Talk:Vertebral artery dissection/Archive 3

Archive 1

Archive 2

Archive 3

Archive 4

Partial Horner

If the Horner has all three symptoms it shouldn't be called partial. If it is partial, there should be no anhidrosis. I've added the definitial of a partial Horner to the page on Horner. Currently, I don't have access to the Kim article, but if he talks about a partial Horner having all three symptoms he's not right. See my two references at Horner's_syndrome#Pathophysiology. PizzaMan (talk) 09:48, 24 June 2011 (UTC)

Changed.[1] JFW | T@lk 13:50, 4 July 2011 (UTC)

QG's proposal to change the article

QG has posted elsewhere with a proposal to change this article. I strongly object to this change, based on my comment above, and how not all views are represented in his new proposal, and per WP:COATRACK again. DigitalC (talk) 04:13, 1 July 2011 (UTC)

A most unwelcome move. We are not amused. JFW | T@lk 06:22, 1 July 2011 (UTC)

You have not provided V from the current source and the source is not specifically about vertebral artery dissection. QuackGuru (talk) 20:53, 1 July 2011 (UTC)

Mass original research

This part of the proposal is to rewrite a vague/unsourced sentence in Traumatic.

The main problem is the current vague sentence.

Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection.

Proposal to improve the incoherent vague sentence.

The causality between chiropractic, particularly neck manipulation, and vertebral artery dissection is probable.

Current paragraph in Traumatic.

Chiropractic and other forms of neck manipulation have been linked[original research?] to vertebral artery dissection. In hospital-based studies this was the underlying cause for 16–28% of cases, but[original research?] it has been suggested[original research?] that the true figure may be higher and that there is significant under-reporting. Reports of the association are of weak to moderately strong quality, but[original research?] many of the reports have methodological flaws. The association between chiropractic neck manipulation and vertebral artery dissection is disputed by proponents of these treatment modalities.[original research?]

I request WP:V for the text that seems to be inaccurate or is original research.

I propose the following text to remove the rest of the WP:OR, taken out of context opinion.

Proposal to improve current paragraph with this rewrite.

The causality between chiropractic, particularly neck manipulation, and vertebral artery dissection is probable. In hospital-based studies this was the underlying cause for 16–28% of cases. The true figures for vascular accidents is higher because there is substantial underreporting. Reports of the association are of weak to moderately strong quality, and many of the reports have methodological flaws.

Discussion.

• See WP:MEDRS: Ideal sources for these aspects include general or systematic reviews in reputable medical journals; professional and academic books written by experts in a field and from a respected publisher; and medical guidelines or position statements from nationally or internationally reputable expert bodies.
• See WP:WEIGHT: Neutrality requires that each article or other page in the mainspace fairly represents all significant viewpoints that have been published by reliable sources, in proportion to the prominence of each viewpoint. Giving due weight and avoiding giving undue weight means that articles should not give minority views as much of or as detailed a description as more widely held views.
• This MEDRS compliant source does discuss vertebral arterial dissection associated with manipulation of the spine throughout the systematic review. If this is an issue of WP:WEIGHT then we must give the recent systematic review due weight.
• "What’s known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death."
• "What’s new The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished."
• "Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g. 1,2). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism(2)."
• "This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death (1,2,26,30)."
• "Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial."
• E Ernst (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice. 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715.

It is speculation/original research that chiropractic and other forms of neck manipulation have been 'linked' to VAD. The text does not pass V. This specific proposal is to replace the vague, 'unsourced' sentence with the 'sourced' evidence. I have previously requested verification but no editor was able to provide. WP:V. See Wikipedia:Fringe theories/Noticeboard/Archive 23#Vertebral artery dissection.

It is indeed speculation/original research that neck manipulation has been 'linked' to VAD. Research examining the causality has been recently published in 2010 using a systematic review in accordance with WP:MEDRS. The VAD article currently does not satisfy NPOV, FRINGE, MEDRS, and V and does need to be changed. The current source being used at VAD is about adverse affects with spinal maniplaution in general. The Ernst 2007 source is not specifically about the relationship with VAD. We should not use a source not specific to the topic when there is a better and newer source avaliable from the same author. The proposal is sourced to the Ersnt 2010 that is clearly specific to the topic at hand. The taken out of context WP:OR sentence is: "The association between chiropractic neck manipulation and vertebral artery dissection is disputed by proponents of these treatment modalities." This sentence is a fringe minority view and does not represent the current source being used. The mainstream view states that the assocation between VAD and spinal manipulation is likely according to the 2010 recent systematic review (PMID 20642715).

Do editors agree the OR from at this article must be removed. Does any editor want the OR removed from this article? From the previous discussions it seems editors have not provided verification for the unsourced text. The current source is about adverse effects of spinal manipulation in general. I think the source must be replaced with the source that is specifically about chiropractic manipulation and spinal manipluation as it relates to vertebral artery dissection. Please respond to the specific argument including the mass OR against core Wikipedia policy. We can the source that is specific to the topic and remove the OR. Okay? QuackGuru (talk) 20:49, 1 July 2011 (UTC)

Is part of your proposal to replace a vague but understandable sentence with "The causality between chiropractic, particularly neck manipulation, and vertebral artery dissection is probable"?

I agree with your description of this sentence ("The causality...") as incoherent, and I therefore oppose its inclusion in the article. WhatamIdoing (talk) 21:28, 1 July 2011 (UTC)

I don't see any OR, but would you be happy if the wording was changed from "linked" to "associated", to better match the source? DigitalC (talk) 00:14, 2 July 2011 (UTC)

I do not see any OR in this section and I also think that the current sentence is better than the proposed new sentence. I agree with Digital C that replacing the word "linked" with "associated" would be more true to the source (perhaps appeasing QG's criticisms), but I dont think that this change would really add any value.Puhlaa (talk) 01:47, 2 July 2011 (UTC)

You have not provided V for the current text under dispute and you have not explained why the source related to this article is not allowed in the article. The current source is about adverse effects in general but the newer source is specifically discusses VAD in detail. QuackGuru (talk) 02:29, 2 July 2011 (UTC)

The current source meets WP:V. DigitalC (talk) 19:11, 2 July 2011 (UTC)

The cuurent source is about adverse effects of spinal manipulation in general. See WP:COATRACK. QuackGuru (talk) 16:17, 3 July 2011 (UTC)

The "current source" (you probably mean Ernst-death) does not displace the older source. There are very few cases of confirmed VAD in the newer paper. With regards to COATRACK, I believe it is you who is trying to hijack an article about a clinical entity and trying the utmost to use it to damage chiropractic. As I have explained numerous times, I am not a supporter of alternative medicine and not an apologist for chiropractic, but you are going too far. JFW | T@lk 19:11, 3 July 2011 (UTC)

QuackGuru, you are simply repeating the same arguments that you have made in previous discussions. There is consensus for the current version that is not overturned by you placing your preferred version in pretty boxes with lots of ^{[original research?]} tags in it. You have already managed to get a number of concessions (e.g. whether to mention the possibility of underreporting, despite the poor quality of the data), and that's where I think we should leave it. JFW | T@lk 23:34, 2 July 2011 (UTC)

You are continuing to ignore that there is mass OