence has been provided that it is still fringe, circa 2008. Contemporary chiropractic is scientific. Bachelors and Masters Degrees in Chiropractic Science are been awarded by public, government-sponsored universities. The fringe argument also applies to the science of chiropractic medicine which insists there is no such thing as 'true' chiropractic science because it is fringe and a pseudoscience. A bit of education on the matter and then a a little applied common sense (rather than dogmatic skepticism that is uninformed) decidedly (and perhaps surprisingly) proves the point made by pro-chiropractic editors. As it stands, the anti-chirorpractic editors are pushing (civilly and uncivlly) that chiropractic medicine is fringe despite evidence presented to the contrary. CorticoSpinal05:52, 30 May 2008 (UTC)

Thank you for your reply, CorticoSpinal. I recognize that you're trying to address my question, but I'm sorry: I'm completely missing your point! If there are peer-reviewed scientific publications giving evidence of benefit of chiropractic treatment, then regardless of whether "chiropractic" (some particular theory of?) is labelled "fringe", those publications need to be represented in the article, balanced by other, more critical sources. Surely there are enough reliable sources about chiropractic that we don't need to resort to using self-published websites and such as sources? While labelling something "fringe" allows self-published websites etc. to be used, it doesn't require that they be used, and for this article I don't think it's necessary. So, what would be different about the article depending on whether "chiropractic" is classified as "fringe" or not? ☺ Coppertwig12:22, 30 May 2008 (UTC)

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

I agree that the article should only cover the chiropractic fringe the way that any article (Evolution, say) should briefly discuss closely-related fringe theories (such as creationism). The current treatment in ChiropracticScientific investigation does that: it is almost entirely about mainstream chiropractic care. Eubulides01:08, 31 May 2008 (UTC)

Coppertwig, while I definitely agree with your logic, the problem is that currently chiroskeptic editors are treating Chiropractic by default is fringe. Accordingly the research I try to include in crucial areas of safety, efficacy, cost-effectiveness is being given the fringe treatment, getting less weight, worse tone and less credibility. Basically, MD/PhD research on chiropractic or SMT is being given superior weight than research by DC/PhD at Chiropractic because the chiropractic viewpoint on its own research is interpreted as fringe and automatically at odds with mainstream health care. That's not the case at all. Look at the TaskForce thread. Some major players are DC/PhDs, (but do not dominate the representation of the TaskForce as suggested repetitively by Eubulides despite the evidence to the contrary) and its even led by a DC/MD/PhD. Yet the interpretation is that the document is a mainstream chiropractic one and not a mainstream science one. It's implied that chiropractic and science are at odds despite the obvious fact that its clearly not. CorticoSpinal19:46, 30 May 2008 (UTC)

This mischaracterizes the dispute in question. The current article uses high-quality reviews from all sources, including chiropractic sources. The dispute in question was over whether we should ignore the guidelines in MEDRS, override the opinions of published and detailed reliable reviews by experts in the field, and highlight results of primary studies that the reviews did not think worthy of mention. Eubulides01:08, 31 May 2008 (UTC)

One question, is Edzard Ernst debunking the fringe elements of chiro, or the stuff that seems to have some effect on back and neck pain? Is this the only source which is extremely critical? If so, then is this being presented as the view of most doctors? If it is, then is there anything backing up the claim that this is the veiw of most doctors? What exactly is said to be wrong with sources like http://www.ama-assn.org/ama/pub/category/13638.html this? I'm sorry to ask all this, but my god, it's a long talk page.

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

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

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

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

That last statement is patently false quoted here is patently false, but the rest of it is spot on. First, the majority group is the mixers (of the 35 accredited schools world wide only 8 are straight 27 are not). Next, DeVocht (2006) has nicely illustrated the controversy over theory http://en.wikipedia.org/wiki/User:CorticoSpinal/notesSubluxation_Theory:_DeVocht here. It should be noted this is from Palmer College, which is the minority view yet it still has universal elements (manipulable lesion) Next, and most important is that the literature (tertiary source) provided by the World Health Organization in 2005 states explicitly http://www.kiropraktiikka.fi/media/Final_Chiro-guidelines_03-11-2005.pdf here the basics of chiro theory; none of which mentions anything of disease and adhering to the palmers methods (which is why mixer chiropractic separated and differentiated itself from straight chiropractic). What source made the claim? Who wrote it? Professional designation? Was it an MD? MDDC and other multidisciplinary collaboration? If not, that's problematic; Medicine has always tried to marginalize chiropractic and was found guilty by the US Supreme Court of anti-competitive practices trying to contain, disrupt and eliminate the chiropratic profession. CorticoSpinal23:50, 30 May 2008 (UTC)

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

In "the above is a pretty good source" which source are you referring to?

Things are more complicated than that, I'm afraid. Mixers also treat for conditions other than back pain.

Mainstream sources are not in agreement for back and neck. Please see ChiropracticEffectiveness for details, and look for "Low back pain" and "Whiplash and other neck pain".

It is not so easy to isolate which part of Chiropractic is "fringe". Some sections (e.g., ChiropracticVertebral subluxation are quite "fringish", and some (e.g., ChiropracticSafety are not, but some (e.g., ChiropracticPhilosophy) cover both the "fringe" and the "non-fringe" parts and separation would be difficult.

Eubulides

07:56, 31 May 2008 (UTC)

"Things are more complicated than that, I'm afraid. Mixers also treat for conditions other than back pain." Sure they do, they also treat the rest of the neuromusculoskeletal system. For instance, what is the best treatment for tennis elbow? plantar fasciitis? thoracic outlet syndrome?. While we're at it, don't physical therapists treat conditions other than back pain? Does that mean they are fringe? AFAIK the scope of practice overlap between the two professions is huge. PTs also manipulate, although they call their manipulatable lesion (clinical entity) a "joint fixation" or "facet sprain" (as do some mixers), instead of a "subluxation". DigitalC03:44, 5 June 2008 (UTC)

I wrote "back pain" and "back and neck" in response to Martinphi's comments about "mainstream sources which say it works for back and neck". I agree that Mixers also treat for other conditions, but unfortunately there's little scientific evidence for effectiveness against these other conditions. I don't know the answers to your questions; I agree that the scope of practice overlap is large. Eubulides07:05, 5 June 2008 (UTC)

There isn't necessarily "little scientific evidence for effectiveness against these other conditions", it depends on the modality being used, such as ultrasound for plantar fasciitis.DigitalC07:46, 5 June 2008 (UTC)

Yes, that's true. By "other conditions" I meant only those conditions for which we have reliable reviews concerning chiropractic care. Eubulides19:46, 5 June 2008 (UTC)

Request for comment

Education, licensing, and regulation

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

Scientific research vs Scientific investigation

Which section name do Wikipedians prefer. Scientific research or Scientific investigation for the section title. QuackGuru02:00, 31 May 2008 (UTC)

A better name would be "Evidence basis". Not all the material in this section is scientific; some of it is based only on case studies. Eubulides07:56, 31 May 2008 (UTC)

I prefer to stay with Scientific research. Most of the research is scientific. QuackGuru17:30, 1 June 2008 (UTC)

Vertebral subluxation

ChiropracticVertebral subluxation This section is not about history. I suggest we move the section and perhaps expand on the subluxation theory. Thoughts? QuackGuru02:00, 31 May 2008 (UTC)

I agree with moving the section; I've already suggested moving it to ChiropracticPhilosophy; see Other POV issues above. Also, ChiropracticSchools of thought and practice styles should be made a subsection of ChiropracticPhilosophy, as schools of thought are inevitably tightly bound to philosophy. Eubulides07:56, 31 May 2008 (UTC)

My thoughts are that we should focus on forming a consensus on effectiveness and education first, before moving on to other sections. I'm not trying to stonewall here, but there is no rush. Given the amount of talk page space we take up discussing 1 section, I think its better that we don't try to fix every section at once. We ARE making progress. DigitalC07:16, 31 May 2008 (UTC)

I disagree. I think that every proposal should be considered as long as editors are willing to entertain them. I, for one, am willing to review QG's proposals. If you aren't, that's fine, but there's no need to prevent others from reviewing them. ScienceApologist07:30, 31 May 2008 (UTC)

I moved the philosophy stuff to the philosophy section. QuackGuru09:13, 31 May 2008 (UTC)

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

similar cost-benefit sentences

An initial study found that the benefits of chiropractic care for neck pain seem to outweigh the possible risk. When compared with treatment options such as physiotherapeutic exercise (also performed by a chiropractor), the risk-benefit balance does not favor SMT. These two above sentences are similar and should both be in the cost-benefit section together. QuackGuru02:00, 31 May 2008 (UTC)

I agree that it makes no sense to separate those two sentences. As discussed in Comments on 2008-05-25 issues list above, the sentence based on the primary source is dubious and the simplest thing would be to remove it, along with its source. Fancier solutions are also possible, such as summarizing the primary source more carefully, or putting in another primary source to balance the dubious one. Eubulides07:56, 31 May 2008 (UTC)

Which paper does that sentence come from? Because the majority of the research suggests the opposite (risk balance does not favour SMT). CorticoSpinal02:31, 31 May 2008 (UTC)

Both sentences are referenced. QuackGuru03:06, 31 May 2008 (UTC)

That wasn't my question. I'm asking you about which paper that it came from and who the author was. CorticoSpinal05:15, 31 May 2008 (UTC)

Check the article. ScienceApologist07:23, 31 May 2008 (UTC)

I checked the article, and easily found that the two sources in question are Rubinstein "et al" 2007 (PMID|17693331) and Ernst Canter 2006 (PMID|16574972). Eubulides07:56, 31 May 2008 (UTC)

That's what I thought. The Ernst citation disagrees with the majority of the literature yet being used to subvert the majority opinion. More weight issues. More Ernst. Interesting. Thanks. CorticoSpinal17:41, 31 May 2008 (UTC)

I don't doubt that the Ernst citation disagrees with the majority of the literature written by chiropractors, and that this literature in turn is a majority of the literature about chiropractic; but that is not the same thing as saying that the Ernst-supported material is not mainstream. Eubulides08:39, 2 June 2008 (UTC)

Medical opposition neutrality

ChiropracticMedical opposition describes a debate between conventional medicine and chiropractors. The debate can be covered more neutrally. QuackGuru03:06, 31 May 2008 (UTC)

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

I'm not sure what you mean by "worst it gets", but currently Chiropractic History, which contains Chiropractic Medical opposition is the section with the most POV problems in Chiropractic. I wouldn't agree with rewriting Chiropractic to reflect mainly a "resounding rejection of chiropractic by the scientific and medical establishment in general", as that doesn't describe mainstream opinion accurately. It's not "that" negative. Eubulides07:56, 31 May 2008 (UTC)

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

Formal mediation would make sense, yes. The biggest disputes here are about which sources are reliable and which represent mainstream opinion (for some definition of "mainstream").

Please see DigitalC's comment below, and my followup, for whether Ernst is "mainstream".

Eubulides

08:39, 2 June 2008 (UTC)

There are editors that argue that Ernst represents mainstream opinion, and editors that argue that he doesn't. I haven't seen any evidence that he DOES represent mainstream opinion, but I have seen evidence put forward that he doesn't. For instance, the guidelines of the American College of Physicians American Pain Society, recommend as follows: "Recommendation 7: For patients who do not improve with selfcare options, clinicians should consider the addition of nonpharmacologic therapy with proven benefits—for acute low back pain, spinal manipulation; for chronic or subacute low back pain, intensive interdisciplinary rehabilitation, exercise therapy, acupuncture, massage therapy, spinal manipulation, yoga, cognitive-behavioral therapy, or progressive relaxation (weak recommendation, moderate-quality evidence)." So here we have the American College of Physicians recommending SMT for acute, sub-acute, and chronic low back pain, as therapy with PROVEN BENEFITS. Now, which represents mainstream opinion more here, Ernst, or the ACP? Now, lets see how this is worded in the aricle? "For example, a 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail," DigitalC00:58, 2 June 2008 (UTC)

Ernst's work is cited more often about chiropractic in scholarly works than is Haldeman (perhaps the leading D.C. researcher), and a spot-check suggests that most of the citations to his work is positive. For details, please see Comments on Scientific investigation 3C (look for the words "spot-check" and "Google Scholar" in that section). In that sense, at least, Ernst's work is mainstream.

If there's something wrong with the quoted wording in the article, can you please suggest specific improvement to it? I do notice the "nonpregnant adults" as not being in the source's text that you quote, but it is supported by other text of the same source.

Eubulides

08:39, 2 June 2008 (UTC)

It is a major civil-POV push. If it was a moderate strength recommendation, we wouldn't write "moderately recommends". Yes, the strength of the recommendation is "weak", but to word that as "weakly recommends" is not NPOV. DigitalC02:19, 5 June 2008 (UTC)

The phrase "weakly recommends" is not NPOV; it is used by the ACP itself when describing its recommendations whose strength is weak. For example, the ACP's summary (PMID|17975179) of their 2007 COPD clinical practice guideline says "The ACP weakly recommends that doctors and patients should: 1. Consider a combination of inhaled drugs if the FEV1 is less than 60% and symptoms continue during treatment with 1 drug. 2. Consider pulmonary rehabilitation for patients with COPD symptoms and an FEV1 less than 50% predicted." Eubulides07:05, 5 June 2008 (UTC)

MartinPhi, that is history and the opposition story has changed, medicine has partially embraced chiropractic care (TaskForce, integrative medicine models) yet a fringe element within it continues to critically attack it, via "research" now such as Ernst'. I could add about 5 references regarding the deliberate misattribution of strokes to chirorpactors despite the fact no chiropractor was involved in the treatment yet received 'chiropractic manipulation'. It's that kind of shadiness that has gone on. The AMA also recently tried to prevent chiropractors from conducting examinations outside the spine in a clearly anti-competitive move that actually breached the US Supreme Court decision ruled against the AMA. Also, one must differentiate between chiropractic integration into mainstream medicine vs. integration into mainstream health care. One is occurring (medicine) where one has already occurred (licensure, regulation, reimbursement, governmental and health agency recognition, use of services, scientific contributions, etc.). More evidence that chiropractic is mainstream as opposed to fringe. Quack we haven't heard your opinion yet, I'm going to assume you believe Chiropractic is fringe but I'd rather you tell the community for yourself your stance on this issue. Cheers. CorticoSpinal05:27, 31 May 2008 (UTC)

Again, Ernst's work represents mainstream criticism of chiropractic, published in reputable journals and widely cited. It is not "fringe" by any reasonable measure. Eubulides07:56, 31 May 2008 (UTC)

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

Criticism of the fringe views which exist within chiro is not a problem. For example, I found this article, which makes it clear that chiro still has a large component of fringe ideas within it http://findarticles.com/p/articles/mi_qa3987/is_200403/ai_n9394083. Yet I think that chiro nevertheless is fairly mainstream in medical practice, though not completely so. Does this sound like I'm taking the general picture into account? ——"'—— 01:50, 2 June 2008 (UTC)

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

After following this argument for some time, I am coming to the viewpoint that perhaps Ernst is somewhat extreme, within "mainstream". I second: ""Ernst is a good source, but his point of view should not be the basis for the article as a whole"." (It hasn't and won't be 'the basis' at all, anyway. Just one factor) There is considerable evidence that chiropractic is effective for back pain and the European back pain guidelines take this into account...just one example. "UK National Clinical Practice Guideline Evidence Review states: "Within the first 6 weeks of acute or recurrent low back pain, manipulation provides better short-term improvement in pain and activity levels and higher patient satisfaction than the treatments to which it has been compared." http://www.bmj.com/cgi/eletters/317/7152/160--CynRN ""'—CynRN""' "" 05:30, 2 June 2008 (UTC)

I agree with the basic outline of what Martinphi said, and in particular that Ernst does not represent "the" mainstream, just as the Bone and Joint Task Force does not represent "the" mainstream.

This is reflected by differing national guidelines as well: CynRN says the UK guideline favors chiropractic, whereas Murphy "et al." 2006 (PMID|16949948) says the Swedish guideline no longer favors it (it used to, but this got changed in 2002). My own vague impression is that national guidelines tend to favor chiropractic in countries where chiropractic is more strongly established and tend not to favor it where other forms of CAM are stronger.

It is controversial whether chiropractic is "fairly mainstream in practice". One can find recent sources either way. The above discussion found multiple reliable sources saying that chiropractic is not "mainstream" (for some value of "mainstream"), and multiple reliable sources saying that it is "mainstream" (ditto).

This is why Chiropractic Scientific investigation gives reasonable space to both kinds of mainstream views. There is no real consensus in this area; both sides should be given. Ernst is certainly not the basis for the Chiropractic as a whole, which is as things should be.

Other mainstream medical sources use much stronger wording than Ernst does. See, for example, Fink 2002 (PMID|12379082), which says "The dictionary deefines quackery as 'the pretension to medical skill.' In my opinion, which is unchanged by Meeker and Haldeman's paper, that describes chiropractic." You don't see Ernst using such extreme words. And yet Fink's views, I expect, are fairly common in mainstream medicine. (I don't know of any opinion poll in this area, alas.)

Eubulides

08:39, 2 June 2008 (UTC)

Incorrect. Ernst's work is disputed and has been invalidated. His opinion on the subject is fringe because it is a) extremist and b) refuted by the majority of the literature. So, regardless of where Ernst' review was published his conclusions are diametrically opposed to conclusions of the TaskForce. We're comparing the strength of those 2 papers. CorticoSpinal17:54, 31 May 2008 (UTC)

Ernst's work has certainly been disputed, but it has not been invalidated, and it is certainly not "refuted by the majority of the literature". Eubulides08:39, 2 June 2008 (UTC)

REDFLAG. The TaskForce document is written by chiropractors who are not reliable sources when it comes to whether mainstream medicine has embraced chiropractic care. You can see that the Task Force received its funding mainly from chiropractic organizations http://findarticles.com/p/articles/mi_qa3987/is_200111/ai_n9014691 here. Small wonder they declared chiropractic to be as effective and safe as they did! We can hardly expect chiropractors to be reliable when they admit to their agenda to make chiropractic a part of the "mainstream". No, we need consistent statements from medical doctors who are not chiropractors to establish this so-called "fact". ScienceApologist07:28, 31 May 2008 (UTC)

Complete misuse of REDFLAG. The document has 16 MDs to 8 DCs as important authors. Regardless, your statement that the literature is somehow fudged should be withdrawn. That is a grossly biased statement that has absolutely no merit. You, an editor who represents the fringe viewpoint are giving your PERSONAL OPINION to rebuke the character of Dr. Haldeman. Wikipedia doesn't work that way, SA. You need evidence to back up your claim. So far, there isn't any. Quite simply the TaskForce is multidisciplinary document that has more MD representation than DC. Thats a fact. Also, we don't need statements from medical doctors to demonstrate that chiropractic is part of mainstream health care. MDs want to supress DCs, generally speaking. That doesn't mean that the public, governmental and health agenecies other health care providers, legilators, scientists and others haven't already brought chiropractic into the mainstream. Bottom line: evidence has been presented that chiropractic is moreso mainstream (health care not medicine (profession)) if not completely part of mainstream health care. You have provided no evidence that it is fringe. Please provide evidence rather than conspiracy theories that question the integrity of the TaskForce. Thanks. CorticoSpinal17:54, 31 May 2008 (UTC)

The above comment confuses a document (Hurwitz "et al." 2008, PMID|18204386), with a task force. They are different things, and statistics about one don't necessarily apply to the other. Certainly evidence has been supplied from reliable sources who do not consider chiropractic to be part of mainstream health care; see Langworthy Cambron 2007 (PMID|17693332) and Hirschkorn Bourgeault 2004 (PMID|15847969), both mentioned above. Eubulides08:39, 2 June 2008 (UTC)

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

It's true that the article currently summarizes the effectiveness of various chiropractic treatments, without going into the issue as to whether chiropractors are capable of determining the best treatment for each case. It would be helpful to briefly discuss that issue too, if we can find a reliable source about it.

ChiropracticUtilization and satisfaction rates does mention satisfaction rates; chiropractors indeed do quite well by that measure (though not as well as pharmacists :-).

I agree with your comments on the right way to cover chiropractic, and that it's tricky.

Currently ChiropracticScientific investigation attempts to make it quite clear when the results are about chiropractic care in general, or a particular treatment form (often SMT). If this isn't clear enough, the wording should be improved.

Which chart are you referring to? I just now looked at Hurwitz "et al." 2008 (PMID|18204386),cite journal |journal=Spine |date=2008 |volume=33 |issue= 4 Suppl |pages=S123–52 |title= Treatment of neck pain: noninvasive interventions: results of the Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders |author= Hurwitz EL, Carragee EJ, van der Velde G "et al." |doi=10.1097/BRS.0b013e3181644b1d |pmid=18204386 and the only occurrence of the string "chart" that I found was in the phrase "Uncharted territory" (which somehow seems appropriate…).

Eubulides

16:45, 2 June 2008 (UTC)

History

The lead paragraph for the history section is a bit too short. I think it should be expanded. Any suggestions? QuackGuru09:20, 31 May 2008 (UTC)

My suggestion is that the lead paragraph should summarize all of chiropractic history, that the rest of Chiropractic History be merged into Chiropractic history. I.e., that Chiropractic History should be trimmed down to one paragraph. I realize this suggestion will take quite a bit of work. Eubulides08:39, 2 June 2008 (UTC)

Arabian Nights tidbit

It was suggested that more context should be added to the Arabian Nights tidbit. Thoughts? QuackGuru17:41, 1 June 2008 (UTC)

Sorry, I forget. What sort of context was asked for, and why? Eubulides08:39, 2 June 2008 (UTC)

Read http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=prevoldid=215151047 this comment. QuackGuru19:12, 2 June 2008 (UTC)

Thanks, I reread that, and I don't see the need for further context. It wasn't clear from the comment what information was being requested, so perhaps I'm just misunderstanding the request. Eubulides19:45, 2 June 2008 (UTC)

OK, never mind, just leave it. I looked at where it says "Arabian Nights" in the source, and it doesn't explain it either. I suppose maybe it means fictional, made up in desperation in order to save something. I'm sorry I hadn't looked at the source before I commented in the first place. ☺ Coppertwig23:20, 3 June 2008 (UTC)

Archiving

I suggest a lot of old threads should be archives. Further, there are a lot of obsolete education drafts that can also be archived. This talk page is way too long. QuackGuru17:50, 1 June 2008 (UTC)

Perhaps you could start by choosing one of the versions of education drafts that you submitted which you support, and archive the rest? DigitalC00:39, 2 June 2008 (UTC)

Threads inactive for 14 days were archived automatically. I just now changed that to 10 days; that should help a bit. 7 days seems a bit aggressive to me. Eubulides08:39, 2 June 2008 (UTC)

lead

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

A "bit long" is an understatement; the lead is way too long. By my count it has 431 words. By comparison, Coeliac disease, a recent featured article on a medical topic, has 263 words in its lead. Suggestions for improving and trimming down Chiropractic's lead are welcome. Eubulides20:11, 6 June 2008 (UTC)

Education, licensing, and regulation drafts

Education, Licensing, Regulation 3

Chiropractors obtain a first-professional degree in the field of Chiropractic medicine.cite web |url=http://ed.gov/about/offices/list/ous/international/usnei/us/edlite-professional-studies.html |title= First-professional studies |publisher= U.S. Network for Education Information |accessdate=2008-05-27 Canada and the U.S. require a minimum 90 semester hours of undergraduate education as a prerequisite for chiropractic school. Matriculation through an accredited chiropractic program includes no less than 4200 instructional hours (or the equivalent) of full‐time chiropractic education.cite web |url=http://www.cce-usa.org/uploads/File/2007%20January%20STANDARDS.pdf |title=The Council on Chiropractic Education Standards

for Doctor of Chiropractic Programs and Requirements for Institutional Status |accessdate=2008-06-13 |date=January 2007 |publisher=Council on Chiropractic Educationcite web |url=http://www.cfcrb.org/english/pdf/Standards_for_Doctor_of_Chiropractic_Programmes.pdf CFCRB standards |title=Standards for Doctor of Chiropractic Programmes |accessdate=2008-06-13 |date=2006-10-21 |publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards Internationally, the World Health Organization (WHO) guidelines suggest three major full-time educational paths culminating in either a DC, DCM, BSc, or MSc degree. Besides the full-time paths, they also suggest a conversion program for people with other health care education and limited training programs for regions where no legislation governs chiropractic.cite paper |author= World Health Organization |date=2005 |title= WHO guidelines on basic training and safety in chiropractic |url=http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf |format=PDF |accessdate=2008-03-03

Up to four years of pre-requisite training in basic sciences at university level followed by a four year full‐time program; DC.

A five year bachelor degree; BSc (Chiro).

A two to three year Masters following a bachelor; MSc (Chiro).

The WHO also says that health care professionals with advanced clinical degrees can meet the educational and clinical requirements to practice as a chiropractor in 2200 hours.cite paper |author= World Health Organization |date=2005 |title= WHO guidelines on basic training and safety in chiropractic |url=http://www.who.int/medicines/areas/traditional/Chiro-Guidelines.pdf |format=PDF |accessdate=2008-03-03 In both cases (4200/2200 hours) this includes a minimum of 1000 hours of supervised clinical training. Once graduated, the chiropractor may then be required to pass national, state or provincial boards before being licensed to practice in a particular location.cite web |url=http://www.cfcrb.org/english/becoming.html |title=CFCREAB - Becoming a Chiropractor

|publisher=Canadian Federation of Chiropractic Regulatory and Educational Accrediting Boards |accessdate=2008-06-13 Depending on the location, continuing education may be required to renew these licenses.cite journal | url =http://www.pubmedcentral.nih.gov/articlerender.fcgi?artinstid=1839972 |title=Continuing Health Education in Canada |author = Grod, J.P. | journal = Journal of the Canadian Chiropractic Association | volume = 50 | issue = 1 | pages = 14 | year = 2006 | publisher = The Canadian Chiropractic Association | accessdate = 2008-06-13

In the United States, chiropractic schools are accredited through the Council on Chiropractic Education (CCE). The CCE-USA has joined with CCEs in Australia, Canada, and Europe forming CCE - International (CCE-I) as a model of accreditation standards with the goal of having credentials portable internationally.cite web |url=http://home.earthlink.net/~ccei/id15.html |title=Chiropractic Education Worldwide |publisher=cceintl.org |accessdate=2008-06-13 Today, there are 18 accredited Doctor of Chiropractic programs in the USA, 2 in Canada, and 4 in Europe and the UK.cite web |title= Accredited Doctor of Chiropractic programs |url=http://cce-usa.org/adcp.php |publisher= The Council on Chiropractic Education |accessdate=2008-02-22cite web | url = http://www.chirofed.ca/english/accreditation.html | title = CFCREAB - Accreditation of Educational Programmes | format = | work = | accessdate = 2008-05-28cite web | url = http://www.cce-europe.org/institutions.php | title = Institutions holding Accredited Status with the Council | format = | work = | accessdate =2008-05-28 All but one of the chiropractic colleges in the United States are privately funded, but in several other countries they are in government-sponsored universities and colleges.

Regulatory colleges and chiropractic boards in the U.S., Canada, Australia, Mexico and U.S. territories are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.cite web |url=http://www.ccachiro.org/Client/cca/cca.nsf/web/Facts%20%26%20FAQs |title=Facts FAQs |accessdate=2008-05-08 |publisher=Canadian Chiropractic Associationcite web |url=http://www.fclb.org/boards.htm |title=FCLB - Member Boards

|publisher=www.fclb.org |accessdate=2008-06-17 In 2006, there were approximately 53,000 chiropractors in the United Statescite web |url=http://www.bls.gov/oco/ocos071.htmemply |title=Chiropractors |publisher=U.S. Department of Labor Bureau of Labor Statistics |accessdate= |last= |first= and over 6500 chiropractors licensed in Canada.cite web | url = http://www.ccachiro.org/Client/cca/cca.nsf/web/Number%20of%20Licensed%20Chiropractors%20in%20Canada?OpenDocument | title = Number of Licensed Chiropractors in Canada | format = | work = | accessdate = 2008-05-28

Comments on Education 3

I prefer this draft to the others. However, I think that this line from Eubulides, "but in several other countries they are in government-sponsored universities and colleges" is better than "but the colleges in Australia, South Africa, Denmark, one in Canada, and two in Great Britain are located in government-sponsored universities and colleges". DigitalC05:55, 30 May 2008 (UTC)

I support this draft as well. I removed the strikeouts that QG inserted for the educational paths; his argument that its too much weight is unfounded; moreover, not all degrees conferred to chiropractors are the same. As the section suggests, some are 2-3 years MSc (chiro), some are 4 years BSc(chiro) and in North America, it's 4 years after a minimum of 3 (total of 7). The article needs to reflect this global perspective. The source is not in dispute, the source is not fringe so I don't know where the weight argument comes from. I think it's more IDONTLIKEIT than anything else. CorticoSpinal00:30, 31 May 2008 (UTC)

This draft is still mutating so I hesitate to make comments on it, but on the offchance that people are taking it seriously I will say that the draft is disappointing, as it has essentially ignores many of the comments in Education draft needed work. For example, I don't see anything in the cited source about the 2200 hours being "most commonly done in countries where the profession is in its infancy", and I am quite skeptical that that 2200-hour claim is true. This is just one example of a comment being ignored; there are others. Dematt, have you had a chance to read the bullets at the start of Education draft needed work? (Just the top-level bullets; you can ignore all the to-and-fro underneath if you like....) Eubulides01:08, 31 May 2008 (UTC)

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

Education 3 improvement suggestions

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

"Most commonly, chiropractors obtain a first professional degree in Chiropractic medicine (DC or DCM).cite web |url=http://ed.gov/about/offices/list/ous/international/usnei/us/edlite-professional-studies.html |title= First-professional studies |publisher= U.S. Network for Education Information |accessdate=2008-05-27" The cited source does not say anything about "Most commonly". It says only that DC or DCM are the recognized first-professional degrees. The source is a U.S. source so this would be for the U.S., which should be stated in the text (or a better source should be found).

*I agree that this is a problem sentence, mostly because I have never seen a DCM degree in the US, yet this is a US source. I could be very wrong, but I would feel better with a better source. I think we do need to say something about what the degree is (DC or DCM) if there is one somewhere. Also, this is the source that says the degree differentiates straight and progressive. I highly doubt that myself, but again could be wrong. I would like to see another source calling anyone progressive? However, because it is a verifiable and reliable source, I will put it in if that is what everyone decides. I'm just thinking we would be looking rather dated at the very least and quite possibly just wrong. -- Dematt Dēmatt 13:59, 31 May 2008 (UTC)

** I see someone removed the "DC or DCM". But my objection was to the "Most commonly", not to the "DC or DCM". The sentence as written implies that chiropractors uncommonly do something other than get a first professional degree in chiropractic medicine. Is that really true? I'm skeptical. And the source doesn't say "most commonly". Or perhaps I'm misunderstanding the phrase "obtain a first professional degree"? In that case, the sentence needs to be clarified. Eubulides08:39, 2 June 2008 (UTC)

"In North America, a 3 year university undergraduate education (90 semester hours) is required before applying to chiropractic college,cite web |url=http://ac-fpeh.com/PDF/academic/Chiropractic.pdf |format=PDF |title= FPEH Guide to Chiropractic Programs |accessdate=2008-05-31 |date=2008 |publisher= Faculty of Physical Education and Health, University of Torontocite web |url=http://www.ccachiro.org/Client/cca/cca.nsf/web/Chiropractic%20Education?OpenDocument |title= Chiropractic Education |accessdate=2008-05-31 |date=2008 |publisher= Canadian Chiropractic Association" The 2nd citation (ccachiro) has nothing to do with the claim; it says nothing about prerequisites. It can be removed. The 1st citation (FPEH) is only about Canada, so the text should be changed from "North America" to "Canada" or better citations should be found. The claim is not true for all of North America (it's not true for Mexico). Neither source says anything about "90 semester hours", so that part should be removed from the text (or a better source found).

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

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

"

*"A four‐year full‐time programme within specifically designated colleges or universities, with a 1 - 4 year pre-requisite training in basic sciences at university level;

*" A five‐year bachelor integrated chiropractic degree programme offered within a public or private university;

*" A two or three‐year pre‐professional Masters programme following the satisfactory completion of a specifically designed bachelor degree programme in chiropractic or a suitably adapted health science degree."

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

Besides you thinking this vital detail, which comes from a reputable source (WHO), which gives a representative sampling of the various degrees and educational paths obtained by details worldwide (to give a global POV), which is written neutrally, which is a core part of the education subsection, and which directly provides evidence that chiropractic is scientific (as opposed to a pseudoscience or fringe science as advocated by SA, OM, Jefffire, QG) is there a legitimate reason, besides 'boring' that you want to remove it? CorticoSpinal18:21, 31 May 2008 (UTC)

The WHO guidelines are not "a representative sample"; they are guidelines, which various countries are free to accept or reject, and which have not been accepted by the governments of most of the world's population. They represent a reasonable point of view which should be covered, but they are not by any means definitive, and should not be presented as the current state of affairs in practice.

They "are" boring. This is not just my opinion; multiple other editors have agreed on that point. They may well be worth mentioning in a subarticle, but they can be just summarized here.

Eubulides

08:39, 2 June 2008 (UTC)

Again, boring is a subjective, personal point of view, and opinions differ between editors. They may not have been accepted by government of most of the world's population, but they HAVE been accepted by the CCEs of the countries with the majority of chiropractic colleges. DigitalC00:00, 3 June 2008 (UTC)

"Health care professionals with advanced clinical degrees can meet the educational and clinical requirements to practice as a chiropractor in 2200 hours." Again, this is part of a international guideline, not strictly a requirement; this is not made clear in the text. Also, it's not made clear that the 2200 hours includes 1000 hours of supervised clinical training. Eubulides05:13, 31 May 2008 (UTC)

*"not less than 2,200 hours over a two or three-year full-time or part time program, including not less than 1000 hours of supervised clinical training" - The 2200 hours includes the 1000 hours, however I agree that it should be worded to clarify that this is a guidelines, not a requirement. On the other hand, we may be giving undue weight to the 2200 hours by including it, as I don't know if this recommendation is followed anywhere.

** Thanks, I'd support removing the 2200 hours issue from here, and moving it to Chiropractic education. It is rather an unimportant detail. Eubulides08:39, 2 June 2008 (UTC)

"Upon meeting all clinical and didactic requirements of chiropractic school, a degree in chiropractic medicine is granted." This sentence is too much detail and is unsourced. At the very least it needs to be sourced. Eubulides05:13, 31 May 2008 (UTC)

*"Upon meeting all clinical and didactic requirements of chiropractic school, a degree in chiropractic medicine is granted. The chiropractor may then be required to pass national, state, or provincial boards before being licensed to practice in a particular jurisdiction." I recommend that this is changed to "Upon finishing chiropractic education, the chiropractor may then be required to pass national, state or provincial boards before bring licensed to practice in a particular location". I disagree that this needs to be sourced. See ReferenceWhen_adding_material_that_is_challenged_or_likely_to_be_challenged. This is not the type of material that is contentious and likely to be challenged. On the otherhand, in QG's draft 6 (now struck out), he uses http://www.life.edu/Current_Students/licensure.asp this site as a reference, which might satisfy requests of other editors, as may this http://www.cceb.ca/home/lang-pref/en/. DigitalC11:16, 31 May 2008 (UTC)

** That wording is much better, thanks. Some quibbles: non-experts won't know what "boards" are, so perhaps change "boards" to "examinations"? Also, change "national, state or provincial" to "national or local", for brevity and completeness (it could be that some localities are neither states nor provinces). Finally, it should be cited, and any one of the local sources would suffice as a citation for this (less-general) claim. Eubulides08:39, 2 June 2008 (UTC)

***How about "board examinations"? Does local really imply provincial or state level? Refernces are directly above your comment and can easily be incorporated. DigitalC00:00, 3 June 2008 (UTC)

****"Board examinations" would be better, thanks. Sorry, I guess I assumed there were exams in countries other than the U.S., Canada, and Australia, countries that might not have either states or provinces. But now that I think of it, those are the only 3 countries that have board exams, right? In that case, the list of the 3 countries should be mentioned, to avoid giving the incorrect impression that this is a universal practice. Eubulides06:34, 3 June 2008 (UTC)

*****Its not just these 3 countries. For example, to practice in Europe or Australasia, one may need to write 'board' exams. The term 'board' exam is used, although it may be an exam for a regulatory college, or CCE exam. I don't see how it could give the impression that it is a universal practice, as it states "the chiropractor may then be required to pass national, state or provincial..." (my emphasis).

"The chiropractor may then be required to pass national, state, or provincial boards before being licensed to practice in a particular jurisdiction. Depending on the state or province, continuing education (CE) may be required to renew these licenses and chiropractors may further specialize in fields such as Chiropractic Orthopedics (DABCO), Chiropractic Radiology (DABCR), and Chiropractic Sports Physician (DABCSP) by completing additional study and passing specified boards that are separate and distinctly different than medical boards." This material is completely unsourced. It needs a source. There is some duplication between this material and the "radiology" and "sports sciences" of Chiropractic Scope of practice; I suggest trimming the material either here or there, as we don't need it both places. Eubulides05:13, 31 May 2008 (UTC)

*I'm not sure which section it is better in, Scope of Practice, or Education. I think that Education is probably a better spot for it, although a blurb that they can specialize would still be good in SOP. DigitalC00:24, 3 June 2008 (UTC)

"In the United States, chiropractic schools are accredited through the Council on Chiropractic Education (CCE) and recognized by the US Department of Education with the stated purpose of insuring the quality of chiropractic education by means of accreditation, educational improvement and public information and allowing for grants and loans to chiropractic schools and prospective chiropractic students." This material needs to be sourced. Does the DoE really recognize chiropractic schools directly? Also, this stuff is really boring and too much detail and doen't all belong here. "insuring the quality of"? "public information"? "grants and loans"? "prospective chiropractic students"? My goodness but the unnecessary words are really thick here.

"Recently, CCE standards were integrated into the English speaking countries of Australia/New Zealand, Canada, and Europe. These councils have since developed CCE - International in an effort to maintain chiropractic education standards globally.http://www.cceintl.org/ The cited source says nothing about "recently" or "integrated" or "Australia" or "New Zealand" or "Canada" or "Europe". The text needs to be reworded to match the source, or a better source found. Eubulides05:13, 31 May 2008 (UTC)

*I propose a rewording to "The US CCE has integrated with CCEs in Australia, Canada, and Europe forming CCE - International to "assure excellence in chiropractic education and quality in the profession through accreditation"using http://home.earthlink.net/~ccei/id15.html this as a reference. DigitalC11:47, 31 May 2008 (UTC)

**That's better, but it still says "integrated". CCE - International is not an "integration". The quote is not accurate, as it contains wording like "assure" that is not in the source. (Ouch! Quotes "must" be accurate.) But let's not simply quote the source; let's say what CCEI does. CCEI's main accomplishment is to generate model accreditation standards with the goal of having credentials be portable internationally.http://www.cceintl.org/id2.html Let's say this rather than quoting its nearly-vacuous text about "excellence in chiropractic education". Eubulides08:39, 2 June 2008 (UTC)

***CCE-I is an integration, the source uses "join" (as in "join together" to "form one whole"). Further, the quote IS accurate, and the word "assure" is directly from the source, directly from the quoted section. DigitalC00:00, 3 June 2008 (UTC)

**** Sorry about the quote: I must have been looking at the wrong citation. You're right, the quote is indeed accurate. However, the other points remain: let's talk about what CCEI does rather than just quoting their blurb about "excellence". Eubulides06:34, 3 June 2008 (UTC)

"Today, there are 18 accredited Doctor of Chiropractic programs in the USA, 2 in Canada, and 4 in Europe and the UK.cite web |title= Accredited Doctor of Chiropractic programs |url=http://cce-usa.org/adcp.php |publisher= The Council on Chiropractic Education |accessdate=2008-02-22cite web | url = http://www.chirofed.ca/english/accreditation.html | title = CFCREAB - Accreditation of Educational Programmes | format = | work = | accessdate = 2008-05-28cite web | url = http://www.cce-europe.org/institutions.php | title = | format = | work = | accessdate =2008-05-28" The cited sources cover just the U.S. and Canada; they do not mention Europe. Please just copy the sentence and citations from Education, licensing, and regulation 6.

"Regulatory colleges and chiropractic boards are responsible for protecting the public, standards of practice, disciplinary issues, quality assurance and maintenance of competency.cite web |url=http://www.ccachiro.org/Client/cca/cca.nsf/web/Facts%20%26%20FAQs |title=Facts FAQs |accessdate=2008-05-08 |publisher=Canadian Chiropractic Association" The cited source is just about Canada, and only about regulatory colleges; it does not mention chiropractic boards. Eubulides05:13, 31 May 2008 (UTC)

*If we include the following reference http://www.fclb.org/QA.htm as well, it will also cover boards. DigitalC12:14, 31 May 2008 (UTC)

**Yes, that covers the boards (in the U.S.), but there's still the issue about Canada colleges vs. boards and the U.S. Eubulides08:39, 2 June 2008 (UTC)

***Ah, I see what you are saying here. I think that is easily fixed with an and/or statement, as each location would have one or the other. So "Regulatory college and/or chiropractic boards are responsible..." DigitalC00:24, 3 June 2008 (UTC) in hindsight, I don't think an and/or would work. In fact, I think it is fine the way it is. Reguatory boards, AND regulatory colleges are repsonsible, just not in the same jurisdiction. x DigitalC 03:55, 3 June 2008 (UTC)

****I suppose so. But now the current draft says there are colleges or boards in Mexico! How did that sneak in? I didn't see Mexico in the sources when I read them earlier. Is it really true that Mexico has boards? Eubulides06:34, 3 June 2008 (UTC)

*****Yes they have a regulatory college, the "Colegio De Profesionistas Cientifico-Quiropracticos De Mexico" (College of Professional Scienfific-Chiropractors of Mexico). As currently referenced. DigitalC07:08, 3 June 2008 (UTC)

"The Federation of Chiropractic Licensing Boards (FCLB) oversees most of these regulatory bodies.http://www.fclb.org/boards.htm" The cited source does not mention "overseeing"; it's just a list of member bodies. The FCLB is more of a clearinghouse and forum; it does not have a formal oversight role. Eubulides05:13, 31 May 2008 (UTC)

*I agree with Eubulides that the FCLB does not oversee the boards, and I think it may be undue weight to mention the FCLB in this section. DigitalC12:14, 31 May 2008 (UTC)

Nothing is said about the distinction between straight and mixer schools. (QuackGuru also raised this point.) The straight/mixer distinction is worth mentioning briefly here, far more than the eye-glazing material about student loans. We do have a source for it, no? Eubulides05:13, 31 May 2008 (UTC)

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

Thanks. Eubulides05:13, 31 May 2008 (UTC)

:*"The cited sources cover just the U.S. and Canada; they do not mention Europe." The cited source clearly mentioned Europe, however there was a formatting error in the citation template. DigitalC09:37, 31 May 2008 (UTC)resolved

""Most commonly, chiropractors obtain a first professional degree in Chiropractic medicine (DC or DCM).198" The cited source does not say anything about "Most commonly". It says only that DC or DCM are the recognized first-professional degrees. The source is a U.S. source so this would be for the U.S., which should be stated in the text (or a better source should be found)." I think the best way around this is to use QuackGurus wording, which is "Most commonly, chiropractors obtain a first professional degree in the field of chiropractic medicine." this then covers the B.AppSci, M.Sc (Chiro) etc. DigitalC09:52, 31 May 2008 (UTC)

"In North America, a 3 year university undergraduate education (90 semester hours) is required before applying to chiropractic college" - This should be changed to "In the United States...", using the http://www.cce-usa.org/uploads/File/2007%20January%20STANDARDS.pdf CCE standards as a ref (p. 22). This is not true for Mexico or Canada(UQTR). Although, I guess using a CMCC reference as well, it could be said for Canada and the US, since UQTR is a university, not a chiropractic college... but thats just semantics. FTR, UQTR students enter directly from CEGEP Possibly inaccurate information struck - UQTR is accredited by CFCREAB, as such must follow its standards.DigitalC10:04, 31 May 2008 (UTC)

:*"followed by no less than 4200 student/teacher contact hours (or the equivalent) in four years of full‐time education. This includes a minimum of 1000 hours of supervised clinical training." Again, this should be referenced using the http://www.cce-usa.org/uploads/File/2007%20January%20STANDARDS.pdf CCE standards and http://www.cfcrb.org/english/pdf/Standards_for_Doctor_of_Chiropractic_Programmes.pdf CFCRB standards, removing the 1000 hours part, which isn't mentioned in either document. Or, as Eubulides mentioned, it could all be rephrased to show the suggestions of the WHO, although I think its better to show the requirements. DigitalC10:32, 31 May 2008 (UTC)resolved

"It's tacky to have such an extensive quote. This should be reworded and trimmed. This sort of yawningly-boring detail is not needed in Chiropractic; it might be suited for Chiropractic education." It is interesting to see differing POVs (and I'm not talking NPOV here). I actually see this section as one of the highlights of this draft. It breaks up with wall of text with some bullet points. I see no reason to not quote the source here, and don't find it tacky. I also see this as an important detail, not a boring detail. There isn't Policy over this type of thing, so it is best to get further input on disagreements like this. DigitalC10:39, 31 May 2008 (UTC)

Unfortunately, it seems like Vassyana's plea to avoid nitpicking over minutiae was not followed by a couple of editors. I also disagree with Eubulides' claim that version 6 is "far better sourced". To me this is more of IDONTLIKEIT than genuine concerns about content. There is a continuous attempt to remove the educational paths from the cited WHO source. Besides Eubulides personal opinion of it being 'boring' is there a more valid reason why it shouldn't be included? CorticoSpinal18:16, 31 May 2008 (UTC)

Take another look at 3

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

The long end run of WHO quotes is boooring stuff and undueweight. QuackGuru09:47, 1 June 2008 (UTC)

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

They are just suggestions and guidelines and not something official. No reason has been given to give so much weight to something unofficial. This is the section on education and not education suggestions. Too much weight is being given for the suggestions. Besides, they are boring. There is a chiropractic education article for more detailed stuff. QuackGuru16:00, 1 June 2008 (UTC)

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

I thought there was more detailed info about CCE - International but it got deleted. "The WHO guidelines, especially using your suggestion to use the word "suggests", seems to be a good way to handle it?" I disagree. The best way to handle the quotes is to delete the quotes. Draft 3 is very disappointing and a big step backwards. Draft 3 has been chopped up and detailed information has removed and the long WHO quotes remain. QuackGuru20:43, 1 June 2008 (UTC)

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

What is it that you oppose about the "WHO guidelines on basic training and safety in chiropractic"? Also, why is it that you feel that these are "not something official"? They are the official WHO guidelines. DigitalC01:35, 2 June 2008 (UTC)

The guidelines does not always equal official standards. The guidelines are suggestions according to draft number 3. The quotes are boring, they are too long, and have weight problems. At this point, this draft has too many problems. This draft has things backwards. The boring quotes have been kept and useful information has been removed. For potential chiropractors, this section is essential. I hope we can create something that is both detailed and concise. I do not understand why quality information has been removed. QuackGuru02:41, 2 June 2008 (UTC)

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

QG, Just because the guidelines are recommendations/suggestions (thats what a guideline is, a guideline is not a requirement) does not mean they are not official. I for one think that they are what set this draft apart from the others as being better, and disagree with the assertion that they "are boring and are too long", which is really just a personal point of view. Specifically, which quality information was removed that you are objecting to? I believe that some things were removed per RS, and others due to UNDUE. DigitalC04:27, 2 June 2008 (UTC)

The guidelines are not official world stanadards. The end run of quotes can be removed due to UNDUE. QuackGuru02:22, 3 June 2008 (UTC)

Please read my previous comments along with this http://en.wikipedia.org/w/index.php?title=Talk%3AChiropracticdiff=216539742oldid=216536490 edit summary. QuackGuru19:45, 2 June 2008 (UTC)

I have read your previous comments, and they do not provide a valid reason for objecting to the WHO guidelines, nor do they explain specifically which "quality information" you object to the removal of. DigitalC00:36, 3 June 2008 (UTC)

And in reply to your subsequent edit, no one is stating that they ARE official world standards. However, they are official WHO guidelines. Again, this is not a reason for their removal, and I don't see how it is undue weight. DigitalC03:15, 3 June 2008 (UTC)

They are not official world standards. So therefore too much weight is being given to have long block quotes for merely suggestions. QuackGuru03:47, 3 June 2008 (UTC)

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

"Most commonly" The cited source does not say anything about "Most commonly".

*deleted. -- Dematt Dēmatt 14:13, 3 June 2008 (UTC)

"In the U.S., minimum prerequisites" is supported by two sources, one of which is for Canada, not the U.S. Please drop the Canadian reference, or rewrite the text to match the source.

*rewrote. -- Dematt Dēmatt 14:13, 3 June 2008 (UTC)

"followed by no less than 4200 student/teacher contact hours". This sentence is worded as if the 4200 hours are a prerequisite for applying to chiropractic school! Please fix the wording. The 4200 hours are during school, not a prerequisite for school.

*rewrote. -- Dematt Dēmatt 14:13, 3 June 2008 (UTC)

Again, the quoted three bullet-points should be shortened and summarized. I'm not opposed to the material, or even to the bullets; but there is too much detail here.

*I think the quote is likely the most succinct I can think to write it. You can give it a try, but I like the bullets. -- Dematt Dēmatt 14:13, 3 June 2008 (UTC)

The 2200 hours are part of the same suggestion as the 4200 hours; this should be stated. Also, the 1000 hours applies equally to the 4200 hours and to the 2200 hours. This should also be stated.

*Not clear on this one. -- Dematt Dēmatt 14:13, 3 June 2008 (UTC)

"state or provincial" - "local"

*some provinces or states could be HUGE. Local sounds small. -- Dematt Dēmatt 14:13, 3 June 2008 (UTC)

A source is needed for "Upon finishing .... licenses". And a period is needed after it.

*Really?

"has integrated with" isn't supported by the source.

*How about "joined". -- Dematt Dēmatt 14:13, 3 June 2008 (UTC)

The "assure excellence in ... accreditation" quote is fluff. Just say that the CCE-I has generated model accreditation standards with the goal of having credentials be portable internationally.http://www.cceintl.org/id2.html It's much better to say what the CCE-I has done than to quote its fluff about what it wants to do.

*agree, rewrote. -- Dematt Dēmatt 14:13, 3 June 2008 (UTC)

"Regulatory colleges and chiropractic boards..." The cited source says this is true for the U.S., Canada, and Australia, but apparently it's not true elsewhere. Please mention that this statement applies only to these 3 countries.

*It may be true elsewhere. If we just put in those three, we lose others. -- Dematt Dēmatt 14:13, 3 June 2008 (UTC)

Hope this helps. Eubulides08:39, 2 June 2008 (UTC)

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

So are we ready to insert education 3 into mainspace? DigitalC23:10, 10 June 2008 (UTC)

Comments on Education, licensing, and regulation drafts

A Chiropractic Examining Board requires all candidates to complete a twelve-month clinical internship to obtain licensure.Fact|date=May 2008

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

I found a couple of refs that might be useful. I suggest we improve the above draft to replace the current section. Thoughts? QuackGuru16:31, 27 May 2008 (UTC)

The proposed additions (in Education, licensing, and regulation 1) to Chiropractic Education, licensing, and regulation draft are an improvement. Thanks for making the proposal here, and avoiding the temptation to edit directly. Eubulides16:59, 27 May 2008 (UTC)

This draft (again) omits the various education degrees granted. Why do you keep on trying to delete this key piece of information? Also, you omitted all the new citations too which are relevant. Chiropractic education, licensing and regulation covers ALL of it, not just present tense. Please include those sections. Thanks. CorticoSpinal17:02, 27 May 2008 (UTC)

None of the drafts specifically mentions any degrees. It's not a key piece of information at any rate, to say whether it's DC Flavor A or DC flavor B. It would be relevant and useful to mention DC. I suggest mentioning that. Currently the article uses the acronym "DC" without defining it, which is a real shortcoming, and the "Education" section is the logical place to define it. Eubulides20:52, 27 May 2008 (UTC)

Actually, this proves how you don't get it. Only in North America are they DCs. Overseas they're MSc (Chiro) or BSc (Chiro). Skeptics claim there is no such thing as chiropractic science. I present evidence of the contrary. Not only that, it's a minimum of 7 years of schooling in North America, that's not the case overseas. Anyways, your argument has problems with logical fallacies. CorticoSpinal22:43, 27 May 2008 (UTC)

None of the drafts specifically mentions any degrees, wither DC or MSc (Chiro) or BSc (Chiro). This is a shortcoming in all the drafts. This has nothing to do with chiropractic science; it's an issue of which degrees are granted. Eubulides09:05, 28 May 2008 (UTC)

I think the point CorticoSpinal is trying to make is that these are 1) Different degrees than the DC/DCM, 2) That they are Bachelors of Science (or B. Appl Sci (Chiro)) or Masters of Science from publicly funded universities. Therefore, when critics say that these Chiropractors are anti-science, they are calling into question the reputability of Science degrees from these institutions. DigitalC05:53, 29 May 2008 (UTC)

Bingo Where's Orangemarlin when you need him? ;) CorticoSpinal06:15, 29 May 2008 (UTC)

A sentence asserts the guidelines are official guidelines. Are the guidelines "official" guidelines or merely suggestions. The next sentence says: The WHO guidelines suggest... This is confusing. QuackGuru17:30, 27 May 2008 (UTC)

Official guidelines are still just that - guidelines. They are not requirements. DigitalC05:53, 29 May 2008 (UTC)

Seeing as Eubulides keeps on deleting cited material and is trying to water down education (as he attempted with scope of practice) I have included a succint draft that introduces the salient points. "'It is critical to include the different degrees DCs get, not all chiropractors receive the doctorate in chiropractic."' Some programs are 4 years, some are 5, some are Masters of Science some are Bachelors of Science. These are important facts to note. Chiroskeptics who claim chiropractic is fringe must deal with the fact that outside the US, chiropractic is integrated in public universities and are receiving Bachelors and Masters degrees OF SCIENCE. These are mixer schools; they're not promoting straight/Palmer chiropractic. The skeptics here only want that side of the story covered (even though they form a minority) and obstruct any attempts to tell the other side and especially a non-US side. CorticoSpinal18:58, 27 May 2008 (UTC)

"Keeps on deleting"? I have not deleted any material from Chiropractic Education, licensing, and regulation since May 14. We are discussing possible improvements, not any actions I have taken on Chiropractic.

It is not "watering down" to remove boring and overly detailed material. On the contrary, it strengthens Chiropractic to limit it to highly-useful and relevant material.

* The boring material you refer is notable enough for the WHO. It's not boring Eubulides if it's not controversial. All your edits here either play up controversy by using poor sources such as Ernst, Ernst-Cantor, or attempt to drum some up out of nowhere. CorticoSpinal23:30, 27 May 2008 (UTC)

The WHO generates reams and reams of boring material. Eubulides09:05, 28 May 2008 (UTC)

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

That level of detail doesn't belong here? It's less than 10 words. Why are you fighting so hard to prevent it's inclusion. Even Dematt's draft has included it. CorticoSpinal23:30, 27 May 2008 (UTC)

We are talking about far more than 10 words of boring material. Eubulides09:05, 28 May 2008 (UTC)

To each their own I suppose. So to clarify, you object to listing the various educational paths for lincensure throughout the globe? CorticoSpinal16:52, 28 May 2008 (UTC)

Yes. That is excessive detail here. It should be in Chiropractic education. Eubulides21:19, 28 May 2008 (UTC)

You seem to dispute all the details Eubulides. DigitalC has also said you have been pedantic. I would use tendentious, but that's just me. Either way, you might want to look at what admin Vassyana said yesterday, here, about arguing http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=prevoldid=215453098 minutiae. Thanks. CorticoSpinal06:08, 29 May 2008 (UTC)

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

Eubulides

20:52, 27 May 2008 (UTC)

Dematt's draft is superior to both yours and mine. I endorse his draft. It would be nice if you could compromise too and let Dematt try to work his magic. Thanks. CorticoSpinal23:30, 27 May 2008 (UTC)

I am sure we can work together starting with Dematt's draft. But it will need a lot of work, as described elsewhere. Eubulides09:05, 28 May 2008 (UTC)

Doubt it needs as much work as you imply, but its agreed that we shall use Dematts draft as the template and starting point. CorticoSpinal16:52, 28 May 2008 (UTC)

Well, I'm in Britain and things are pretty much exactly the same here. Jefffire19:48, 27 May 2008 (UTC)

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

I'm not aware of any significant differences between the quality of UK and US MD's, but what I meant is that Chiropractic is not considered mainstream medicine. I wouldn't say it any more integrated than in the US. Jefffire21:00, 27 May 2008 (UTC)

Something tells me it is more integrated than the US and that the BCA said chiropractic had the most potential to be integrated in the mainstream. I'll ask my colleague at AACC for materials/sources that can shed more light. CorticoSpinal23:30, 27 May 2008 (UTC)

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

If Jefffire would be so kind to perhaps tell us a bit about the educational system in the UK that would be helpful. I'm aware of Anglo-European, Welsh Institute and McTimmoney. I believe the first two have formal associations with universities as well. One of the biggest oversights of the article is it's heavy US-centric look without giving the rest of the chiropractic world their due. There is now officially more schools of chiropractic outside the US than within in. Also, all schools except New Zealand are mixer. So, of the 35 schools of chiropractic in the world, I believe only 7-8 are straight with 6-7 coming from the USA. USA is the only jurisdiction in the world whereby the education is divided into straight or progressive (mixer). These details need to be in the article. They're important for various reasons. CorticoSpinal20:14, 27 May 2008 (UTC)

Details about things like the Welsh Institute's funding arrangements do not need to be in Chiropractic. They can be in Chiropractic education. Eubulides20:52, 27 May 2008 (UTC)

Who mentioned anything about funding arrangements? CorticoSpinal23:30, 27 May 2008 (UTC)

The main point, as I understand it, is that the chiropractic colleges outside the U.S. are at government-sponsored universities. Eubulides09:05, 28 May 2008 (UTC)

The main point is that, outside the US, chiropractic education is almost exclusively taught in public universities which is in contrast to the US where its almost exclusively private schools (except Bridgeport). CorticoSpinal16:52, 28 May 2008 (UTC)

Yes, that's the main point, and it can be made without a long list of countries. Eubulides21:19, 28 May 2008 (UTC)

IMHO, I think Dematt's (3) version above is the most clear and concisely written. That said, I do like the way that CorticoSpinal's version opens with a brief overview of the history of chiropractic education. I agree that there should be a section (perhaps separate from education) discussing regulation and licensing. -- Levine211220:45, 27 May 2008 (UTC)

Dematt's may be clear and concise, but it has serious problems with citations and POV. Please see I lost track below for more details. Eubulides20:52, 27 May 2008 (UTC)

Draft 1 is too much of a mess to work with and suffers from more citation and NPOV issues. Let's start with Dematt's version as a base of this discussion and work out a consensual version from there. See below. -- Levine211221:33, 27 May 2008 (UTC)

All the drafts have serious citation problems; Draft 1 has the fewest. NPOV is harder to measure. We can start with any of the versions, of course; Dematt's hasn't addressed more of the bullets in Education draft needed work, but it may well be that it's easier to fix those bullets one by one in a better-structured draft. Eubulides21:56, 27 May 2008 (UTC)

I support Dematt's draft as a compromise. Eubulides' complaints regarding citations are not valid. Your opinion on draft 1 is just that, an opinion. Which I do not share. So, please, stop pushing your views on the rest of of us. Thanks. CorticoSpinal22:33, 27 May 2008 (UTC)

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

Dematt, I think it would be preferred that rather than highlighting the US CCE we use the http://www.cceintl.org/ Council on Chiropractic Education International. This is more globally representative and represents the CCE(USA) CCE(Canada) the CCE(Europe) and the CCE(Oz). There might be good tibits in there too. CorticoSpinal16:41, 28 May 2008 (UTC)

I continue to be puzzled by which of the drafts is currently worth reviewing. Edits seem to be happening to two sets of drafts at the same time. This makes it very difficult to follow the intent. Can someone please explain what's going on vis-a-vis these drafts? Thanks. Eubulides08:47, 29 May 2008 (UTC)

Improving the cost-benefit section

I finally sprung some time free to review the ChiropracticCost-benefit section, which got http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=212339642oldid=212336675 added on May 14 without previous discussion, and which has mutated a bit since then without much discussion. Here are my comments, along with a proposed rewrite Cost benefit 2. Please comment at Cost-effectiveness 2 comments. Eubulides23:46, 4 June 2008 (UTC)

The sources tend to prefer "cost-effectiveness" to "cost-benefit", so the section title and discussion should use "cost-effectiveness". Eubulides23:46, 4 June 2008 (UTC)

The organization of the section is confusing. For example, it starts off with the cost-effectiveness of maintenance care, which one would expect to find later (as maintenance care comes after initial care). Eubulides23:46, 4 June 2008 (UTC)

Sentences often do not hook together well. They often seem to be isolated sentences without any connection. Contradictory sentences are sometimes put next to each other, with no explanation. Eubulides23:46, 4 June 2008 (UTC)

"The cost-effectiveness of maintenance chiropractic care is unknown and not well researched. Of the limited quantity of studies found, there is diversity in the findings." The source (Leboeuf-Yde C Hestbæk 2008, PMID|18466623)cite journal |journal= Chiropr Osteopat |date=2008 |volume=16 |issue=1 |pages=3 |title= Maintenance care in chiropractic - what do we know? |author= Leboeuf-Yde C, Hestbæk L |doi=10.1186/1746-1340-16-3 |pmid=18466623 |url=http://chiroandosteo.com/content/pdf/1746-1340-16-3.pdf |format=PDF says only that the cost-effectiveness is unknown. The bit about "there is diversity in findings" is not about cost-effectiveness; it is about other properties of maintenance care. This should be reworded to simply say "The cost-effectiveness of maintenance chiropractic care is unknown." Eubulides23:46, 4 June 2008 (UTC)

"Of the various interventions available, the most cost-effective treatment for lower back pain could not be determined because of the lack of more higher quality evaluations." The "could not be determined" leaves the reader hanging. "Could not be determined" by whom? More context is needed here. Eubulides23:46, 4 June 2008 (UTC)

"Spinal manipulation appears to be relatively cost-effective for chronic lower back pain." This directly contradicts the previous sentence, but the contradiction is not addressed or explained. Also, this cites a primary source for chronic low back pain (Haas "et al." 2005, PMID|16226622), not a secondary review. As per 18164469). This secondary source addresses cost-effectiveness for chronic low back pain, citing several high-quality primary sources. I suggest using the sentence "A 2008 review of treatments for chronic low back pain found two studies reporting no difference in cost-effectiveness for chiropractic versus physical therapy, one arguing for cost savings for chiropractic versus hospital outpatient management, and one, and one concluding that SMT is a cost-effective addition to general-practice best care." Eubulides23:46, 4 June 2008 (UTC)

"The cost-effectiveness of spinal manipulation therapy has not been demonstrated beyond a reasonable doubt." Again, this contradicts the previous sentence. More context is needed. This sentence is citing a critical review (Ernst 2008, PMID|18280103). I suggest rewording it to "A critical 2008 review concluded that the cost-effectiveness of chiropractic spinal manipulation has not been demonstrated beyond reasonable doubt." But (looking below) I see that this sentence is largely duplicative of another sentence supported by a more-specific Ernst review. Let's remove this sentence; it doesn't really add anything. Eubulides23:46, 4 June 2008 (UTC)

"The data indicates that SMT typically represents an additional cost to conventional treatment." This sentence is about cost, but the section is about cost-effectiveness. The article should be mentioning the cost-effectiveness results of the source, not its cost results. I suggest "A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain." Eubulides23:46, 4 June 2008 (UTC)

"After initial therapy, preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care." This cites an older review (Cherkin "et al." 2003, PMID|12779300) and is superseded by information already given supported by newer reviews on the same subject; it should be removed. Eubulides23:46, 4 June 2008 (UTC)

"Chiropractic managed care may reduce overall health care costs." This cites a primary study (Legorreta "et al." 2004, PMID|15477432) that is already covered by the already-cited recent reviews; as per MEDRS it should be removed. Eubulides23:46, 4 June 2008 (UTC)

"When comparing primary care physicians (PCPs) medical management to nonsurgical nonpharmaceutical chiropractic management approaches (CAM-oriented PCPs), a followup study demonstrated with some reservations both a reduction in clinical and cost utilization of in-hospital admissions, hospital days, outpatient surgeries and procedures, and pharmaceutical costs when compared with using conventional medicine IPA performance alone." This is about cost, not cost-effectiveness. Also, this is a relatively extensive discussion of a primary study (Sarnat "et al." 2007, PMID|17509435) that is too recent to be reviewed. We must take great care in citing primary studies as per MEDRS. Since the primary study is not about cost-effectiveness this one is an easy call: it doesn't belong here and let's remove it. Eubulides23:46, 4 June 2008 (UTC)

"An initial study found that the benefits of chiropractic care for neck pain seem to outweigh the possible risk." This cites a primary study (Rubinstein "et al." 2007, PMID|17693331) so as per MEDRS should be scrutinized closely. The study is about risk-benefit, not cost-benefit, so it's a bit dubious to put it here. As mentioned above, in Comments on 2008-05-25 issues list, the source is dubious, as it has no control groupof any kind, and it has no risk-benefit model to support its claim that the "the benefits of chiropractic care for neck pain seem to outweigh the potential risks". Since this study is misplaced in Chiropractic now, one possible fix is to move the risk part of this study to ChiropracticSafety and the benefit part to ChiropracticEffectiveness; but a simpler fix, given the MEDRS issue, is to omit this sentence from the article. If it is included somewhere, the info should be clearly identified as coming from just one primary study. Eubulides23:46, 4 June 2008 (UTC)

"When compared with treatment options such as physiotherapeutic exercise (also performed by a chiropractor), the risk-benefit balance does not favor SMT." Again, this is about risk-benefit, not cost-benefit, so it doesn't really belong here. A much better home for this statement is Chiropractic Safety. However, I suggest omitting it from the article entirely, as the review (Ernst Canter 2006, PMID|16574972)cite journal |journal= J R Soc Med |date=2006 |volume=99 |issue=4 |pages=192–6 |title= A systematic review of systematic reviews of spinal manipulation |author= Ernst E, Canter PH |doi=10.1258/jrsm.99.4.192 |pmid=16574972 |url=http://www.jrsm.org/cgi/content/full/99/4/192 doesn't have a risk-benefit model and its assertion about risk vs benefit is not well supported. I suppose it could be included if the Rubinstein "et al." is included, but neither source inspires much confidence on this particular point. Eubulides23:46, 4 June 2008 (UTC)

"In occupational low back pain, the research found that shorter chiropractor care had a benefit for reducing work-disability recurrence and a longer chiropractic care did not show a benefit for preventing work-disability recurrence." This is about benefit, not cost-benefit. It cites a primary study (Wasiak "et al." 2007, PMID|18000417) and should be scrutinized carefully as per MEDRS. It doesn't really belong in this article, as ChiropracticEffectiveness is already chock-full of more-relevant claims supported by reviews. Eubulides23:46, 4 June 2008 (UTC)

"SMT helps to reduce time lost due to workplace back pain, and thus employer savings." This cites one ancient source (Frank "et al." 1998, PMID|9645178) and one older non-peer-reviewed consultant reporthttp://www.wsib.on.ca/wsib/wsibsite.nsf/LookupFiles/DownloadableFileALBIEvaluationReport/$File/ALBIReport.pdf. Both sources are too low in quality to make the cut here. Also, the claim is not about cost-effectiveness; it is merely about benefits. It should be removed. Eubulides23:46, 4 June 2008 (UTC)

Here's the draft rewrite. Again, please comment at Cost-effectiveness 2 comments below. Eubulides23:46, 4 June 2008 (UTC)

Cost-effectiveness 2

A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=9 |pages=707–25 |title= Health services research related to chiropractic: review and recommendations for research prioritization by the chiropractic profession |author= Mootz RD, Hansen DT, Breen A, Killinger LZ, Nelson C |doi=10.1016/j.jmpt.2006.09.001 |pmid=17142165 A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain.cite journal |journal= Evid Based Complement Alternat Med |date=2006 |volume=3 |issue=4 |pages=425–32 |title= Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425 A 2005 systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention.cite journal |journal= Best Pract Res Clin Rheumatol |date=2005 |volume=19 |issue=4 |pages=671–84 |title= What is the most cost-effective treatment for patients with low back pain? a systematic review |author= van der Roer N, Goossens MEJB, Evers SMAA, van Tulder MW |doi=10.1016/j.berh.2005.03.007 |pmid=15949783 The cost-effectiveness of maintenance chiropractic care is unknown.

Cost-effectiveness 2 comments

"(Please add comments here.)" Eubulides23:46, 4 June 2008 (UTC)

A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific placebo effects) remains uncertain.cite journal |journal= Evid Based Complement Alternat Med |date=2006 |volume=3 |issue=4 |pages=425–32 |title= Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425

*I don't see any of this in the source. Do we have the right one? -- Dematt Dēmatt 01:22, 5 June 2008 (UTC)

I just now checked the source, and the following quotes support the abovementioned claim. First, the abstract says "Estimates of the incremental cost of achieving improvements in quality of life compare favorably with other treatments approved for use in the National Health Service. Because the specific efficacy of the complementary therapies for these indications remains uncertain, and the studies did not include sham controls, the estimates obtained may represent the cost-effectiveness of non-specific effects associated with the complementary therapies." Second, the discussion section says: "Second, estimates of cost-effectiveness based on data from clinical trials without sham controls compare favorably with other treatments approved for use in the NHS. Third, the specific treatment effects of the complementary therapies for the indications in question remains uncertain. We therefore strongly suspect that such studies may be estimating the cost-effectiveness of non-specific treatment effects." Eubulides07:05, 5 June 2008 (UTC)

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

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

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

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

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

"A 2006 UK systematic cost-effectiveness review found that reports on complementary care that are based on data from clinical trials without sham controls remains uncertain.cite journal |journal= Evid Based Complement Alternat Med |date=2006 |volume=3 |issue=4 |pages=425–32 |title= Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425"

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

Canter "et al."39;s conclusions were based not only on the Meade "et al." studies that you mention, but also on the UK Beam studies on low back pain, which also involved chiropractors (along with other professions). The UK Beam studies generated results more-favorable to chiropractic, and these results caused Canter "et al."39;s overall conclusions to be more favorable to chiropractic than they otherwise would have been. This explains why the wording proposed in Cost-effectiveness 2:

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

is more favorable to chiropractic than the wording you propose:

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

Eubulides

19:46, 5 June 2008 (UTC)

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

A 2005 systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention.cite journal |journal= Best Pract Res Clin Rheumatol |date=2005 |volume=19 |issue=4 |pages=671–84 |title= What is the most cost-effective treatment for patients with low back pain? a systematic review |author= van der Roer N, Goossens MEJB, Evers SMAA, van Tulder MW |doi=10.1016/j.berh.2005.03.007 |pmid=15949783 The cost-effectiveness of maintenance chiropractic care is unknown.

*I haven't read the sources yet, but if this is what they are saying then why do we want a cost effectiveness section? Just to say we can say we don't know anything seems to be a waste of space? -- Dematt Dēmatt 01:26, 5 June 2008 (UTC)

** There are many claims on the Internet that chiropractic care is more cost-effective than common alternatives. Chiropractic itself made such a claim pretty much continuously from August 2006http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=70133831oldid=70117359 to May 12,http://en.wikipedia.org/w/index.php?title=Chiropracticoldid=211766313 a period during which Chiropractic cited several obsolete reports supporting the claim. There is clearly significant interest in cost-effectiveness, both among Wikipedia editors and in the scholarly literature, so it's worth a brief mention from recent high-quality reviews saying the topic lacks good evidence. Eubulides07:05, 5 June 2008 (UTC)

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

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

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

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

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

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

But Canter "et al." 2006 doesn't say chiropractic methods are not efficacious. So their discussion of cost-effectiveness would not be moot if chiropractic methods were determined to be efficacious. Eubulides06:12, 6 June 2008 (UTC)

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

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

OK, I followed up below. Eubulides17:43, 6 June 2008 (UTC)

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

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

This is the "Cost-effectiveness" section, so the only part of Bronfort "et al." that's relevant is its discussion of cost-effectiveness. Bronfort "et al." is also cited (twice) in ChiropracticEffectiveness: there, we're relying on the paper's efficacy discussion. It is a big paper and it has results relevants to multiple sections of Chiropractic.

Which statement are we attributing to Bronfort "et al." that they are not actually making?

I'd rather not cite primary sources directly; I'd rather cite a high-quality review like Bronfort "et al."

Bronfort "et al." is not merely about efficacy of SMT for chronic low back pain; it is about all aspects of management of CLBP with SMT and mobilization. This includes several issues other than efficacy, including safety, clinical guidelines, mechanism, diagnostic testing, indications, and cost. It's true that over half of Bronfort "et al." is about efficacy; but the rest of the paper is still significant work.

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

OK, I followed up below. Eubulides17:43, 6 June 2008 (UTC)

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

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

Again, there seems to be some confusion here. The part of Bronfort "et al." that you mention is not about cost-effectiveness, and is not relevant to Cost-effectiveness 2 or to this thread. (It "is" relevant to other parts of Chiropractic, where it's already cited.) The ball is not in Ernst's court as far as cost-effectiveness goes, as Bronfort "et al." neither cite nor address the cost-effectiveness points raised in Canter, Coon Ernst 2006 (PMID|17173105) (this is the paper that Cost-effectiveness 2 cites). Eubulides06:12, 6 June 2008 (UTC)

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

Eubulides

19:46, 5 June 2008 (UTC)

Well done, Eubulides. I agree with your changes. Thank you for your diligent work and organized presentation, as usual.The section should have been discussed on the talk page before being inserted into the article.In reply to Dematt's question about why to have the section: we do have things to say about cost-effectiveness, as said in the first two sentences. The third sentence is a differing opinion, for NPOV: in other words, perhaps some people think we don't know the cost-effectiveness while others think we know some things about it; also, it says we can't draw "definitive" conclusions but this doesn't rule out the possibility that some other kind of conclusion or information might still be available: preliminary conclusions, or suggestive evidence or something. The last sentence is about maintenance care, which does not contradict the idea that we may be able to say something about acute care.☺ Coppertwig12:27, 5 June 2008 (UTC)

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

The sources are indeed about cost-effectiveness; please see my followup above.

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

Eubulides

19:46, 5 June 2008 (UTC)

Each side of what controversy, Dematt? What negative statement? The first two sentences seem to me to be saying roughly the same thing: that there's some evidence that chiropractic care is cost-effective but not overwhelming evidence. The last two sentences say there isn't enough evidence, but barely contradict or don't really contradict the first two sentences: the last sentence doesn't contradict them because it's focussed on maintenance care specifically. Dematt, I'm sorry, but I just don't know what you mean in much of your comment. Your second sentence doesn't parse. I don't know what "two negatives" you're referring to. Do you mean that there's another source that should be included that's been left out? If so, what is it? (I haven't actually read the sources yet).☺ Coppertwig01:32, 6 June 2008 (UTC)

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

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

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

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

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

"(I later inserted the How we are using the sources subsection header to break things up.)" Eubulides17:43, 6 June 2008 (UTC)

How we are using the sources

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

I don't see any improper suggestion in Cost effectivness 2's summary of Bronfort "et al." It merely says "A 2008 review of treatments for chronic low back pain found one study arguing X, another study concluding Y, and two studies reporting Z." There's no conclusion there; there's just a list of studies assembled by a team of experts (who can be presumed to do a good job assembling studies). That being said, if you can see an improper suggestion there somewhere, please suggest wording to fix the problem. I'm sure we can work something out. Or, if you prefer, we can simply remove the first sentence of Cost-effectiveness 2 (though this sounds a bit drastic).

You're correct that the summary uses "placebo" where the source uses "non-specific effect". The two terms are synonymous here, but I agree it'd be safer to not substitute the wording. I changed the draft to use "non-specific effect" alone (without "placebo"); to help the nonexpert reader I also added a wikilink to Non-specific effect (which I have added as a redirect to Placebo).

Eubulides

06:12, 6 June 2008 (UTC)

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

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

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

OK, I take your point: Bronfort "et al." 2008 (PMID|18164469) didn't make any conclusions about cost-effectiveness; they merely cited 4 sources without comment. So I went back to the well and found a different source: Mootz "et al." 2006 (PMID|17142165). This source is older, but it does have the advantage of being more on point, as it has a much longer discussion of cost-effectiveness, and it makes conclusions on its own rather than just citing primary sources. Like Bronfort "et al.", it is written by chiropractors and fairly represents the pro-chiropractic POV. I removed the text sourced by Bronfort "et al." and replaced it with "A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.", citing Mootz "et al." Eubulides17:43, 6 June 2008 (UTC)

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

But Canter "et al." didn't say "efficacy" is not certain; they said "specific" efficacy is uncertain. Specific efficacy is just part of efficacy; it is not the whole thing. Canter "et al." are saying that the cost-effectiveness studies aren't separating specific efficacy from overall efficacy. Eubulides17:43, 6 June 2008 (UTC)

Dematt wrote "But not cost effectiveness, the last paragraph suggests further research into cost effectiveness." Yes, but surely that is boilerplate. Almost all research papers suggest further research at the end. I'm not sure it's worth saying "more research is needed" here, as the point is already explicitly made about how little is known about cost-effectiveness. Eubulides17:43, 6 June 2008 (UTC)

No further comment (other than Dematt's saying he'll check it when he gets to the library in no agreement for blanking entire sections below), so I http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=218679718oldid=218667112 installed it. We can fix any wording problems later, once the source is checked by someone other than me. Eubulides18:32, 11 June 2008 (UTC)

Cost-benefit

The cost-effectiveness of maintenance chiropractic care is unknown and not well researched. Of the limited quantity of studies found, there is diversity in the findings. Of the various interventions available, the most cost-effective treatment for lower back pain could not be determined because of the lack of more higher quality evaluations.cite journal |journal= Best Pract Res Clin Rheumatol |date=2005 |volume=19 |issue=4 |pages=671–84 |title= What is the most cost-effective treatment for patients with low back pain? a systematic review |author= van der Roer N, Goossens MEJB, Evers SMAA, van Tulder MW |doi=10.1016/j.berh.2005.03.007 |pmid=15949783 Spinal manipulation appears to be relatively cost-effective for chronic lower back pain.cite journal |journal=J Manipulative Physiol Ther |date=2005 |volume=28 |issue=8 |pages=555–63 |title= Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain |author= Haas M, Sharma R, Stano M |doi=10.1016/j.jmpt.2005.08.006 |pmid=16226622 The cost-effectiveness of spinal manipulation therapy has not been demonstrated beyond a reasonable doubt. The data indicates that SMT typically represents an additional cost to conventional treatment.cite journal |journal= Evid Based Complement Alternat Med |date=2006 |volume=3 |issue=4 |pages=425–32 |title=Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425 After initial therapy, preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care.cite journal |journal=Ann Intern Med |date=2003 |volume=138 |issue=11 |pages=898–906 |title=A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain |author=Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. |pmid=12779300 |url=http://www.annals.org/cgi/reprint/138/11/898.pdf |format=PDF Chiropractic managed care may reduce overall health care costs.cite journal |journal=Arch Intern Med |date=2004 |volume=64 |issue=18 |pages=1985–92 |title=Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs |author= Legorreta AP, Metz RD, Nelson CF, Ray S, Chernicoff HO, Dinubile NA |pmid=15477432 |url=http://archinte.ama-assn.org/cgi/content/full/164/18/1985

When comparing primary care physicians (PCPs) medical management to nonsurgical nonpharmaceutical chiropractic management approaches (CAM-oriented PCPs), a followup study demonstrated with some reservations both a reduction in clinical and cost utilization of in-hospital admissions, hospital days, outpatient surgeries and procedures, and pharmaceutical costs when compared with using conventional medicine IPA performance alone.cite journal |journal= J Manipulative Physiol Ther |date=2007 |volume=30 |issue=4 |pages=263–9 |title= Clinical utilization and cost outcomes from an integrative medicine independent physician association: an additional 3-year update |author= Sarnat RL, Winterstein J, Cambron JA |doi=10.1016/j.jmpt.2007.03.004 |pmid=17509435 An initial study found that the benefits of chiropractic care for neck pain seem to outweigh the possible risk.cite journal |journal=J Manipulative Physiol Ther |date=2007 |volume=30 |issue=6 |pages=408–18 |title=The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study |author=Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW |doi=10.1016/j.jmpt.2007.04.013 |pmid=17693331 When compared with treatment options such as physiotherapeutic exercise (also performed by a chiropractor), the risk-benefit balance does not favor SMT. In occupational low back pain, the research found that shorter chiropractor care had a benefit for reducing work-disability recurrence and a longer chiropractic care did not show a benefit for preventing work-disability recurrence.cite journal |journal= J Occup Environ Med |date=2007 |volume=49 |issue=10 |pages=1124–34 |title= The association between timing and duration of chiropractic care in work-related low back pain and work-disability outcomes |author= Wasiak R, Kim J, Pransky GS |pmid=18000417 SMT helps to reduce time lost due to workplace back pain, and thus employer savings.cite journal |journal=CMAJ |date=1998 |volume=158 |issue=12 |pages=1625–31 |title= Preventing disability from work-related low-back pain. New evidence gives new hope—if we can just get all the players onside |author=Frank J, Sinclair S, Hogg-Johnson S, Shannon H, Bombardier C, Beaton D, Cole D |pmid=9645178 |url=http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1229415blobtype=pdf |format=PDFcite web |date=2004 |url=http://www.wsib.on.ca/wsib/wsibsite.nsf/LookupFiles/DownloadableFileALBIEvaluationReport/$File/ALBIReport.pdf |format=PDF |title=Program of Care for Acute Low Back Injuries One-Year Evaluation Report |accessdate= |publisher=Workplace Safety and Insurance Board

Comments on Cost-benefit

Is there anything worth merging into other sections or adding to cost-effectiveness. QuackGuru18:39, 11 June 2008 (UTC)

I don't see anything that would be useful in other sections of Chiropractic; this stuff is all about cost and Chiropractic Cost-effectiveness is the only section that is about cost. If we expanded Chiropractic Scientific research into a subarticle it may be useful to cite some of those primary studies, but even there we'd need considerable caution, as it's better to stick with reliable reviews. Please see the bullet list at the start of Improving the cost-benefit section for some problems with the primary sources cited in Cost-benefit. Eubulides19:03, 11 June 2008 (UTC)

Improving the cost-benefit section

I finally sprung some time free to review the ChiropracticCost-benefit section, which got http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=212339642oldid=212336675 added on May 14 without previous discussion, and which has mutated a bit since then without much discussion. Here are my comments, along with a proposed rewrite Cost benefit 2. Please comment at Cost-effectiveness 2 comments. Eubulides23:46, 4 June 2008 (UTC)

The sources tend to prefer "cost-effectiveness" to "cost-benefit", so the section title and discussion should use "cost-effectiveness". Eubulides23:46, 4 June 2008 (UTC)

The organization of the section is confusing. For example, it starts off with the cost-effectiveness of maintenance care, which one would expect to find later (as maintenance care comes after initial care). Eubulides23:46, 4 June 2008 (UTC)

Sentences often do not hook together well. They often seem to be isolated sentences without any connection. Contradictory sentences are sometimes put next to each other, with no explanation. Eubulides23:46, 4 June 2008 (UTC)

"The cost-effectiveness of maintenance chiropractic care is unknown and not well researched. Of the limited quantity of studies found, there is diversity in the findings." The source (Leboeuf-Yde C Hestbæk 2008, PMID|18466623)cite journal |journal= Chiropr Osteopat |date=2008 |volume=16 |issue=1 |pages=3 |title= Maintenance care in chiropractic - what do we know? |author= Leboeuf-Yde C, Hestbæk L |doi=10.1186/1746-1340-16-3 |pmid=18466623 |url=http://chiroandosteo.com/content/pdf/1746-1340-16-3.pdf |format=PDF says only that the cost-effectiveness is unknown. The bit about "there is diversity in findings" is not about cost-effectiveness; it is about other properties of maintenance care. This should be reworded to simply say "The cost-effectiveness of maintenance chiropractic care is unknown." Eubulides23:46, 4 June 2008 (UTC)

"Of the various interventions available, the most cost-effective treatment for lower back pain could not be determined because of the lack of more higher quality evaluations." The "could not be determined" leaves the reader hanging. "Could not be determined" by whom? More context is needed here. Eubulides23:46, 4 June 2008 (UTC)

"Spinal manipulation appears to be relatively cost-effective for chronic lower back pain." This directly contradicts the previous sentence, but the contradiction is not addressed or explained. Also, this cites a primary source for chronic low back pain (Haas "et al." 2005, PMID|16226622), not a secondary review. As per 18164469). This secondary source addresses cost-effectiveness for chronic low back pain, citing several high-quality primary sources. I suggest using the sentence "A 2008 review of treatments for chronic low back pain found two studies reporting no difference in cost-effectiveness for chiropractic versus physical therapy, one arguing for cost savings for chiropractic versus hospital outpatient management, and one, and one concluding that SMT is a cost-effective addition to general-practice best care." Eubulides23:46, 4 June 2008 (UTC)

"The cost-effectiveness of spinal manipulation therapy has not been demonstrated beyond a reasonable doubt." Again, this contradicts the previous sentence. More context is needed. This sentence is citing a critical review (Ernst 2008, PMID|18280103). I suggest rewording it to "A critical 2008 review concluded that the cost-effectiveness of chiropractic spinal manipulation has not been demonstrated beyond reasonable doubt." But (looking below) I see that this sentence is largely duplicative of another sentence supported by a more-specific Ernst review. Let's remove this sentence; it doesn't really add anything. Eubulides23:46, 4 June 2008 (UTC)

"The data indicates that SMT typically represents an additional cost to conventional treatment." This sentence is about cost, but the section is about cost-effectiveness. The article should be mentioning the cost-effectiveness results of the source, not its cost results. I suggest "A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain." Eubulides23:46, 4 June 2008 (UTC)

"After initial therapy, preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care." This cites an older review (Cherkin "et al." 2003, PMID|12779300) and is superseded by information already given supported by newer reviews on the same subject; it should be removed. Eubulides23:46, 4 June 2008 (UTC)

"Chiropractic managed care may reduce overall health care costs." This cites a primary study (Legorreta "et al." 2004, PMID|15477432) that is already covered by the already-cited recent reviews; as per MEDRS it should be removed. Eubulides23:46, 4 June 2008 (UTC)

"When comparing primary care physicians (PCPs) medical management to nonsurgical nonpharmaceutical chiropractic management approaches (CAM-oriented PCPs), a followup study demonstrated with some reservations both a reduction in clinical and cost utilization of in-hospital admissions, hospital days, outpatient surgeries and procedures, and pharmaceutical costs when compared with using conventional medicine IPA performance alone." This is about cost, not cost-effectiveness. Also, this is a relatively extensive discussion of a primary study (Sarnat "et al." 2007, PMID|17509435) that is too recent to be reviewed. We must take great care in citing primary studies as per MEDRS. Since the primary study is not about cost-effectiveness this one is an easy call: it doesn't belong here and let's remove it. Eubulides23:46, 4 June 2008 (UTC)

"An initial study found that the benefits of chiropractic care for neck pain seem to outweigh the possible risk." This cites a primary study (Rubinstein "et al." 2007, PMID|17693331) so as per MEDRS should be scrutinized closely. The study is about risk-benefit, not cost-benefit, so it's a bit dubious to put it here. As mentioned above, in Comments on 2008-05-25 issues list, the source is dubious, as it has no control groupof any kind, and it has no risk-benefit model to support its claim that the "the benefits of chiropractic care for neck pain seem to outweigh the potential risks". Since this study is misplaced in Chiropractic now, one possible fix is to move the risk part of this study to ChiropracticSafety and the benefit part to ChiropracticEffectiveness; but a simpler fix, given the MEDRS issue, is to omit this sentence from the article. If it is included somewhere, the info should be clearly identified as coming from just one primary study. Eubulides23:46, 4 June 2008 (UTC)

"When compared with treatment options such as physiotherapeutic exercise (also performed by a chiropractor), the risk-benefit balance does not favor SMT." Again, this is about risk-benefit, not cost-benefit, so it doesn't really belong here. A much better home for this statement is Chiropractic Safety. However, I suggest omitting it from the article entirely, as the review (Ernst Canter 2006, PMID|16574972)cite journal |journal= J R Soc Med |date=2006 |volume=99 |issue=4 |pages=192–6 |title= A systematic review of systematic reviews of spinal manipulation |author= Ernst E, Canter PH |doi=10.1258/jrsm.99.4.192 |pmid=16574972 |url=http://www.jrsm.org/cgi/content/full/99/4/192 doesn't have a risk-benefit model and its assertion about risk vs benefit is not well supported. I suppose it could be included if the Rubinstein "et al." is included, but neither source inspires much confidence on this particular point. Eubulides23:46, 4 June 2008 (UTC)

"In occupational low back pain, the research found that shorter chiropractor care had a benefit for reducing work-disability recurrence and a longer chiropractic care did not show a benefit for preventing work-disability recurrence." This is about benefit, not cost-benefit. It cites a primary study (Wasiak "et al." 2007, PMID|18000417) and should be scrutinized carefully as per MEDRS. It doesn't really belong in this article, as ChiropracticEffectiveness is already chock-full of more-relevant claims supported by reviews. Eubulides23:46, 4 June 2008 (UTC)

"SMT helps to reduce time lost due to workplace back pain, and thus employer savings." This cites one ancient source (Frank "et al." 1998, PMID|9645178) and one older non-peer-reviewed consultant reporthttp://www.wsib.on.ca/wsib/wsibsite.nsf/LookupFiles/DownloadableFileALBIEvaluationReport/$File/ALBIReport.pdf. Both sources are too low in quality to make the cut here. Also, the claim is not about cost-effectiveness; it is merely about benefits. It should be removed. Eubulides23:46, 4 June 2008 (UTC)

Here's the draft rewrite. Again, please comment at Cost-effectiveness 2 comments below. Eubulides23:46, 4 June 2008 (UTC)

Cost-effectiveness 2

A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=9 |pages=707–25 |title= Health services research related to chiropractic: review and recommendations for research prioritization by the chiropractic profession |author= Mootz RD, Hansen DT, Breen A, Killinger LZ, Nelson C |doi=10.1016/j.jmpt.2006.09.001 |pmid=17142165 A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific effects) remains uncertain.cite journal |journal= Evid Based Complement Alternat Med |date=2006 |volume=3 |issue=4 |pages=425–32 |title= Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425 A 2005 systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention.cite journal |journal= Best Pract Res Clin Rheumatol |date=2005 |volume=19 |issue=4 |pages=671–84 |title= What is the most cost-effective treatment for patients with low back pain? a systematic review |author= van der Roer N, Goossens MEJB, Evers SMAA, van Tulder MW |doi=10.1016/j.berh.2005.03.007 |pmid=15949783 The cost-effectiveness of maintenance chiropractic care is unknown.

Cost-effectiveness 2 comments

"(Please add comments here.)" Eubulides23:46, 4 June 2008 (UTC)

A 2006 UK systematic cost-effectiveness review found that the reported cost-effectiveness of chiropractic manipulation compares favorably with other treatments for back pain, but that reports are based on data from clinical trials without sham controls and that the specific cost-effectiveness of the treatment (as opposed to non-specific placebo effects) remains uncertain.cite journal |journal= Evid Based Complement Alternat Med |date=2006 |volume=3 |issue=4 |pages=425–32 |title= Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425

*I don't see any of this in the source. Do we have the right one? -- Dematt Dēmatt 01:22, 5 June 2008 (UTC)

I just now checked the source, and the following quotes support the abovementioned claim. First, the abstract says "Estimates of the incremental cost of achieving improvements in quality of life compare favorably with other treatments approved for use in the National Health Service. Because the specific efficacy of the complementary therapies for these indications remains uncertain, and the studies did not include sham controls, the estimates obtained may represent the cost-effectiveness of non-specific effects associated with the complementary therapies." Second, the discussion section says: "Second, estimates of cost-effectiveness based on data from clinical trials without sham controls compare favorably with other treatments approved for use in the NHS. Third, the specific treatment effects of the complementary therapies for the indications in question remains uncertain. We therefore strongly suspect that such studies may be estimating the cost-effectiveness of non-specific treatment effects." Eubulides07:05, 5 June 2008 (UTC)

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

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

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

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

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

"A 2006 UK systematic cost-effectiveness review found that reports on complementary care that are based on data from clinical trials without sham controls remains uncertain.cite journal |journal= Evid Based Complement Alternat Med |date=2006 |volume=3 |issue=4 |pages=425–32 |title= Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425"

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

Canter "et al."39;s conclusions were based not only on the Meade "et al." studies that you mention, but also on the UK Beam studies on low back pain, which also involved chiropractors (along with other professions). The UK Beam studies generated results more-favorable to chiropractic, and these results caused Canter "et al."39;s overall conclusions to be more favorable to chiropractic than they otherwise would have been. This explains why the wording proposed in Cost-effectiveness 2:

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

is more favorable to chiropractic than the wording you propose:

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

Eubulides

19:46, 5 June 2008 (UTC)

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

A 2005 systematic review of economic evaluations of conservative treatments for low back pain found that significant quality problems in available studies meant that definite conclusions could not be drawn about the most cost-effective intervention.cite journal |journal= Best Pract Res Clin Rheumatol |date=2005 |volume=19 |issue=4 |pages=671–84 |title= What is the most cost-effective treatment for patients with low back pain? a systematic review |author= van der Roer N, Goossens MEJB, Evers SMAA, van Tulder MW |doi=10.1016/j.berh.2005.03.007 |pmid=15949783 The cost-effectiveness of maintenance chiropractic care is unknown.

*I haven't read the sources yet, but if this is what they are saying then why do we want a cost effectiveness section? Just to say we can say we don't know anything seems to be a waste of space? -- Dematt Dēmatt 01:26, 5 June 2008 (UTC)

** There are many claims on the Internet that chiropractic care is more cost-effective than common alternatives. Chiropractic itself made such a claim pretty much continuously from August 2006http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=70133831oldid=70117359 to May 12,http://en.wikipedia.org/w/index.php?title=Chiropracticoldid=211766313 a period during which Chiropractic cited several obsolete reports supporting the claim. There is clearly significant interest in cost-effectiveness, both among Wikipedia editors and in the scholarly literature, so it's worth a brief mention from recent high-quality reviews saying the topic lacks good evidence. Eubulides07:05, 5 June 2008 (UTC)

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

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

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

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

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

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

But Canter "et al." 2006 doesn't say chiropractic methods are not efficacious. So their discussion of cost-effectiveness would not be moot if chiropractic methods were determined to be efficacious. Eubulides06:12, 6 June 2008 (UTC)

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

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

OK, I followed up below. Eubulides17:43, 6 June 2008 (UTC)

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

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

This is the "Cost-effectiveness" section, so the only part of Bronfort "et al." that's relevant is its discussion of cost-effectiveness. Bronfort "et al." is also cited (twice) in ChiropracticEffectiveness: there, we're relying on the paper's efficacy discussion. It is a big paper and it has results relevants to multiple sections of Chiropractic.

Which statement are we attributing to Bronfort "et al." that they are not actually making?

I'd rather not cite primary sources directly; I'd rather cite a high-quality review like Bronfort "et al."

Bronfort "et al." is not merely about efficacy of SMT for chronic low back pain; it is about all aspects of management of CLBP with SMT and mobilization. This includes several issues other than efficacy, including safety, clinical guidelines, mechanism, diagnostic testing, indications, and cost. It's true that over half of Bronfort "et al." is about efficacy; but the rest of the paper is still significant work.

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

OK, I followed up below. Eubulides17:43, 6 June 2008 (UTC)

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

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

Again, there seems to be some confusion here. The part of Bronfort "et al." that you mention is not about cost-effectiveness, and is not relevant to Cost-effectiveness 2 or to this thread. (It "is" relevant to other parts of Chiropractic, where it's already cited.) The ball is not in Ernst's court as far as cost-effectiveness goes, as Bronfort "et al." neither cite nor address the cost-effectiveness points raised in Canter, Coon Ernst 2006 (PMID|17173105) (this is the paper that Cost-effectiveness 2 cites). Eubulides06:12, 6 June 2008 (UTC)

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

Eubulides

19:46, 5 June 2008 (UTC)

Well done, Eubulides. I agree with your changes. Thank you for your diligent work and organized presentation, as usual.The section should have been discussed on the talk page before being inserted into the article.In reply to Dematt's question about why to have the section: we do have things to say about cost-effectiveness, as said in the first two sentences. The third sentence is a differing opinion, for NPOV: in other words, perhaps some people think we don't know the cost-effectiveness while others think we know some things about it; also, it says we can't draw "definitive" conclusions but this doesn't rule out the possibility that some other kind of conclusion or information might still be available: preliminary conclusions, or suggestive evidence or something. The last sentence is about maintenance care, which does not contradict the idea that we may be able to say something about acute care.☺ Coppertwig12:27, 5 June 2008 (UTC)

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

The sources are indeed about cost-effectiveness; please see my followup above.

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

Eubulides

19:46, 5 June 2008 (UTC)

Each side of what controversy, Dematt? What negative statement? The first two sentences seem to me to be saying roughly the same thing: that there's some evidence that chiropractic care is cost-effective but not overwhelming evidence. The last two sentences say there isn't enough evidence, but barely contradict or don't really contradict the first two sentences: the last sentence doesn't contradict them because it's focussed on maintenance care specifically. Dematt, I'm sorry, but I just don't know what you mean in much of your comment. Your second sentence doesn't parse. I don't know what "two negatives" you're referring to. Do you mean that there's another source that should be included that's been left out? If so, what is it? (I haven't actually read the sources yet).☺ Coppertwig01:32, 6 June 2008 (UTC)

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

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

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

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

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

"(I later inserted the How we are using the sources subsection header to break things up.)" Eubulides17:43, 6 June 2008 (UTC)

How we are using the sources

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

I don't see any improper suggestion in Cost effectivness 2's summary of Bronfort "et al." It merely says "A 2008 review of treatments for chronic low back pain found one study arguing X, another study concluding Y, and two studies reporting Z." There's no conclusion there; there's just a list of studies assembled by a team of experts (who can be presumed to do a good job assembling studies). That being said, if you can see an improper suggestion there somewhere, please suggest wording to fix the problem. I'm sure we can work something out. Or, if you prefer, we can simply remove the first sentence of Cost-effectiveness 2 (though this sounds a bit drastic).

You're correct that the summary uses "placebo" where the source uses "non-specific effect". The two terms are synonymous here, but I agree it'd be safer to not substitute the wording. I changed the draft to use "non-specific effect" alone (without "placebo"); to help the nonexpert reader I also added a wikilink to Non-specific effect (which I have added as a redirect to Placebo).

Eubulides

06:12, 6 June 2008 (UTC)

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

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

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

OK, I take your point: Bronfort "et al." 2008 (PMID|18164469) didn't make any conclusions about cost-effectiveness; they merely cited 4 sources without comment. So I went back to the well and found a different source: Mootz "et al." 2006 (PMID|17142165). This source is older, but it does have the advantage of being more on point, as it has a much longer discussion of cost-effectiveness, and it makes conclusions on its own rather than just citing primary sources. Like Bronfort "et al.", it is written by chiropractors and fairly represents the pro-chiropractic POV. I removed the text sourced by Bronfort "et al." and replaced it with "A 2006 qualitative review found that the research literature suggests that chiropractic obtains at least comparable outcomes to alternatives with potential cost savings.", citing Mootz "et al." Eubulides17:43, 6 June 2008 (UTC)

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

But Canter "et al." didn't say "efficacy" is not certain; they said "specific" efficacy is uncertain. Specific efficacy is just part of efficacy; it is not the whole thing. Canter "et al." are saying that the cost-effectiveness studies aren't separating specific efficacy from overall efficacy. Eubulides17:43, 6 June 2008 (UTC)

Dematt wrote "But not cost effectiveness, the last paragraph suggests further research into cost effectiveness." Yes, but surely that is boilerplate. Almost all research papers suggest further research at the end. I'm not sure it's worth saying "more research is needed" here, as the point is already explicitly made about how little is known about cost-effectiveness. Eubulides17:43, 6 June 2008 (UTC)

No further comment (other than Dematt's saying he'll check it when he gets to the library in no agreement for blanking entire sections below), so I http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=218679718oldid=218667112 installed it. We can fix any wording problems later, once the source is checked by someone other than me. Eubulides18:32, 11 June 2008 (UTC)

Cost-benefit

The cost-effectiveness of maintenance chiropractic care is unknown and not well researched. Of the limited quantity of studies found, there is diversity in the findings. Of the various interventions available, the most cost-effective treatment for lower back pain could not be determined because of the lack of more higher quality evaluations.cite journal |journal= Best Pract Res Clin Rheumatol |date=2005 |volume=19 |issue=4 |pages=671–84 |title= What is the most cost-effective treatment for patients with low back pain? a systematic review |author= van der Roer N, Goossens MEJB, Evers SMAA, van Tulder MW |doi=10.1016/j.berh.2005.03.007 |pmid=15949783 Spinal manipulation appears to be relatively cost-effective for chronic lower back pain.cite journal |journal=J Manipulative Physiol Ther |date=2005 |volume=28 |issue=8 |pages=555–63 |title= Cost-effectiveness of medical and chiropractic care for acute and chronic low back pain |author= Haas M, Sharma R, Stano M |doi=10.1016/j.jmpt.2005.08.006 |pmid=16226622 The cost-effectiveness of spinal manipulation therapy has not been demonstrated beyond a reasonable doubt. The data indicates that SMT typically represents an additional cost to conventional treatment.cite journal |journal= Evid Based Complement Alternat Med |date=2006 |volume=3 |issue=4 |pages=425–32 |title=Cost-effectiveness of complementary therapies in the United kingdom—a systematic review |author= Canter PH, Coon JT, Ernst E |doi=10.1093/ecam/nel044 |pmid=17173105 |url=http://ecam.oxfordjournals.org/cgi/content/full/3/4/425 After initial therapy, preliminary evidence suggests that massage but not spinal manipulation may reduce the costs of care.cite journal |journal=Ann Intern Med |date=2003 |volume=138 |issue=11 |pages=898–906 |title=A review of the evidence for the effectiveness, safety, and cost of acupuncture, massage therapy, and spinal manipulation for back pain |author=Cherkin DC, Sherman KJ, Deyo RA, Shekelle PG. |pmid=12779300 |url=http://www.annals.org/cgi/reprint/138/11/898.pdf |format=PDF Chiropractic managed care may reduce overall health care costs.cite journal |journal=Arch Intern Med |date=2004 |volume=64 |issue=18 |pages=1985–92 |title=Comparative analysis of individuals with and without chiropractic coverage: patient characteristics, utilization, and costs |author= Legorreta AP, Metz RD, Nelson CF, Ray S, Chernicoff HO, Dinubile NA |pmid=15477432 |url=http://archinte.ama-assn.org/cgi/content/full/164/18/1985

When comparing primary care physicians (PCPs) medical management to nonsurgical nonpharmaceutical chiropractic management approaches (CAM-oriented PCPs), a followup study demonstrated with some reservations both a reduction in clinical and cost utilization of in-hospital admissions, hospital days, outpatient surgeries and procedures, and pharmaceutical costs when compared with using conventional medicine IPA performance alone.cite journal |journal= J Manipulative Physiol Ther |date=2007 |volume=30 |issue=4 |pages=263–9 |title= Clinical utilization and cost outcomes from an integrative medicine independent physician association: an additional 3-year update |author= Sarnat RL, Winterstein J, Cambron JA |doi=10.1016/j.jmpt.2007.03.004 |pmid=17509435 An initial study found that the benefits of chiropractic care for neck pain seem to outweigh the possible risk.cite journal |journal=J Manipulative Physiol Ther |date=2007 |volume=30 |issue=6 |pages=408–18 |title=The benefits outweigh the risks for patients undergoing chiropractic care for neck pain: a prospective, multicenter, cohort study |author=Rubinstein SM, Leboeuf-Yde C, Knol DL, de Koekkoek TE, Pfeifle CE, van Tulder MW |doi=10.1016/j.jmpt.2007.04.013 |pmid=17693331 When compared with treatment options such as physiotherapeutic exercise (also performed by a chiropractor), the risk-benefit balance does not favor SMT. In occupational low back pain, the research found that shorter chiropractor care had a benefit for reducing work-disability recurrence and a longer chiropractic care did not show a benefit for preventing work-disability recurrence.cite journal |journal= J Occup Environ Med |date=2007 |volume=49 |issue=10 |pages=1124–34 |title= The association between timing and duration of chiropractic care in work-related low back pain and work-disability outcomes |author= Wasiak R, Kim J, Pransky GS |pmid=18000417 SMT helps to reduce time lost due to workplace back pain, and thus employer savings.cite journal |journal=CMAJ |date=1998 |volume=158 |issue=12 |pages=1625–31 |title= Preventing disability from work-related low-back pain. New evidence gives new hope—if we can just get all the players onside |author=Frank J, Sinclair S, Hogg-Johnson S, Shannon H, Bombardier C, Beaton D, Cole D |pmid=9645178 |url=http://www.pubmedcentral.nih.gov/picrender.fcgi?artid=1229415blobtype=pdf |format=PDFcite web |date=2004 |url=http://www.wsib.on.ca/wsib/wsibsite.nsf/LookupFiles/DownloadableFileALBIEvaluationReport/$File/ALBIReport.pdf |format=PDF |title=Program of Care for Acute Low Back Injuries One-Year Evaluation Report |accessdate= |publisher=Workplace Safety and Insurance Board

Comments on Cost-benefit

Is there anything worth merging into other sections or adding to cost-effectiveness. QuackGuru18:39, 11 June 2008 (UTC)

I don't see anything that would be useful in other sections of Chiropractic; this stuff is all about cost and Chiropractic Cost-effectiveness is the only section that is about cost. If we expanded Chiropractic Scientific research into a subarticle it may be useful to cite some of those primary studies, but even there we'd need considerable caution, as it's better to stick with reliable reviews. Please see the bullet list at the start of Improving the cost-benefit section for some problems with the primary sources cited in Cost-benefit. Eubulides19:03, 11 June 2008 (UTC)

&quot;Like many other medical procedures&quot;

I'm not sure it's fair to say that "Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective.18 Chiropractic care, like all medical treatment, benefits from the placebo response." Mainstream medical procedures, do, in principle, need to be justified by a reasonably solid evidence base. Similarly, I think that the second sentence may be misleading because the allegation is that chiropractic may have no efficacy beyond the placebo effect. David.Mestel David Mestel 18:30, 10 June 2008 (UTC)

Sorry, I don't follow the first point. It's true that mainstream medical procedures "should" be justified by a solid evidence base. But Chiropractic doesn't disagree with that; it merely says that many medical procedures have not been rigorously proven. Is your point that the wording should be changed to say that chiropractic lacks a reasonably solid evidence base? If so, what wording should be used and what reliable source would justify such a claim? Eubulides19:43, 10 June 2008 (UTC)

I don't follow the second point either, alas. Are you suggesting that text be added saying that it's alleged that chiropractic has no efficacy beyond the placebo? If so, could you be specific about the wording (and ideally, supply a source)? Thanks. Eubulides19:43, 10 June 2008 (UTC)

Sorry if I wasn't clear. What I meant to say was the allegation that "many" medical procedures haven't been proven to be effective is probably something that needs a source if it's to be included (I can obviously only see the abstract of http://www.ncbi.nlm.nih.gov/pubmed/16523145 this, but it doesn't seem really to be saying that). Wrt the second point, I think that that misleadingly implies that much medical treatment is not effective beyond the placebo effect. My proposed wording would be something like, "Opinions differ as to the efficacy of chiropractic treatment,18 beyond the proven placebo effect.98". How does that sound? David.Mestel David Mestel 16:04, 11 June 2008 (UTC)

The allegation that many medical procedures haven't been "rigorously" proven to be effective is made by the cited source. For quotes from the source and more discussion about this allegation, please see Continued discussion of Scientific investigation 3C and "Rigorously proven" above.

I'm afraid that "Opinions differ as to the efficacy of chiropractic treatment,18 beyond the proven placebo effect.98" would be 12044130) doesn't actually say that chiropractic treatment has a proven placebo effect.

I disagree that ChiropracticEffectiveness's claim "Chiropractic care, like all medical treatment, benefits from the placebo response." implies that much medical treatment is not effective beyond the placebo effect. The claim merely says that treatment "benefits" from placebo response, which is a far cry from saying that there is no effect "beyond" the placebo response. That being said, if you can suggest a better wording that reflects the source while avoiding this unwanted implication, please do so.

Eubulides

17:58, 11 June 2008 (UTC)

Fair enough; as you can imagine, it's pretty difficult working from just the abstracts.

Ditto: I assumed from the abstract that it did.

Hmmm. I shall think on this some more. David.Mestel David Mestel 11:30, 12 June 2008 (UTC)

no agreement for blanking entire sections

Sections have been blanked. There is no agreement for blanking entire sections. QuackGuru19:25, 9 June 2008 (UTC)

I agree.

It's quite unhelpful to remove Chiropractic Scientific research because of perceived NPOV problems. There are NPOV problems with several sections of Chiropractic. Currently Chiropractic History is by far the worst, as it presents chiropractic as a profession attacked by mainstream medicine, and it presents mainstream medicine as being essentially clueless about disease, without fairly presenting the mainstream side. Despite these NPOV problems, which are much worse than any POV problems in Chiropractic Scientific investigation, nobody has simply removed Chiropractic History.

If one could remove an entire section simply because it "has problems and no consensus"http://en.wikipedia.org/w/index.php?title=Chiropracticcurid=7738diff=218229735oldid=218208036, then all the sections in Chiropractic could be removed. They all have problems. There is not a universal consensus for any of the sections.

Removing Chiropractic Scientific research also turned several citations into red links; this is a relatively minor problem but it's another reason changes like these should be discussed first.

Removing "all" discussion of effectiveness is an even bigger, and to my mind more-controversial, change than QuackGuru's controversial edit of last month (which I also opposed). This is not the right way to edit this article. Effectiveness, safety, and cost-effectiveness are valid and important topics that should be covered in Chiropractic.

Again, let's discuss major controversial changes like this "before" installing the change. I have put my discussion of the content (as opposed to the procedure) in Questions above.

Eubulides

20:01, 9 June 2008 (UTC)

It hasn't been blanked. It has been moved to the talk page. I think that is better than replacing it with the version that was there previously, which I was happy with but others were not. Nothing says that we have to leave something in that has no consensus and has issues concerning NPOV and OR that we need to correct. -- Dematt Dēmatt 20:05, 9 June 2008 (UTC)

This doesn't address the above bullet points. Other sections have major POV problems and lack full consensus; should they be removed as well? Removal is an extreme step and requires better justification than a terse comment about "issues concerning NPOV and OR". Please reconsider the removal in the light of the discussion above and in Questions. Eubulides20:37, 9 June 2008 (UTC)

I didn't realize a conversation was going on here about this, and I rarely participate in long, tendentious discussions on controversial articles, but I undid the blanking of content. Dematt is a regular, so he doesn't deserve a template, but if I had seen this with someone I didn't know, I'd have given them a Level 2 or 3 warning about deleting content. Whatever you feel about QC's additions, a simple deletion is undeserved. 21:01, 9 June 2008 (UTC)

I think you all have misunderstood what I am doing. I am not reverting anyone's edits. I am not replacing it with anything that is controversial, I am only moving it here to the talk page till we do reach consensus. Unfortunately, I have to work in spurts and can't react to all of your issues as fast as you like, but AGF.-- Dematt Dēmatt 21:36, 9 June 2008 (UTC)

I see; but from the point of view of the article, this was a big deletion, and big deletions can be controversial and can lack consensus too. I realize that the text being deleted is controversial, but still I'd feel more comfortable discussing an improved version here first than simply deleting the old version (leaving a big hole in the article) and waiting (for quite some time, most likely) for a new consensus. The newer version wouldn't have to be perfect; just better than what is there now.

Cost-effectiveness 2 contains a draft replacement for Chiropractic Cost-benefit, the last subsection of the deleted-then-restored text. I hope this proposal addresses some of the concerns raised. This draft was proposed five days ago, discussed quite a bit in Cost-effectiveness 2 comments, and revised in response to the discussion; no comment has been made since then. Perhaps it's time to install it? Again, it doesn't have to be perfect; just better than what's in there now. We can discuss and improve it further later.

Eubulides

23:14, 9 June 2008 (UTC)

I didn't remove the Chiropractic Cost-benefit section, just the intro and the Effectiveness section of Scientific evaluation. I am encouraged that you changed the sourcing of first sentence, but am waiting to get to the library for that source before I comment further. Let me take a better look at both versions again before replacing them to avoid the perception of "consensus versioning" again, making it impossible for anyone to change anything. I am also ready for education 3 to go in as well if it works for you. -- Dematt Dēmatt 11:45, 10 June 2008 (UTC)

We can fix any problems in wording once you've gotten to the library and checked the citation. In the meantime there doesn't seem to be any serious objection to Cost-effectiveness 2 and there's been no further comment on it for several days, so I http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=218679718oldid=218667112 installed it. Eubulides18:32, 11 June 2008 (UTC)

Okay, I'll put in Education 3 as well since everyone but QG seems okay with that version. We can work on any other issues that aren't perfect from there. It will be good to get some of these under our belts. -- Dematt Dēmatt 03:48, 12 June 2008 (UTC)

Ah, sorry, I didn't notice that you did not remove the "Safety" and "Cost-benefit" subsections. I support either education 3 or education 7 as improvements over what's in Chiropractic now. Eubulides19:43, 10 June 2008 (UTC)

(unindent) I've tagged several of the issues with tl|Syn until we can fix them. I stopped after the first two paragraphs so it wouldn't look quite so bad. -- Dematt Dēmatt 15:54, 11 June 2008 (UTC)

I don't think those tags were appropriate. Each single statement in ChiropracticEffectiveness is directly supported by material in the corresponding section; that is, the cited sources explicitly reach the same conclusion that is summarized in the statement. So there is no SYN problem at the statement level.

I don't see any SYN problem in ChiropracticEffectiveness; but if there is one, it must be something about the overall section, a gestalt if you will, and it therefore is not a property of any single statement.

I see now that QuackGuru http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=218667112oldid=218647684 removed the individual tags and kept the tag for the whole section, and I agree with that removal.

Eubulides

17:58, 11 June 2008 (UTC)

Well, the whole reason for the tl|Syn template was to be specific about which sentences I considered needing work and remind us and motivate us to fix it since bringing it to the talk page caused some upset. But, as long as we work them through quickly and get them fixed quickly, I'll leave them off and instead work on them above again. -- Dematt Dēmatt 04:10, 12 June 2008 (UTC)

Dematt and QuackGuru (and everyone else), please don`t make significant changes without prior discussion, whether blanking sections or adding new material. Small changes such as fixing grammatical errors may not require discussion.

Eubulides, re ""then all the sections of chiropractic could be removed"": LOL, that reminds me of this comment by x Jakew at Circumcision: ""http://en.wikipedia.org/w/index.php?title=Talk:Circumcisiondiff=217956913oldid=217951312 ...or b) have no material whatsoever in the lead. Since the latter outcome is absurd, ..."" ☺ Coppertwig01:01, 13 June 2008 (UTC)

The problem is that we have changes that lack consensus, violate NPOV and SYN, that have been boldly railroaded into the article. Per BRD, we should be reverting those changes, and THEN discussing it on the talk page. However, we also have an agreement by most of the editors here not to install major changes into the article without consensus, and to NOT use the BRD editing cycle, as it results in edit wars. Until EVERYONE abides by this editing style though, it won't work, and we will have to revert the significant changes that are installed into mainspace without consensus. DigitalC04:32, 13 June 2008 (UTC)

I support the reverting of major changes installed without consensus. ☺ Coppertwig00:53, 14 June 2008 (UTC)

I have always, in many articles, supported reverting to the version before nonconsensus edits began. Then build consensus from there. This not only upholds the principle of consensus, it makes edit warring useless, and thus eliminates one of the main problems. ——"'—— 01:13, 14 June 2008 (UTC)

Alas, for Chiropractic there is no "version before nonconsensus edits began". You can go back as far as you like: you'll never find a consensus version.

I opposed QuackGuru's May 14 edits on procedural grounds. But on content grounds, the edits were a clear improvement over what came before. The http://en.wikipedia.org/w/index.php?title=Chiropracticoldid=211934121 pre-May-14 version (a version that also suffered from nonconsensus edits) had severe POV problems. Every single one of the effectiveness sources it cited were strongly pro-chiropractic, dated, low-quality, primary studies; the overall effect was astonishingly biased in favor of chiropractic. In contrast, the current ChiropracticEffectiveness cites both supportive and critical sources, and uses recent high-quality reviews. As far as quality of sources go, it's night and day compared to the low-quality stuff that was in the older version. The new version is also less biased. It's not perfect; far from it. But it's much better than the pre-May-14 version was.

In short, we should not go back to the pre-May-14 version; it's much worse than what we have now. We should work on improving what we have now.

Eubulides

09:23, 14 June 2008 (UTC)

I agree that we should not go back to the May 14th version, but the current version is a problem as well. This was my rationale for just bringing it to the talk page where we could work on it - get it out of mainspace. I thought I would have support. My concern was that nothing would be been done on this section if not - and nothing has been since it was edit warred back in... instead that editor moved on to something else because they are happy to have their version in mainspace - not to mention they don't have to work anything through when they have outside help who is willing to edit war to keep anything in before they even read it. I think in principle, we all agree that we can work things out here, but in spirit, we all equally lack the necessary committment. I will be able to work with either way we want to do it, but if it is good for the goose, it has to be good for the gander. And the other geese need to back it up. -- Dematt Dēmatt 18:14, 14 June 2008 (UTC)

Article locked before that Canadian case with the woman suing for 500 million, due to the whole body paralysis caused by strokes, caused by chiropractics was adequately added

Somebody should fix this instead of just locking the article —Preceding 04:42, 15 June 2008 (UTC)

I'm not sure that the article needs to be changed at all just because of a case in the news involving a single individual. Do we urgently re-write the article on automobiles every time the newspapers report a collision that caused serious injuries? However, if a change does need to be made, someone would have to suggest a specific edit, and if there's consensus for it it can be added by requesting an edit to a protected page using the tl|editprotected template. ☺ Coppertwig19:01, 15 June 2008 (UTC)

Case not even closed yet, is it? ——"'—— 04:33, 16 June 2008 (UTC)

I see nothing about the case that suggests it's important enough to be mentioned in Chiropractic. Eubulides19:20, 16 June 2008 (UTC)

Removed Scientific research on 6/9/2009

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

That was too bold, I think. It's better to discuss the changes first. I'll follow up in Questions and no agreement for blanking entire sections below. Eubulides20:01, 9 June 2008 (UTC)

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care. Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims.cite journal |author= Keating JC Jr |journal= Skept Inq |volume=21 |issue=4 |pages=37–43 |url=http://findarticles.com/p/articles/mi_m2843/is_n4_v21/ai_19727577 |title= Chiropractic: science and antiscience and pseudoscience side by side |date=1997 |accessdate=2008-05-10 A 2007 survey of Alberta chiropractors found that they do not consistently apply research in practice which may have resulted from a lack of research education and skills.cite journal |journal= J Manipulative Physiol Ther |year=2007 |volume=30 |issue=2 |pages=109–15 |title= How important is research-based practice to chiropractors and massage therapists? |author= Suter E, Vanderheyden LC, Trojan LS, Verhoef MJ, Armitage GD |doi=10.1016/j.jmpt.2006.12.013 |pmid=17320731 Evidence-based chiropractors possess the ability to apply research in practice. Continued education enhances the scientific knowledge of the practitioner.cite journal |journal=Chiropr Osteopat |year=2006 |volume=24 |issue=14 |pages=14:18 |title=Effectiveness of an evidence-based chiropractic continuing education workshop on participant knowledge of evidence-based health care |author=Feise RJ, Grod JP, Taylor-Vaisey A |pmid=16930482 |url=http://www.pubmedcentral.nih.gov/articlerender.fcgi?tool=pubmedpubmedid=16930482

Effectiveness (current version)

The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment. Like many other medical procedures, chiropractic treatment has not been rigorously proven to be effective.cite journal |journal= Clin Orthop Relat Res |date=2006 |volume=444 |pages=243–9 |title= History and overview of theories and methods of chiropractic: a counterpoint |author= DeVocht JW |doi=10.1097/01.blo.0000203460.89887.8d |pmid=16523145 Chiropractic care, like all medical treatment, benefits from the placebo response.cite journal |journal= Ann Intern Med |date=2002 |volume=136 |issue=11 |pages=817–25 |title= The placebo effect in alternative medicine: can the performance of a healing ritual have clinical significance? |author= Kaptchuk TJ |pmid=12044130 |url=http://annals.org/cgi/reprint/136/11/817.pdf |format=PDF The efficacy of maintenance care in chiropractic is unknown.cite journal |journal= Chiropr Osteopat |date=2008 |volume=16 |issue=1 |pages=3 |title= Maintenance care in chiropractic - what do we know? |author= Leboeuf-Yde C, Hestbæk L |doi=10.1186/1746-1340-16-3 |pmid=18466623 |url=http://chiroandosteo.com/content/pdf/1746-1340-16-3.pdf |format=PDF

Research has focused on spinal manipulation therapy (SMT) in general,cite journal |journal= Ann Intern Med |date=2002 |volume=137 |issue=8 |pages=702 |title= Chiropractic: in response |author= Meeker WC, Haldeman S |url=http://annals.org/cgi/reprint/137/8/701.pdf |format=PDF rather than specifically on chiropractic SMT. There is little consensus as to who should administer the SMT, raising concerns by chiropractors that orthodox medical physicians could "steal" SMT procedures from chiropractors; the focus on SMT has also raised concerns that the resulting practice guidelines could limit the scope of chiropractic practice to treating backs and necks.cite journal |journal= Soc Sci Med |date=2005 |volume=60 |issue=3 |pages=545–61 |title= Evidence-based medicine and its implications for the profession of chiropractic |author= Villanueva-Russell Y |doi=10.1016/j.socscimed.2004.05.017 |pmid=15550303 Many controlled clinical studies of SMT are available, but their results disagree,cite journal |journal= J R Soc Med |date=2006 |volume=99 |issue=4 |pages=192–6 |title= A systematic review of systematic reviews of spinal manipulation |author= Ernst E, Canter PH |doi=10.1258/jrsm.99.4.192 |pmid=16574972 |url=http://www.jrsm.org/cgi/content/full/99/4/192 and they are typically of low quality.

Quality of SMT studies:

cite journal |journal= J Orthop Sports Phys Ther |date=2006 |volume=36 |issue=3 |pages=160–9 |title= Methodological quality of randomized controlled trials of spinal manipulation and mobilization in tension-type headache, migraine, and cervicogenic headache |author= Fernández-de-las-Peñas C, Alonso-Blanco C, San-Roman J, Miangolarra-Page JC |pmid=16596892

cite journal |journal=Spine |date=2008 |volume=33 |issue=8 |pages=914–8 |title= The use of expertise-based randomized controlled trials to assess spinal manipulation and acupuncture for low back pain: a systematic review |author= Johnston BC, da Costa BR, Devereaux PJ, Akl EA, Busse JW; Expertise-Based RCT Working Group |doi=10.1097/BRS.0b013e31816b4be4 |pmid=18404113

It is hard to construct a trustworthy placebo for clinical trials of SMT, as experts often disagree whether a proposed placebo actually has no effect.cite journal |journal= Aust J Physiother |date=2006 |volume=52 |issue=2 |pages=135–8 |title= Selecting an appropriate placebo for a trial of spinal manipulative therapy |author= Hancock MJ, Maher CG, Latimer J, McAuley JH |pmid=16764551 |url=http://www.physiotherapy.asn.au/AJP/52-2/AustJPhysiotherv52i2Hancock.pdf |format=PDF Although a 2008 critical review found that with the possible exception of back pain, chiropractic SMT has not been shown to be effective for any medical condition, and suggested that many guidelines recommend chiropractic care for low back pain because no therapy has been shown to make a real difference,cite journal |journal= J Pain Symptom Manage |date=2008 |volume=35 |issue=5 |pages=544–62 |title= Chiropractic: a critical evaluation |author= Ernst E |doi=10.1016/j.jpainsymman.2007.07.004 |pmid=18280103 a 2008 supportive review found serious flaws in the critical approach, and found that SMT and mobilization are at least as effective for chronic low back pain as other efficacious and commonly used treatments.

Available evidence covers the following conditions:

Low back pain (current version)

"'Low back pain"'. There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability.cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=7 |pages=576–81, 581.e1–2 |title= Inconsistent grading of evidence across countries: a review of low back pain guidelines |author= Murphy AYMT, van Teijlingen ER, Gobbi MO |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948 A 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,cite journal |journal= Ann Intern Med |date=2007 |volume=147 |issue=7 |pages=492–504 |title= 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 |author= Chou R, Huffman LH; American Pain Society; American College of Physicians |pmid=17909210 |url=http://annals.org/cgi/content/full/147/7/478 whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help, possibly because the guideline's recommendations were based on a high evidence level. A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care.cite journal |journal= Spine J |date=2008 |volume=8 |issue=1 |pages=213–25 |title= Evidence-informed management of chronic low back pain with spinal manipulation and mobilization |author= Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S |doi=10.1016/j.spinee.2007.10.023 |pmid=18164469 A 2007 literature synthesis found good evidence supporting SMT for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.cite web |title= Chiropractic management of low back pain and low back related leg complaints |author= Meeker W, Branson R, Bronfort G "et al." |url=http://ccgpp.org/lowbackliterature.pdf |format=PDF |date=2007 |accessdate=2008-03-13 |publisher= Council on Chiropractic Guidelines and Practice Parameters Of four systematic reviews published between 2000 and May 2005, only one recommended SMT, and a 2004 Cochrane review (cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=1 |pages=CD000447 |title= Spinal manipulative therapy for low back pain |author= Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG |doi=10.1002/14651858.CD000447.pub2 |pmid=14973958) stated that SMT or mobilization is no more or less effective than other standard interventions for back pain.

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

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

"'Low back pain"'. Guidelines for the treatment of low back pain divided into 3 categories; acute pain (less than 6 weeks duration), subacute (6 to 12 week) and chronic (more than 12 weeks). The efficacy for the use of any of these modalities varies depending on the category. There is still conflict of opinion concerning the proper frequency and duration of any of the interventions, or whether the guidelines accurately reflect effectiveness.cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=7 |pages=576–81, 581.e1–2 |title= Inconsistent grading of evidence across countries: a review of low back pain guidelines |author= Murphy AYMT, van Teijlingen ER, Gobbi MO |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948http://www.ncbi.nlm.nih.gov/pubmed/11313612?ordinalpos=6itool=EntrezSystem2.PEntrez.Pubmed.Pubmed_ResultsPanel.Pubmed_RVDocSum However, most guidelines based on best evidence support the use of SMT for nonspecific (i.e., unknown cause) chronic low back pain (CLBP). A 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail.cite journal |journal= Ann Intern Med |date=2007 |volume=147 |issue=7 |pages=492–504 |title= 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 |author= Chou R, Huffman LH; American Pain Society; American College of Physicians |pmid=17909210 |url=http://annals.org/cgi/content/full/147/7/478 The Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help, possibly because the guideline's recommendations were based on a high evidence level. A 2008 review found strong evidence that SMT is similar in effect to medical care with exercise, and moderate evidence that SMT is similar to physical therapy and other forms of conventional care.cite journal |journal= Spine J |date=2008 |volume=8 |issue=1 |pages=213–25 |title= Evidence-informed management of chronic low back pain with spinal manipulation and mobilization |author= Bronfort G, Haas M, Evans R, Kawchuk G, Dagenais S |doi=10.1016/j.spinee.2007.10.023 |pmid=18164469 A 2007 literature synthesis found good evidence supporting SMT for low back pain and exercise for chronic low back pain; it also found fair evidence supporting customizable exercise programs for subacute low back pain, and supporting assurance and advice to stay active for subacute and chronic low back pain.cite web |title= Chiropractic management of low back pain and low back related leg complaints |author= Meeker W, Branson R, Bronfort G "et al." |url=http://ccgpp.org/lowbackliterature.pdf |format=PDF |date=2007 |accessdate=2008-03-13 |publisher= Council on Chiropractic Guidelines and Practice Parameters Of four systematic reviews published between 2000 and May 2005, only one recommended SMT, and a 2004 Cochrane review (cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=1 |pages=CD000447 |title= Spinal manipulative therapy for low back pain |author= Assendelft WJJ, Morton SC, Yu EI, Suttorp MJ, Shekelle PG |doi=10.1002/14651858.CD000447.pub2 |pmid=14973958) stated that SMT or mobilization is no more or less effective than other standard interventions for back pain. Flexion/distraction was determined to be as effective as exercise...

fact

Massage was beneficial during the chronic phase but was not effective or recommended during the acute phase.

fact

Physiotherapeutics have little support on their own, though may have some benefit when used in combination with other modalities.

fact

Exercise is not recommended during the acute phase, though is strongly supported in subacute and chronic phases.

fact

Ergonomic advice and pamphlets alone were found to have little effect in any phase.

fact

Low back pain comments

Comment 1

"There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain; methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability.cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=7 |pages=576–81, 581.e1–2 |title= Inconsistent grading of evidence across countries: a review of low back pain guidelines |author= Murphy AYMT, van Teijlingen ER, Gobbi MO |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948"

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

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

It isn't the first statement made about SMT in ChiropracticScientific research. There are several earlier statements. For example: "Many controlled clinical studies of SMT are available, but their results disagree, and they are typically of low quality."

Earlier sentences in the section already talk about guidelines. Here is one example among several: "The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which chiropractic treatments are legitimate and perhaps reimbursable under managed care."

The source does not answer questions like "Which of the guidelines are wrong? All of them? Is one right?". We'd all love to know the answers to those questions, but I'm afraid definitive answers are not available.

There is already an introductory statement saying something along the lines you suggest. Here it is: "The effectiveness of chiropractic treatment depends on the medical condition and the type of chiropractic treatment."

I agree that "Scientific research" is not a good name for the section, and have proposed a different name, but the proposal didn't gain consensus. I don't recall what the name was now, but it was something about being evidence-based. I still think a name like "Evidence basis" would be better than "Scientific research".

Eubulides

19:43, 10 June 2008 (UTC)

"It isn't the first statement made about SMT in ChiropracticScientific research." We're getting back into being pedantic. It is clearly the first sentence in the subsection about low back pain. I agree with Dematt that this section doesn't seem to be NPOV. In fact, to me it reads like a negative POV sandwhich - put in the beginning negative (continuing conflict of opinion on efficy), sandwhich the positive POV in the middle, and then end with negative POV again (of 4 systematic reviews, ONLY 1, AND...). DigitalC00:31, 11 June 2008 (UTC)

I apologize for referencing the wrong section, and thank you DigitalC for stating it clearly. -- Dematt Dēmatt 03:02, 11 June 2008 (UTC)

There is a paragraph about low back pain (not a subsection) that is part of a ChiropracticScientific research section and ChiropracticEffectiveness subsection that clearly establish context for that paragraph. This context applies to all the paragraphs in the subjection: not just low back pain, but also whiplash and other neck pain, headache, etc. It is not "pedantic" to mention prefatory remarks, which are applicable to several paragraphs in the section, as being part of context for that section. Copying this context over and over again into each paragraph would make the article longer, more repetitive, and more boring.

Furthermore, the paragraph on low back pain is not a simple sandwich. Here's what it does:

It leads with the fact that there is conflict (neutral).

It says that this casts doubts on guidelines' reliability (neutral, because since some guidelines favor chiropractic and some don't).

It mentions the 2007 U.S. guideline (positive).

It mentions the 2002 Swedish guideline (negative).

It mentions the 2008 review (positive).

It mentions the 2007 literature synthesis (positive).

It briefly summarizes four pre-2006 reviews (negative).

This isn't a sandwich: it is a smorgasbord, and it is a faithful attempt to write an NPOV summary of high-quality reviews in this area. The order is reverse-chronological within source type (where the types are overviews, guidelines, and reviews). There was no attempt to write a "sandwich", and the resulting order is not that of a "sandwich".

Eubulides

17:58, 11 June 2008 (UTC)

It is NPOV when we closely follow the sources. If editors do not like "Scientific research" then my second choice would be "Evidence basis". QuackGuru01:48, 11 June 2008 (UTC)

You added that without consensus again. If we are to continue to work with consensus rules then I would ask that you revert your edit. "Evidence base" does not fit what we have written either. We woud have to edit it differently with a name like that. -- Dematt Dēmatt 03:02, 11 June 2008 (UTC)

Thanks for reverting yourself. How about "Research and guidelines"? -- Dematt Dēmatt 13:26, 11 June 2008 (UTC)

Me thinks something along the lines of "Evidence-based medicine and research" would be a better name. QuackGuru17:49, 11 June 2008 (UTC)

Shorter names are better. Eubulides17:58, 11 June 2008 (UTC)

Whiplash and neck pain

"'Whiplash and other neck pain"'. There is no overall consensus on manual therapies for neck pain.cite journal |journal= Eura Medicophys |date=2007 |volume=43 |issue=1 |pages=91–118 |title= Manual therapy for neck pain: an overview of randomized clinical trials and systematic reviews |author= Vernon H, Humphreys BK |pmid=17369783 |url=http://www.minervamedica.it/pdf/R33Y2007/R33Y2007N01A0091.pdf |format=PDF A 2008 review found evidence that educational videos, mobilization, and exercises appear more beneficial for whiplash than alternatives; that SMT, mobilization, supervised exercise, low-level laser therapy and perhaps acupuncture are more effective for non-whiplash neck pain than alternatives but none of these treatments is clearly superior; and that there is no evidence that any intervention improves prognosis. A 2007 review found that SMT and mobilization are effective for neck pain. Of three systematic reviews of SMT published between 2000 and May 2005, one reached a positive conclusion, and a 2004 Cochrane review (cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=1 |pages=CD004249 |title= Manipulation and mobilisation for mechanical neck disorders |author= Gross AR, Hoving JL, Haines TA "et al." |doi=10.1002/14651858.CD004249.pub2 |pmid=14974063) found that SMT and mobilization are beneficial only when combined with exercise, the benefits being pain relief, functional improvement, and global perceived effect for subacute/chronic mechanical neck disorder. A 2005 review found limited evidence supporting SMT for whiplash.cite journal |journal= Pain Res Manag |date=2005 |volume=10 |issue=1 |pages=21–32 |title= Treatment of whiplash-associated disorders—part I: non-invasive interventions |author= Conlin A, Bhogal S, Sequeira K, Teasell R |pmid=15782244

Headache

"'Headache"'. A 2006 review found no rigorous evidence supporting SMT or other manual therapies for tension headache.cite journal |journal= Clin J Pain |date=2006 |volume=22 |issue=3 |pages=278–85 |title= Are manual therapies effective in reducing pain from tension-type headache?: a systematic review |author= Fernández-de-las-Peñas C, Alonso-Blanco C, Cuadrado ML, Miangolarra JC, Barriga FJ, Pareja JA |doi=10.1097/01.ajp.0000173017.64741.86 |pmid=16514329 A 2005 review found that the evidence was weak for effectiveness of chiropractic manipulation for tension headache, and that it was probably more effective for tension headache than for migraine.cite journal |journal=Headache |date=2005 |volume=45 |issue=6 |pages=738–46 |title= Physical treatments for headache: a structured review |doi=10.1111/j.1526-4610.2005.05141.x |author= Biondi DM |pmid=15953306 A 2004 review found that SMT may be effective for migraine and tension headache, and SMT and neck exercises may be effective for cervicogenic headache.cite journal |journal= Cochrane Database Syst Rev |date=2004 |issue=3 |pages=CD001878 |title= Non-invasive physical treatments for chronic/recurrent headache |author= Bronfort G, Nilsson N, Haas M "et al." |doi=10.1002/14651858.CD001878.pub2 |pmid=15266458 Two other systematic reviews published between 2000 and May 2005 did not find conclusive evidence in favor of SMT.

Other

"'Other"'. There is a small amount of research into the efficacy of chiropractic treatment for upper limbs,cite journal |journal= J Manipulative Physiol Ther |date=2008 |volume=31 |issue=2 |pages=146–59 |title= Chiropractic treatment of upper extremity conditions: a systematic review |author= McHardy A, Hoskins W, Pollard H, Onley R, Windsham R |doi=10.1016/j.jmpt.2007.12.004 |pmid=18328941 and a lack of higher-quality publications supporting chiropractic management of leg conditions.cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=8 |pages=658–71 |title= Chiropractic treatment of lower extremity conditions: a literature review |author= Hoskins W, McHardy A, Pollard H, Windsham R, Onley R |doi=10.1016/j.jmpt.2006.08.004 |pmid=17045100 A 2007 literature synthesis found fair evidence supporting assurance and advice to stay active for sciatica and radicular pain in the leg. There is very weak evidence for chiropractic care for adult scoliosis (curved or rotated spine)cite journal |journal=Spine |date=2007 |volume=32 |issue= 19 Suppl |pages=S130–4 |title= A systematic literature review of nonsurgical treatment in adult scoliosis |author= Everett CR, Patel RK |doi=10.1097/BRS.0b013e318134ea88 |pmid=17728680 and no scientific data for idiopathic adolescent scoliosis.cite journal |journal=Scoliosis |date=2008 |volume=3 |pages=2 |title= Manual therapy as a conservative treatment for adolescent idiopathic scoliosis: a systematic review |author= Romano M, Negrini S |doi=10.1186/1748-7161-3-2 |pmid=18211702 |url=http://scoliosisjournal.com/content/3/1/2 A 2007 systematic review found that few studies of chiropractic care for nonmusculoskeletal conditions are available, and they are typically not of high quality; it also found that the entire clinical encounter of chiropractic care (as opposed to just SMT) provides benefit to patients with asthma, cervicogenic dizziness, and baby colic, and that the evidence from reviews is negative, or too weak to draw conclusions, for a wide variety of other nonmusculoskeletal conditions, including ADHD/learning disabilities, dizzinesss, and vision conditions.cite journal |journal= J Altern Complement Med |date=2007 |volume=13 |issue=5 |pages=491–512 |title= Chiropractic care for nonmusculoskeletal conditions: a systematic review with implications for whole systems research |author= Hawk C, Khorsan R, Lisi AJ, Ferrance RJ, Evans MW |doi=10.1089/acm.2007.7088 |pmid=17604553 Other reviews have found no evidence of benefit for baby colic,cite journal |journal= Paediatr Nurs |date=2007 |volume=19 |issue=8 |pages=26 |title= Effectiveness of chiropractic treatment for infantile colic |author= Kingston H |pmid=17970361 bedwetting,cite journal |journal= Cochrane Database Syst Rev |date=2005 |issue=2 |pages=CD005230 |title= Complementary and miscellaneous interventions for nocturnal enuresis in children |author= Glazener CM, Evans JH, Cheuk DK |doi=10.1002/14651858.CD005230 |pmid=15846744 fibromyalgia,cite journal |journal= Curr Pharm Des |date=2006 |volume=12 |issue=1 |pages=47–57 |title= Complementary and alternative medical therapies in fibromyalgia |author= Sarac AJ, Gur A |pmid=16454724 or menstrual cramps.cite journal |journal= Cochrane Database Syst Rev |date=2006 |issue=3 |pages=CD002119 |title= Spinal manipulation for primary and secondary dysmenorrhoea |author= Proctor ML, Hing W, Johnson TC, Murphy PA |doi=10.1002/14651858.CD002119.pub3 |pmid=16855988

Questions

What is this section about - is it about effectiveness of chiropractic or is it about effectiveness of SMT. As chiropractors use more than SMT, it would not be NPOV to discuss SMT as if it were chiropractic any more than we would discuss spinal injections as if it were medicine. Medicine may use injections as one option for treatment in the management of low back pain, but that is not all that medicine does, so when the evidence does not support the use of injections, we do not suggest that medicine is not effective, only that injections are not effective. I see that we have three options; either 1) move this to the Spinal manipulation article, or 2) we keep something like this and add details of effectivness of some of the treatment methods that chiropractors use. These would include massage, exercise, nutrition, elctrical muscle stimulation, ultrasound, ice, heat, stretching , trigger point work, acupuncture, etc., etc.. Or 3) we only discuss chiropractic in the general terms and we use the sources appropriately to talk about chiropractic in general without any inferences to any specific treatment modality. Of course any NPOV discussion of chiropractic effectiveness would have to address "compared to what". I think I have seen a few of those sources available. -- Dematt Dēmatt 15:07, 9 June 2008 (UTC)

The main motivation for Chiropractic Scientific research is, as User:Delvin Kelvin put it, "answering simple questions that the reader will have in mind" about scientific evidencehttp://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=prevoldid=198757336. He went on to say "Clearly chiropractic has some sort of benefit according to science. But as with all science views they use limitations, delineations and they are critical. Please lets have that information presented so it is clear for the reader..."http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=prevoldid=198794002.

Then why aren't we telling Delvin Kelvin that chiropractic uses many approaches and each approach has benefits and limitations? -- Dematt Dēmatt 13:57, 10 June 2008 (UTC)

Chiropractic currently covers several treatment forms; it's not just SMT. I agree that coverage of other treatments could be better. Eubulides19:43, 10 June 2008 (UTC)

We agree that we need to cover them better. -- Dematt Dēmatt 02:52, 11 June 2008 (UTC)

The material in ChiropracticScientific research is mostly not suitable for Spinal manipulation. Most of it is about topics other than SMT, and these topics already include exercise, self-care, advice to stay active, and others. If we can find reliable reviews of the other topics we can add them.

Agreed, this material should be under an SMT section of Low back pain, Whiplash, Neck pain, and the various symptoms that chiropractors treat that are not tiny minorities.

The material could also be briefly summarized there as well; but there is still a need to briefly summarize the effectiveness of chiropractic care here, in Chiropractic. Eubulides19:43, 10 June 2008 (UTC)

We agree that Chiropractic should be about chiropractic care. IOWs, if we are going to label a section Low back pain, then it needs to address all the things that chiropractors do for low back pain, not just SMT. However, the brief summary should be here while the details should go in the related articles where it doesn't matter who performs them and therefore we don't have to worry about undue weight. -- Dematt Dēmatt 02:52, 11 June 2008 (UTC)

I would favor addressing all the things chiropractors do about low back pain. We need to find reliable sources, though, preferably reviews as reliable as what we have already for SMT. If there are good sources we should summarize them too. If this section gets too long we can summarize it and put it into a subarticle, but we are not there yet. Eubulides17:58, 11 June 2008 (UTC)

A sizeable fraction of ChiropracticScientific research is about SMT, but that is appropriate, as SMT is the characteristic treatment of chiropractic.

If we can balance this with everything else that chiropractors use, we might be able to present it without undue weight, but a lot has not been evaluated with reviews, so we might be relegated to primary studies to present it with fairness of tone. How would we handle it on the Physical therapy article? -- Dematt Dēmatt 13:57, 10 June 2008 (UTC)

Sorry, I'm lost. Primary studies about what? The main and most common form of treatment chiropractors use is adjustment. They also routinely encourage patients to change lifestyles, and frequently perform procedures other than adjustment, but these are less common than adjustment. So I don't see how a focus on adjustment in Chiropractic Scientific research is undue weight. Eubulides19:43, 10 June 2008 (UTC)

Because the section is on low back pain, not spinal adjustment. -- Dematt Dēmatt 02:52, 11 June 2008 (UTC)

There are plenty of reliable reviews and treatment guidelines on low back pain; we shouldn't need to reach down into primary sources to discuss treatment modalities. Eubulides17:58, 11 June 2008 (UTC)

Chiropractic Scientific research obviously has some problems, but its problems are relatively minor compared to the rest of Chiropractic. Any problems with NPOV that it has are dwarfed by the NPOV problems in Chiropractic History, for example. Any problems it has with OR or with SYN are dwarfed by the OR and SYN problems in Chiropractic Philosophy. It is not right to focus on the relatively minor problems of Chiropractic Scientific research and to use them as an excuse to remove the section, while ignoring the larger problems elsewhere.

This article is currently a work in progress. Your opinion is just as valid as mine. As far as I am concerned, you can make whatever changes you want in article space or here. If I disagree, I'll let you know. I expect you to address my biases just as I address yours. That is what makes WP work, though sometimes dysfunctionally. If we all remain rational and reasoned, the tools that WP provides us, NPOV, VER and RS will allow us to end up with something that we are all equally satisfied with. -- Dematt Dēmatt 13:57, 10 June 2008 (UTC)

Fair enough; I'll keep that in mind. Eubulides19:43, 10 June 2008 (UTC)

Eubulides

20:01, 9 June 2008 (UTC)

I am sure that you can understand that when we equate SMT with chiropractic, we inadvertantly equate SMT's limitations as chiropractic's limitations. IOWs, when we say that SMT is not suggested for acute low back pain, we are inadvertantly telling the reader that chiropractic is not suggested for acute low back pain. We are not even attempting to let the reader know that chiropractors are perfectly capable of managing acute low back pain using scientifically validated methods and modalities- and this is verifiable. This entire section is a violation of NPOV for this reason - giving undue weight to this modality and synthesizing it to equate to chiropractic. If we can't fix it then we need to delete it. -- Dematt Dēmatt 13:21, 10 June 2008 (UTC)

I agree that Chiropractic Scientific research should not attempt to equate SMT with chiropractic care, and that it should make it clear that the two are not the same thing. If the wording can be improved to make this more clear, let's by all means do that. But clarifying this point is not the same as removing the mention of all research about SMT-in-general: it's common among chiropractic sources to cite and rely on such research, even when the research is derived partly from non-chiropractic data, and we should follow the experts' lead in this matter. Eubulides19:43, 10 June 2008 (UTC)

We agree on this. -- Dematt Dēmatt 02:52, 11 June 2008 (UTC)

"Chiropractic Scientific research obviously has some problems, but its problems are relatively minor compared to the rest of Chiropractic. Any problems with NPOV that it has are dwarfed by the NPOV problems in Chiropractic History, for example." OTHERCRAPEXISTS. Just because there are problems with other sections, does not mean that we should not be dealing with this section. Consensus was not reached on this section before someone inserted it, and therefore it should be removed until we can reach such consensus - otherwise editors will continue to insert large edits without consensus. I noticed several editors voicing support for effectiveness 3C, yet that seemed to be ignored. There is a major SYN violation here that has been brought up several times, and ignored several times. DigitalC00:38, 11 June 2008 (UTC)

We agree on this. -- Dematt Dēmatt 02:52, 11 June 2008 (UTC)

I agree with the OTHERCRAPEXISTS point: I do not object to attempts to "improve" coverage of effectiveness. What I objected to was the "procedure" of removing everything until a consensus can be reached. That is a recipe for removing nearly everything in Chiropractic, my point about ChiropracticHistory was merely that blanking sections is not a reasonable way to fix NPOV problems like this.

We have a continuing problem with people inserting changes without consensus, a problem that predates my involvement with Chiropractic, and a problem that will persist indefinitely unless we figure out some way to fix it. I suspect formal mediation will be the next step in that process.

There is some support for 3C, but also much opposition. I do not favor 3C, since it arbitrarily excludes research on SMT-in-general, even though we have reliable sources (e.g., Meeker Haldeman) saying such research should not be excluded.

Eubulides

17:58, 11 June 2008 (UTC)

I suggest combining the sections "Utilization and satisfaction rates" and "Scientific research" into a single section which might be named "Effects", "Results", "Effectiveness and safety", or "Effectiveness, safety and patient satisfaction", which could have subsections on cost-effectiveness, utilization etc. The name "scientific research" doesn't seem to be a very good heading for a section to me: the research is what supplies us with the facts, but this article should focus more on the facts; in other words, scientific research may be used as references to support information in any of the sections of this article, but the heading should indicate what sort of results are being reported in that section. Also, it seems to me that there is a logical similarity between the topic of utilization and satisfaction, and the topics of effectiveness, safety etc., so I'd like them to be at least adjacent sections (without History in between them) and preferably combined into one section. ☺ Coppertwig00:50, 18 June 2008 (UTC)

I agree that "Scientific research" is a bad title. None of the titles you suggest for a combined section work all that well, I'm afraid. "Effects" and "Results" are too vague, and none of those titles cover the topic of utilization. Other titles have been suggested but none have reached consensus. Here's a list of recently-suggested titles (which includes your suggestions):

Effectiveness and safety

Effectiveness, safety, and patient satisfaction

Effects

Evidence base

Evidence basis

Evidence-based medicine and research

Research and guidelines

Results

Of these suggestions, "Evidence base" makes the most sense to me, as it's the shortest title that covers the subsections' topics. Also, the current introduction to Chiropractic Scientific research would fit well under that title. Eubulides08:29, 18 June 2008 (UTC)

Scientific evaluation of methods 2

The principles of evidence-based medicine have been used to review research studies and generate practice guidelines outlining professional standards that specify which treatments are legitimate and perhaps reimbursable under managed care.

Effectiveness

Many medical procedures have not been rigorously proven to be effective, including many of the methods that chiropractors use. This does not infer that they are not effective for some conditions under certain conditions, only that their effectivenss has not been adequately studied.cite journal |journal= Clin Orthop Relat Res |date=2006 |volume=444 |pages=243–9 |title= History and overview of theories and methods of chiropractic: a counterpoint |author= DeVocht JW |doi=10.1097/01.blo.0000203460.89887.8d |pmid=16523145 Particularly, though many chiropractors suggest maintenance care, the effectiveness of this type care is unknown.cite journal |journal= Chiropr Osteopat |date=2008 |volume=16 |issue=1 |pages=3 |title= Maintenance care in chiropractic - what do we know? |author= Leboeuf-Yde C, Hestbæk L |doi=10.1186/1746-1340-16-3 |pmid=18466623 |url=http://chiroandosteo.com/content/pdf/1746-1340-16-3.pdf |format=PDF

Comments on &quot;Scientific evaluation of methods 2&quot;

Is Scientific evaluation of methods 2 a draft of a replacement for Chiropractic Scientific research? It's just a stub and would need much work to be an adequate replacement. Eubulides20:01, 9 June 2008 (UTC)

Yes, Eubilides, I was just working, then got interrupted, but, no, this is not the replacement - a work in progress. -- Dematt Dēmatt

Philosophy rewrite

| align="right" style="border:2px solid; background:f4f4f4"

|+ "'Two chiropractic belief system constructs"'

! THE TESTABLE PRINCIPLE

! nbsp;

! THE UNTESTABLE METAPHOR

|-

|align=center | Chiropractic Adjustment

|

|align=center | Universal Intelligence

|-

|align=center | ↓

|

|align=center | ↓

|-

|align=center | Restoration of Structural Integrity

|

|align=center | Innate Intelligence

|-

|align=center | ↓

|

|align=center | ↓

|-

|align=center | Improvement of Health Status

|

|align=center | Body Physiology

|-

| nbsp;

|-

| ""'MATERIALISTIC:""'

| nbsp;nbsp;nbsp;

| ""'VITALISTIC:""'

|-

| — operational definitions possible

|

| — origin of holism in chiropractic

|-

| — lends itself to scientific inquiry

|

| — cannot be proven or disproven

|-

|align=center colspan=3 | "taken from Mootz Phillips 1997"

|

Traditional and evidence-based chiropractic belief systems vary along a philosophical spectrum ranging from vitalism to materialism. These opposing philosophies have been a source of debate since the time of Aristotle and Plato. Vitalism, the belief that living things contain an element that cannot be explained through matter, was responsible for legally and philosophically differentiating chiropractic from conventional medicine and thereby helping ensure professional autonomy.cite book |author= Keating JC Jr |chapter= Philosophy in chiropractic |pages=77–98 |title= Principles and Practice of Chiropractic |edition= 3rd ed. |editor= Haldeman S, Dagenais S, Budgell B "et al." (eds.) |publisher=McGraw-Hill |date=2005 |isbn=0-07-137534-1 Chiropractic also retains elements of materialism, the belief that all things have explanations, which forms the basis of science. Evidence-based chiropractic balances this dualism by emphasizing both the tangible, testable principle that structure affects function, and the untestable, metaphorical recognition that life is self-sustaining.

The chiropractor's purpose is to foster the establishment and maintenance of an organism-environment dynamic that is the most conducive to functional well-being of the person as a whole. Principles such as holism, naturalism, therapeutic conservatism, critical rationalism, and thoughts from the phenomenological and humanistic paradigms form an important part of the philosophy of chiropractic."cite book |author= Phillips RB |chapter= The evolution of vitalism and materialism and its impact on philosophy |pages=65–76 |title= Principles and Practice of Chiropractic |edition= 3rd ed. |editor= Haldeman S, Dagenais S, Budgell B "et al." (eds.) |publisher=McGraw-Hill |date=2005 |isbn=0-07-137534-1

Chiropractors can adopt or share vitalist, naturalist, or materialist viewpoints and emphasize a holistic, patient-centered approach that appreciates the multifactorial nature of influences (i.e. structural, chemical, and psychological) on the functioning of the body in health and disease and recognizes the dynamics and interplay between lifestyle, environment, and health. This holistic paradigm is also blended with a biopsychosocial approach, which is also emphasized in chiropractic care. In addition, chiropractors also retain naturopathic and naturalist principles that suggest decreased "host resistance" of the body facilitates the disease process and that natural interventions are preferable towards strengthening the host in its effort to optimize function and return to homeostasis. Chiropractic care primarily emphasizes manipulation and other manual therapies as an alternative than medications and surgery.cite book |editor= Mootz RD, Hansen DT |title= Chiropractic technologies |publisher= Jones Bartlett |date=1999 |isbn=0834213737 |author= Hansen DT, Mootz RD |chapter= Formal processes in health care technology assessment: a primer for the chiropractic profession |pages=3–17

Chiropractors also commonly use nutrition, exercise, patient education, health promotion and lifestyle counseling as part of their holistic outlook towards preventive health care.cite journal |journal= J Manipulative Physiol Ther |date=2000 |volume=23 |issue=1 |pages=1–9 |title= A survey of practice patterns and the health promotion and prevention attitudes of US chiropractors, maintenance care: part I |author= Rupert RL |doi=10.1016/S0161-4754(00)90107-6 |pmid=10658870 Chiropractic's claim to improve health by improving biomechanical and neural function by the manual correction of joint and soft tissue dysfunctions of the neuromusculoskeletal system differentiates it from mainstream medicine and other complementary and alternative medicine (CAM) disciplines, but is also rooted, in part, in osteopathy and eastern medicine interventions. All chiropractic paradigms emphasize the spine as their focus, but their rationales for treatment vary depending on their particular belief system.

The philosophy of chiropractic also stresses the importance of prevention and primarily utilizes a pro-active approach and a wellness model to achieve this goal.cite journal |journal= J Manipulative Physiol Ther |date=2000 |volume=23 |issue=1 |pages=10–9 |title= Maintenance care: health promotion services administered to US chiropractic patients aged 65 and older, part II |author= Rupert RL, Manello D, Sandefur R |doi=10.1016/S0161-4754(00)90108-8 |pmid=10658871 For some, prevention includes a concept of "maintenance care" that attempts to "detect and correct" structural imbalances of the neuromusculoskeletal system while in its primary, or functional state.cite web |author= Canadian Chiropractic Association |title= Glenerin guidelines: preventive maintenance care |url=http://www.ccachiro.org/client/cca/cca.nsf/web/Chapter+14+-+Preventative-Maintenance+Care!OpenDocument |date=1996 |accessdate=2008-02-26 The objective is early identification of mechanical dysfunctions to prevent or delay permanent pathological changes.cite book |author= Vear HJ |editor= Vear HJ (ed.) |chapter= Scope of chiropractic practice |title= Chiropractic Standards of Practice and Quality of Care |location= Gaithersburg, MD |publisher=Aspen |date=1992 |oclc=23972994 |pages=49–68

In summary, the major premises regarding the philosophy of chiropractic include holism, conservatism, and manual and biopsychosocial approaches.cite book |chapterurl=http://chiroweb.com/archives/ahcpr/chapter2.htm |chapter= Chiropractic belief systems |author= Mootz RD, Phillips RB |date=1997 |title= Chiropractic in the United States: Training, Practice, and Research |pages=9–16 |editor= Cherkin DC, Mootz RD (eds.) |url=http://curziechiropractic.com/forms/ahcpr/uschiros.pdf |format=PDF |accessdate=2008-05-11 |version= AHCPR Pub No. 98-N002 |location= Rockville, MD |publisher= Agency for Health Care Policy and Research |oclc=39856366

Comments on Philosophy rewrite

I suggest we improve the philosophy section. The section starting with *Holism should be http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticcurid=197022diff=219657361oldid=219656331 briefly summarized. Here is an archived discussion. A better idea may be to rewrite the entire philosophy section. QuackGuru08:30, 16 June 2008 (UTC)

I (and I suspect other editors) currently lack the time to work on this. I suggest we defer this until other, more-pressing matters get resolved. However, if you have the time to come up with a good rewrite, please feel free to draft one here.

More generally, in the future, if you think a section needs improvement, but don't have a proposal with complete specific wording, please don't copy the section into talk space. Please just say what improvements are needed. That will make this talk page smaller and easier for others to read, and will help us improve the article faster.

Eubulides

19:20, 16 June 2008 (UTC)

Philosophy was rewritten just two months ago and you were here for that. As active as you are, I doubt that I will even be able to follow all of your conversations, much less read the sources, so I'll be working on the priority list. Please don't consider anything having my support unless I specifically said I support it. You can always ask me to take a look at something if you want, and I will do the same for you. -- Dematt Dēmatt 21:38, 16 June 2008 (UTC)

I did not really participate in the Philosophy rewrite. I think this http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticcurid=197022diff=219657361oldid=219656331 edit is an improvement. QuackGuru23:08, 16 June 2008 (UTC)

Comments on the very boring bulleted text

"'Holism"'

boring text

"'Conservatism"'

more boring text

"'Manual and biopsychosocial approaches"'

even more boring text

There is an extensive long end run of bulleted text in the Philosophy section. Me thinks this http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticcurid=197022diff=219657361oldid=219656331 change is a great improvement. We can fix this boring stuff by simply summarizing it. QuackGuru00:00, 17 June 2008 (UTC)

I absolutely disagree. I don't find this section boring, and holism, consevatism, and chiropractics manual BPS approaches are extremely important. DigitalC07:39, 17 June 2008 (UTC)

This is far more boring than the blocked quotes/text in education 3. There are also WEIGHT problems. QuackGuru07:50, 17 June 2008 (UTC)

Is the bulleted text necessary?

The bulleted text is hard to follow and extremely boring.

Here is text and a summary from one of the references found in Philosophy: cite book |chapterurl=http://chiroweb.com/archives/ahcpr/chapter2.htm |chapter= Chiropractic belief systems |author= Mootz RD, Phillips RB |date=1997 |title= Chiropractic in the United States: Training, Practice, and Research |pages=9–16 |editor= Cherkin DC, Mootz RD (eds.) |url=http://curziechiropractic.com/forms/ahcpr/uschiros.pdf |format=PDF |accessdate=2008-05-11 |version= AHCPR Pub No. 98-N002 |location= Rockville, MD |publisher= Agency for Health Care Policy and Research |oclc=39856366

Holism represents a philosophic perspective on the integration of body, mind, and spirit that posits that health depends on obedience to natural laws and that deviation can result in illness. Holism is based on the doctrine of teleology, which implies that there is a design or purpose in nature. An idealistic or vitalistic component can be seen in teleology. Based on the vitalism and metaphysics of his time, D.D. Palmer provided chiropractic a teleological metaphor when he expounded the concept that there is a "universal intelligence" that is manifest in living things as an "innate intelligence," which provides purpose, balance, and direction to all biologic function (Palmer, 1910). The classic medical concept of homeostasis also has its roots in the teleology of holism.

A complete reliance on a holistic universal intelligence entails dogma and is not acceptable in current chiropractic philosophy or practice (Phillips, 1992). Although untestable scientifically, the concepts proposed by chiropractic's metaphor (and holistic models in general) can still be subject to critical review and refinement (Milus, 1995). Popper (1960) suggested that the formulation of proper lines of questioning about new knowledge and ideas can be useful. For example, rather than defending assertions (or questioning the source of knowledge) about the body’s self-healing capacity, one might try to identify and revise conceptions regarding self-healing that are inconsistent with available evidence.

G. Summary

Traditional chiropractic belief systems focused on the body's ability to self-heal, the nervous system's role in overall health, and the role body structure was thought to play in function of the nervous system. Early articulation of these concepts by chiropractors was often cloaked in terminology that conveyed spiritual connotations. In addition, vitalistic explanations of self-healing confounded many outside the profession when used by early chiropractors to deny the value of quantitative evidence on clinical effectiveness.

Contemporary chiropractic belief systems embrace a blend of experience, conviction, critical thinking, open-mindedness, and appreciation of the natural order of things. Emphasis is on the tangible, testable principle that structure affects function, and, the untestable, metaphorical recognition that life is self-sustaining and the doctor’s aim is to foster the establishment and maintenance of an organism-environment dynamic that is the most conducive to functional well-being.

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

The above text is more clear and explains which chiropractor is being discussed, whether it is straight (traditional) or mixers (contemporary). The bulleted text is not clear which chiropractor believes in Holism, Conservatism, or Manual and biopsychosocial approaches and is confusing.

Per Wikipedia:Manual of StyleBulleted and numbered lists. Do not use lists if a passage reads easily using plain paragraphs. QuackGuru17:12, 17 June 2008 (UTC)

Both mixers and straights believe in Holistic, Conservative, Manual and BPS approaches. So do many 'mainstream' practitioners. For example, any wellness based health care (diet, exercise, etc.) are holistic in nature, and are also conservative in nature. All chiropractic treatment is conservative in nature (Chiropractors can't use invasive treatments such as surgery that is not conservative), etc. etc. DigitalC10:09, 18 June 2008 (UTC)

copyrighted text in philosophy

… noninvasive, emphasizes patient's inherent recuperative abilities

… recognizes dynamics between lifestyle, environment, and health

… emphasizes understanding cause of illness in an effort to eradicate, rather than palliate, associated symptoms

… recognizes the centrality of the nervous system and its intimate relationship with both the structural and regulatory capacities of the body

… appreciates multifactorial nature of influences (structural, chemical, and psychological) on the nervous system

… balances benefit versus risk of clinical interventions

… recognizes as imperative the need to monitor progress and effectiveness through appropriate diagnostic procedures

… prevents unnecessary barriers in the doctor-patient encounter

… emphasizes a patient-centered, hands-on approach intent on influencing function through structure

… strives toward early intervention emphasizing timely diagnosis and treatment of functional, reversible conditions

Here is a copy of the text from the above source. There seems to be a COPYVIO problem in the philosophy section starting with the Holism bulleted text. QuackGuru23:47, 17 June 2008 (UTC)

The cited source is in the public domain, so there is no copyright violation. However, I agree that it's disturbing that so much text was lifted from the source without proper attribution. It should be quoted if we're quoting it that much; merely citing the source isn't enough for proper credit. The simplest way to fix the problem is to put quote marks around the quoted text, making sure each quote is followed by a citation (this can wait until the end of the sentence).

I also agree that Chiropractic Philosophy is long and repetitive and boring. A better-motivated and better-sourced replacement for its introduction can be found in Talk:Chiropractic/Archive 15 Philosophy 2. That version was rejected by the editors at the time, but not all of them are still active, so perhaps this can be revisited at some point.

Although Chiropractic Philosophy could be improved, it doesn't have serious POV problems as some other sections do, so it is lower priority for me.

Eubulides

08:29, 18 June 2008 (UTC)

The current mainspace version is very boring and can be improved. I have proposed Philosophy 2 rewrite below. QuackGuru18:18, 18 June 2008 (UTC)

Challenge

I claim that FRINGE applies to this article. Who disagrees/agrees and why? ScienceApologist19:38, 29 May 2008 (UTC)

You're not giving me a chance to say I agree? 19:42, 29 May 2008 (UTC)

What theory are you asserting that FRINGE applies to? DigitalC01:18, 30 May 2008 (UTC)

It's not a poopularity contest, SA. It's about evidence. Remember Stephen Colbert and African Elephants? You can easily manipulate and distort "facts" if you are uninformed and don't provide any reliable evidence to support the claims made. Anyone can canvass anyone to get "consensus". You, or any other anti-chiropractic editor has yet to provide any evidence that suggests chiropractic is fringe. There is compelling evidence to the contrary, however. CorticoSpinal02:34, 30 May 2008 (UTC)

I would agree that Filll/WP Challenge wpc) 19:31, 30 May 2008 (UTC)

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

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

Commenting here as an uninvolved editor, I think that there might be a case both ways. Chiropractic is not yet quite mainstream, but is almost mainstream- http://www.ncbi.nlm.nih.gov/sites/entrez?orig_db=PubMeddb=PubMedcmd=Searchterm=136%5Bvolume%5D%20AND%203%5Bissue%5D%20AND%20216%5Bpage%5D%20AND%202002%5Bpdat%5D see this source. However, I think there should be little argument here, because as I see it, the most mainstream sources such as the NIH give chiro an NPOV treatment, in that they are not overly negative or overly positive. Thus there should be little argument about the best sources. Because of this, saying that chiro is covered by FRINGE would not help to promote either the POV of debunkers or the POV of those who wish to present chiro as completely accepted and scientifically fully established.

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

"Contemporary chiropractic philosophy recognizes its partnership with the greater body of philosophy and science in general. Most contemporary chiropractors and their organizations distinguish between what is known and what is believed. Chiropractic belief systems embrace the holistic paradigm of wellness while incorporating deterministic materialism for the establishment of valid chiropractic principles. Chiropractic’s philosophic foundation serves as the basis for theoretical development, not a substitution for it (Phillips, 1992)." http://chiroweb.com/archives/ahcpr/chapter2.htm

http://www.biomedcentral.com/1472-6963/6/49 This is also a mainstream source, and should not be objectionable to those who promote chrio:

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

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

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

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

If you want to achieve consensus, and avoid sanction in the end, stop the name calling completely. ——"'—— 19:34, 30 May 2008 (UTC)

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

The sources you give are a too old to be included in this article, compared to what's already there, and the sources already included in the article make the same basic points; the problem is that these points are under dispute here.

This talk page "is" archived; any topic not touched in 14 days is automatically archived by a bot.

It would indeed help to have a summary of the debate, but nobody has taken the (considerable) time to write one. It would take a lot of time to write one primarily because editors would argue a lot about what its contents should be. It really is quite dysfunctional, I'm afraid.

Eubulides

01:08, 31 May 2008 (UTC)

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

You have to be careful here. The "NIH" source you cite is actually the U.S. National Center for Complementary and Alternative Medicine. Although it falls under the NIH umbrella, it is not a mainstream-medicine organization; it focuses on CAM, which by definition is not mainstream medicine. In the past NCCAM has supported obvious pseudoscience such as remote viewing and distant healing. It has its supporters (enough to get Congressional funding, after all; NCCAM was created for political reasons, not for scientific ones) but it also has sharp critics (for example, http://www.csicop.org/si/2003-09/alternative-medicine.html).

The mainstream view of chiropractic is what is being disputed here. On the one side we have proponents of chiropractic who say that the mainstream view is represented by the http://www.nptf.ualberta.ca/ The Bone and Joint Decade 2000-2010 Task Force on Neck Pain and Its Associated Disorders and that sources critical of chiropractic are fringe. On the other side we have those less supportive of chiropractic, who would point to (say) the American Pain Society/American College of Physicians clinical practice guideline, which only weakly recommends spinal manipulation as one alternative therapy (among many) for spinal low back pain in nonpregnant adults when ordinary treatments fail (see Chou "et al." 2007, PMID|17909210), or maybe to the Swedish guideline for low back pain, which removed chiropractic manipulation as a treatment option in 2002 (see Murphy "et al." 2006, PMID|16949948).

That's just the short version. For more details about what mainstream sources say about effectiveness, please see Chiropractic Effectivness.

Eubulides

07:56, 31 May 2008 (UTC)

Lets look at those ACP guidelines again. For acute LBP, how "many" "alternative" therapies are recommended? One could also point out that those 2002 Swedish Guidelines are obsolete - and that they have been replaced by the European guidelines way back in 2006. For acute LBP they recommend "Consider (referral for) spinal manipulation for patients who are failing to return to normal activities". They also state that "Back schools (for short-term improvement), and short courses of manipulation/mobilisation can also be considered." for chronic LBP (among other options). And now we're back to equating SMT w/ Chiropractic again. DigitalC03:34, 5 June 2008 (UTC)

For acute low back pain, the ACP guidelines recommend the consideration of only one alternative therapy (SMT) for patients who do not improve with standard care. For chronic or subacute LBP, they recommend consideration of eight therapies, one of which is SMT. My understanding is that the European guidelines do not replace national guidelines; is that incorrect? Do you have a source on this point? If the Swedish guidelines have been replaced, Chiropractic should be updated; no point referring to obsolete guidelines. Eubulides07:05, 5 June 2008 (UTC)

Why would the European guidelines NOT replace national guidelines? What are they for then? Interestingly enough, I can't find a 2002 guideline for backpain from SBU, only a http://www.sbu.se/en/Published/Post.aspx?epslanguage=EN 2000 guideline, which DOES recommend SMT ("For chronic low back pain, there is strong evidence (A) that: • manual treatment/manipulation, back training, and multidisciplinary treatment are effective in relieving pain."). Looks like I will have to chase the sources. DigitalC07:50, 5 June 2008 (UTC)

I am still confused why we are refering to the 2002 Swedish Guidelines, when we have the more recent European Guidelines, of which, Sweden was a member country (that, and as far as I can tell, the 2002 Swedish Guidelines have been repealed, as they no longer appear on the website, but the 2000 guidelines do). DigitalC07:25, 12 June 2008 (UTC)

Chiropractic does not cite the 2002 Swedish guidelines directly; it cites Murphy "et al." 2006 (PMID|16949948), which talks about the Swedish guidelines along with four other national guidelines. I wouldn't expect the European guidelines to supersede the Swedish, any more than I would expect the WHO guidelines on education to supersede CCE accreditation standards in the U.S. I'm leery about assuming that the 2002 guidelines have been repealed and the 2000 guidelines reverted to; that sounds like an extraordinary event and I'd expect some documentation of it. Eubulides08:15, 12 June 2008 (UTC)

"'Disagree"'. If we have to debate over whether it's FRINGE or not, it's probably not. Obviously there are a lot of FRINGE elements in some chiropractic practices, and some claims about chiropractic medicine are FRINGE, but mark them as such individually if necessary, or present a NPOV discussion of the issues. This is really an issue of regional differences -- some countries consider Osteopathy and Chiropractic to be main-steam, and other areas they're unheard of. NoDepositNoReturn23:54, 16 June 2008 (UTC)

I agree with much of what you said, but I'm afraid the argument "if we have to debate over whether it's FRINGE or not, it's probably not" doesn't make sense, as it essentially argues that there is no such thing as a fringe theory. After all, for every fringe theory there is a debate over whether the theory is fringe, as the theory's adherents obviously won't think it is. Anyway, I do agree that the "fringe!" / "not-fringe!" argument is oversimplified, and that chiropractic has some aspects of being fringe and some of being mainstream. Eubulides01:30, 17 June 2008 (UTC)

Okay, that was overly simplistic. My point was that this debate, as opposed to many other FRINGE debates that I've witnessed, seems to be taking place between rational people. I should have indicated a more tongue-in-cheek tone. I stand by my argument that it should not be considered FRINGE though for the reasons stated above, minus the part about us debating it. NoDepositNoReturn04:03, 19 June 2008 (UTC)

A little context helps

"In contrast, the more recently updated guideline (2002) made no recommendation to use SMT as a treatment intervention for the acute phase of LBP, possibly because the guideline developers based their treatment recommendations on grade of recommendation “A,” which represents the highest level of evidence. ... Meanwhile, the Danish guideline (2000) based all of their treatment recommendations on a grade of recommendation B" - A little context helps. They don't provide a reference to the 2002 guideline. DigitalC08:08, 5 June 2008 (UTC)

Yes, context helps. Similar context is given in Chiropractic, which makes a similar contrast between the Swedish guidelines and the American. Eubulides19:46, 5 June 2008 (UTC)

No similar context is given. "There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain.104 For example, a 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,105 whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help." This statement implies that the Swedish guidelines are evidence of controversy regarding efficacy, and that the Swedish guidelines don't consider SMT effective. However, the source used explains that the change might not be due to any controversy, but due to the fact that the Swedish guideline developoers "based their treatment recommendations on grade of recommendation "A"..." DigitalC23:30, 5 June 2008 (UTC)

I agree that two points are conflated here.

The first point is that there is continuing conflict on efficacy; this is supported by the following quote from the start of the source's "Discussion" section: "Our study showed that there is insufficient evidence to suggest that the 5 LBP guidelines reviewed should be updated based on best evidence (1999–2004). Inconsistencies in the evidence suggest that there is continuing conflict of opinion regarding: efficacy of SMT for treatment of nonspecific or uncomplicated LBP; optimal time in which to introduce this treatment approach; whether SMT is useful for treatment of chronic LBP; and finally, whether subacute LBP actually exists as a separate category requiring a specific treatment approach in its own right."

The second point is that there is doubt about the reliability of the guidelines due to the levels-of-evidence issue that you mentioned. This is supported by the following quote from the start of the 3rd paragraph of the "Discussion" section: "The mostt surprising finding, and a factor that casts some doubt on the reliability of the recommendations made, was that the levels of evidence and/or grades of recommendation used for formulating treatment recommendations varied so significantly between countries."

ChiropracticEffectiveness currently mentions only the first point; it should also mention the second.

The "For example" in ChiropracticEffectiveness is not in the source and should be removed. The source does not give the 2007 U.S. guideline as an example.

I propose the following change to take the abovementioned points into account. In ChiropracticEffectiveness under "Low back pain", change from this:

"There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain.cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=7 |pages=576–81, 581.e1–2 |title= Inconsistent grading of evidence across countries: a review of low back pain guidelines |author= Murphy AYMT, van Teijlingen ER, Gobbi MO |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948 For example, a 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,cite journal |journal= Ann Intern Med |date=2007 |volume=147 |issue=7 |pages=492–504 |title= 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 |author= Chou R, Huffman LH; American Pain Society; American College of Physicians |pmid=17909210 |url=http://annals.org/cgi/content/full/147/7/478 whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help."

to this:

"There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain. Methods for formulating treatment guidelines differ significantly between countries, casting some doubt on the guidelines' reliability.cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=7 |pages=576–81, 581.e1–2 |title= Inconsistent grading of evidence across countries: a review of low back pain guidelines |author= Murphy AYMT, van Teijlingen ER, Gobbi MO |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948 A 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,cite journal |journal= Ann Intern Med |date=2007 |volume=147 |issue=7 |pages=492–504 |title= 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 |author= Chou R, Huffman LH; American Pain Society; American College of Physicians |pmid=17909210 |url=http://annals.org/cgi/content/full/147/7/478 whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help, possibly because the guideline's recommendations were based on a high evidence level."

Eubulides

06:12, 6 June 2008 (UTC)

No further comment, so I http://en.wikipedia.org/w/index.php?title=Chiropracticdiff=218103884oldid=217852891 installed the above change with the further minor editorial change of replacing a period by a semicolon. Eubulides04:32, 9 June 2008 (UTC)

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

I don't know what is meant by "2002 study" here. Both the original and the revised text cite Murphy "et al." 2006 (PMID|16949948) and Chou "et al." 2007 (PMID|17909210). Eubulides20:01, 9 June 2008 (UTC)

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

By "negative light" which phrases do you mean? Certainly there are several negative phrases in the low back pain section of Chiropractic Effectiveness (e.g., "no longer suggest considering SMT"), but there are several positive phrases too (e.g., "good evidence supporting SMT"). The area is controversial, and Chiropractic needs to present both sides as fairly as possible; inevitably this means that some negative light will be cast, as well as some positive light. Eubulides20:01, 9 June 2008 (UTC)

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

I'm not sure I'd agree with the "chiro is not completely proven but is widely accepted..." wording. More accurate would be "it is controversial whether chiropractic care is effective, but it is partly accepted...". Quoting ChiropracticEffectiveness, "There is continuing conflict of opinion on the efficacy of SMT for nonspecific (i.e., unknown cause) low back pain.cite journal |journal= J Manipulative Physiol Ther |date=2006 |volume=29 |issue=7 |pages=576–81, 581.e1–2 |title= Inconsistent grading of evidence across countries: a review of low back pain guidelines |author= Murphy AY, van Teijlingen ER, Gobbi MO |doi=10.1016/j.jmpt.2006.07.005 |pmid=16949948 For example, a 2007 U.S. guideline weakly recommended SMT as one alternative therapy for spinal low back pain in nonpregnant adults when ordinary treatments fail,cite journal |journal= Ann Intern Med |date=2007 |volume=147 |issue=7 |pages=492–504 |title= 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 |author= Chou R, Huffman LH; American Pain Society; American College of Physicians |pmid=17909210 |url=http://annals.org/cgi/content/full/147/7/478 whereas the Swedish guideline for low back pain was updated in 2002 to no longer suggest considering SMT for acute low back pain for patients needing additional help." This is not what I'd call "wide acceptance" or "not completely proven". Eubulides08:39, 2 June 2008 (UTC)

Challenge continued

I doubt given our respective histories on CAM articles that either )~ 22:03, 30 May 2008 (UTC)

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

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

Ability to improve function in the neuromusculoskeletal system, and overall health, wellbeing and quality of life.*

Specialized approach to examination, diagnosis and treatment, based on best available research and clinical evidence with particular emphasis on the relationship between the spine and the nervous system

Tradition of effectiveness and patient satisfaction

Without use of drugs and surgery, enabling patients to avoid these where possible

Expertly qualified providers of spinal adjustment, manipulation and other manual treatments, exercise instruction and patient education.

Collaboration with other health professionals

A patient-centered and biopsychosocial approach, emphasizing the mind/body relationship in health, the self-healing powers of the individual, and individual responsibility for health and encouraging patient independence.

So, it's a done deal. Primarily NMS yet with a overall holistic approach to health and well-being. The percentages are also clear: 90-95% of DCs treat NMS disorders (primarily back and neck pain), 5-10% treat non-NMS. I've been trying to get this crucial point across for months now. CorticoSpinal00:01, 31 May 2008 (UTC)

I view with great skepticism any claim that the debate is "over" or that "it's a done deal". Remember, this is "chiropractic" we're talking about: put 3 chiropractors in the room and ask them a question, and you're bound to get at least 4 strongly held and widely varying answer. Certainly the WFC approach is not universally held by chiropractors: Homola, a chiropractor, argues that the WFC's definition is "plunging the profession deeper into pseudoscience and away from establishing an identity for chiropractors as back-pain specialists". See: cite journal |journal= Skept Inq |date=2008 |volume=32 |issue=1 |title= Chiropractic: a profession seeking identity |author= Homola S |url=http://csicop.org/si/2008-01/homola.html

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

Those percentages do not sound right, as I expect that far more than 5-10% chiropractors are straights. (I have no idea where those percentages came from; can anyone cite a source?) Furthermore, the vitalistic stuff is important when explaining chiropractic history, so it needs to be covered more than just the current percentage of practitioners would suggest, if only in Chiropractic History. Finally, as the McDonald survey shows, the distance between straights and mixers is not as far as a simple "straights vitalistic, mixers materialistic" discussion would suggest. Eubulides01:08, 31 May 2008 (UTC)

Being a straight DC doesn't imply fringe. Straights by and large majority treat MSK issues, they're just more likely to treat non NMS ones. Vitalism was used to differentiate legally and is better represented by holism today. The concept still stands: the whole is greater than the sum of its parts. Was it Aristotle or Plato who said that? Regardless, I support Dematts suggestion its sensible, but lets not bring skeptical inquirer articles and Homola into this: We have DC/PhDs who produce far better articles with better content on the same subject. Homola has direct ties with Stephen Barrett and his views are completely fringe. See his article in 2006 in Clin Ortho which was rebutted by Dr. Hart and throttled by DeVocht's counterpoint which was a far superior piece of research. Bottom line should be, the identity issue is officially put to rest, primarily NMS yet overall health, and the majority of the profession should not be discredited because of the fringe aspects of a minority of practitioners. Good call by MartinPhi as well. We're moving in the right direction; this is positive, productive dialogue for a change. CorticoSpinal01:46, 31 May 2008 (UTC)

Not surprisingly I disagree with the characterization of Homola's recent publications: I think they're of higher quality than DeVocht's paper. I also disagree that the identity issue has been put to rest. It's not just Homola who says that chiropractic still suffers from a high degree of internal confusion. See, for example, the WCA's take on the WFC's position.http://www.worldchiropracticalliance.org/news/identity.htm Eubulides07:56, 31 May 2008 (UTC)

The WCA is the most fringe element of the profession and they are not to be taken seriously whatsoever. We don't give the WCA any weight because the WCA has no credibility, inside or outside chiropractic. Again, you want to drum up a false sense of controversy, using a fringe source and more fringe association (WCA) and make it doubt the mainstream view. This line of argumentation now is getting very weak and tiresome. I think you've exhausted your last life line, the WCA card has been played and it will be summarily debunked and proven as fringe. Another attempt to have the fringe view of chiropractic exploited to discredit and dispute the notability and credibility of the mainstream view regarding chiropractic identity and the WFC. CorticoSpinal09:33, 31 May 2008 (UTC)

In reply to CorticoSpinal's message of http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=216031989oldid=216029517 19:46, 30 May 2008 (UTC): I think what you're talking about has nothing to do with the FRINGE guideline (or if it does, would someone tell me which part? though see re parity, below). Rather, I think it's about what sources are considered reliable sources of sufficient reliability and notability to be worth mentioning. However, even here I think labelling some things as "fringe" or not is of little use. Reliable sourcesExtremist and fringe sources says that fringe stuff ""should be used only as sources about themselves and in articles about themselves or their activities"". So if some chiropractic sources are fringe, then this article is the place to use them. If they are not fringe, then this is still the place to use them. How would labelling chiropractic as fringe or not make any difference to the content of this article?

On the other hand, labelling some particular parts of chiropractic philosophy as being on the fringe of chiropractic, as Eubulides suggests (last section of http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=215588247oldid=215586472, and ""http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=216091246oldid=216086924 I agree that the article should only cover the chiropractic fringe the way that...""), does seem useful to me. Besides presenting the mainstream science POV of chiropractic, this article should describe the beliefs held by most chiropractors, and those held by a minority of chiropractors should also be more briefly mentioned, but those fringe views held by a tiny minority of chiropractors should not be mentioned, per UNDUE.

QuackGuru also http://en.wikipedia.org/w/index.php?title=User_talk:Coppertwigdiff=215876057oldid=215852310 mentioned Fringe theoriesParity of sources. I'm puzzled as to why it's those who think this article is already too pro-chiropractic who are trying to get it labelled as "fringe" so that sources not normally classified as RS can be used to describe the chiropractic point of view or in order to override Wikipedia:WikiProject Medicine/Reliable sourcesUsing primary sources to "debunk" the conclusions of secondary sources to allow use of certain sources, presumably the ones CorticoSpinal is trying to get included but which have been called primary sources. Anyway, I think there are enough good sources about chiropractic that we don't need to invoke FRINGE to allow lower quality sources: we only need to debate which sources are good and why. I think labelling all of "chiropractic" as either "fringe" or "mainstream" would be an overgeneralization that would not be particularly useful for that.

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

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

I think Fyslee has hit the nail on the head in this diff: ""http://en.wikipedia.org/w/index.php?title=Talk:Chiropracticdiff=215894341oldid=215890887 Come on now guys."" ☺ Coppertwig 14:10, 31 May 2008 (UTC)

The main point of FRINGE, as I understand it, is a comparative one: that fringe views should not receive undue weight when compared with the general mainstream. So, when the topic is Chiropractic, the issue is the weight with which the several schools of practise should be presented. If the McTimmoney school, for example, is a minor one, then it should not get too much attention. If one is taking a wider view of chiropractic's merits vs osteopathy, physiotherapy, surgery, acupuncture or whatever, then this would be addressed in a more general article such as Back pain. This article is not the place to make this comparison since the topic here is specifically Chiropractic. So, in conclusion, it seems logically obvious that Chiropractic cannot be fringe within its own article. Colonel Warden20:01, 31 May 2008 (UTC)

* The dispute is not over whether chiropractic's merits should be compared to osteopathy etc. Almost none of that is in Chiropractic now. The dispute is over what weight to give sources supportive of chiropractic, as opposed to sources critical of chiropractic, in sections like ChiropracticEffectiveness and ChiropracticSafety; also, whether to include sources whose effectiveness or safety results are partly derived from non-chiropractic data. Eubulides08:39, 2 June 2008 (UTC)

That is a different issue and the key factor there would be the independence of the sources to avoid COI. We should look for impartial judges of such issues. This would tend to exclude those with a commercial interest in promoting or denigrating the practise. Note also that we should not give undue weight to such issues. The article's section on cost effectiveness seems dubious for example - I'd like to see some evidence that the cost-effectiveness of this form of treatment is a significant issue which merits the attention given. If the idea is that the FRINGE label can be used as an excuse to turn the article into an attack like the homeopathy one then the answer is an emphatic NOT. Colonel Warden23:43, 3 June 2008 (UTC)

If we excluded everybody who had a commercial interest in promoting or denigrating chiropractic, the article would become practically empty. No D.C. could be a source; no M.D. either. Such a standard is unrealistic. The vast majority of high-quality sources on chiropractic are by D.C.s or M.D.s (or both).

The cost-effectiveness of chiropractic is a valid topic. Dozens (perhaps hundreds) of scholarly papers have mentioned the subject. For a few recent examples, see Leboeuf-Yde Hestbæk 2008 (PMID|18466623), Stochkendahl "et al." 2008 (PMID|18377636), Ernst 2008 (PMID|18280103), and Bronfort "et al.' 2008 (PMID|18164469).

Eubulides

07:24, 4 June 2008 (UTC)

Don't know what it's like in other countries, but in Australia, chiropractic pretty much means musculoskeletal. http://www.yourhealth.com.au/index.php?page=/services/therapies/view-content.php?id=337 When you go there you get an adjustment, and the cost of an adjustment at various concessions is the only price on the wall. In order to practice as one you have to have a Bachelor of Applied Science from a university - ironically the same ones that hand out medical and physiotherapy degrees. Normal health funds here (e.g. http://www.medibank.com.au/Health-Covers/About-Extras-Covers.aspx, http://www.nss.gov.au/nss/home.NSF/surveylookup/Allied+Health+Industries+Survey+(Stage+1)+Financial+Year+1997/1998+Population+Frame?OpenDocument) will pay part of an adjustment and a fair percentage of chiropractic X-rays (in fact I got the latter on Medicare! http://www.brunswickhealth.com.au/EPCMedicareRebateBrochure.pdf) It's certainly not fringe science. That being said, claims reminding one of 1920s ads of things that can cure cancer or AIDS or epilepsy or whatever, would certainly be fringe if they were put as fact. 20:43, 4 June 2008 (UTC)

I have to agree wholeheartedly with Colonel Warden here. FRINGE is not intended to permit attacks on a practice or procedure within its own context, or to enforce evaluations of the relative merits of practices in a larger context. FRINGE's primary purpose is to maintain encyclopedic style - preventing articles from becoming overburdened with a plethora of small, disorganized, tangential discussions. use of FRINGE as an evaluative tool is clearly biased.

I'll add a further caution about the use of the term 'effective' in this discussion. the correct term is 'legitimized'. it is true that effectiveness of a treatment is used to legitimize a practice or procedure in the medical community, but it would be a logical fallacy to assert from that that the lack of legitimization by the medical community implies a lack of effectiveness. --Ludwigs2 06:27, 18 June 2008 (UTC)

Again Chiropractic Effectiveness does not compare chiropractic to alternative health care professions. Furthermore, Chiropractic Effectiveness is not at all about legitimacy: it is about the effectiveness of chiropractic care. Eubulides08:29, 18 June 2008 (UTC)

well, I was think about this passage (which admittedly comes a couple of lines "before" Chiropractic Effectiveness): ""Evidence-based guidelines are supported by one end of an ideological continuum among chiropractors; the other end employs pseudoscientific and antiscientific reasoning and makes unsubstantiated claims."" which aside from being brutally POV, is deeply confused about the relationship between evidence and legitimacy. the more I look through this article, the more I see that, in fact: it's quite disturbing. --Ludwigs2 10:02, 18 June 2008 (UTC)

That quote is about evidence-based guidelines, and which chiropractors support them. It is not about legitimacy. The legitimacy stuff is in Chiropractic Scope of practice. As for POV, the quoted text is based on a reliable source (Keating, perhaps the leading historian of chiropractic in the past two decades), and I don't know of any reliable source seriously disputing it. Eubulides22:20, 18 June 2008 (UTC)

On the surface, I have to agree with Ludwigs on this one. That section needs work, but I am waiting for the priority list because I only want to say things once this time. -- Dematt Dēmatt 02:45, 19 June 2008 (UTC)

Philosophy 2 rewrite

Although a wide diversity of belief exists among chiropractors, they share the principle that the spine and health are related in an important and fundamental way, and this relationship is mediated through the nervous system.cite book |author= Gay RE, Nelson CF |chapter= Chiropractic philosophy |chapterurl=http://www.ncbi.nlm.nih.gov/books/bv.fcgi?rid=altrehab.section.336 |editor= Wainapel SF, Fast A (eds.) |title= Alternative Medicine and Rehabilitation: a Guide for Practitioners |date=2003 |isbn=1-888799-66-8 |location= New York |publisher= Demos Medical Publishing Chiropractors pay careful attention to the biomechanics, structure and function of the spine, its effects on the nervous and musculoskeletal systems, and the role these systems play in preventing disease and restoring health.cite web |title= History of chiropractic care |author= American Chiropractic Association |accessdate=2008-02-21 |url=http://acatoday.org/level2_css.cfm?T1ID=13T2ID=62

Chiropractic philosophy goes beyond simply manipulating the spine. Like naturopathy and several other forms of complementary and alternative medicine, chiropractic assumes that all aspects of a patient's health are interconnected, which leads to the following perspectives:cite book |chapterurl=http://chiroweb.com/archives/ahcpr/chapter2.htm |chapter= Chiropractic belief systems |author= Mootz RD, Phillips RB |date=1997 |title= Chiropractic in the United States: Training, Practice, and Research |pages=9–16 |editor= Cherkin DC, Mootz RD (eds.) |accessdate=2008-02-14 |version= AHCPR Pub No. 98-N002 |location= Rockville, MD |publisher= Agency for Health Care Policy and Research |oclc=39856366

"'Holism"' treats the patient as a whole, and appreciates the multifactorial nature of influences (structural, chemical, and psychological) on the nervous system, recognizing dynamics between lifestyle, environment, and health.

"'Conservativism"' carefully considers the risks of clinical interventions when balancing them against their benefits. It emphasizes noninvasive treatment to minimize risk, and avoids surgery and medication.

"'Homeostasis"' emphasizes the body's inherent self-healing abilities. Chiropractic's early notion of innate intelligence can be thought of as a metaphor for homeostasis.

A "'patient-centered"' approach focuses on the patient rather than the disease, preventing unnecessary barriers in the doctor-patient encounter. The patient is considered to be indispensable in, and ultimately responsible for, the maintenance of health.

Chiropractic's early philosophy was rooted in spiritual inspiration and rationalism. A philosophy based on deduction from irrefutable doctrine helped distinguish chiropractic from medicine, provided it with legal and political defenses against claims of practicing medicine without a license, and allowed chiropractors to establish themselves as an autonomous profession. This "straight" philosophy, taught to generations of chiropractors, rejected the inferential reasoning of the scientific method, and relied on deductions from vitalistic principles rather than on the materialism of science.

As chiropractic has matured, most practitioners accept the value that the scientific method has to offer.cite book |author= Keating JC Jr |chapter= Philosophy in chiropractic |pages=77–98 |title= Principles and Practice of Chiropractic |edition= 3rd ed. |editor= Haldeman S, Dagenais S, Budgell B "et al." (eds.) |publisher=McGraw-Hill |date=2005 |isbn=0-07-137534-1 Balancing the dualism between the metaphysics of their predecessors and the materialistic reductionism of science, their belief systems blend experience, conviction, critical thinking, open-mindedness, and appreciation of the natural order. They emphasize the testable principle that structure affects function, and the untestable metaphor that life is self-sustaining. Their goal is to establish and maintain an organism-environment dynamic conducive to functional well-being of the whole person.

Comments on Philosophy 2 rewrite

This version tells a story and is concise. It will capture the reader. The long and repetitive mainspace version is very boring to read. QuackGuru18:18, 18 June 2008 (UTC)

The figure isn't needed and can be removed, so I removed it. That was the only change from the previous draft, so this draft is now equivalent to what is in the previous draft. I suppose it can be further edited now, but as I said before, this is low priority for me. Eubulides22:20, 18 June 2008 (UTC)

For what it's worth, I like this draft much better than what's up now. I understand the point about priorities, though. --CynRN ""'—CynRN""' "" 23:47, 19 June 2008 (UTC)

References

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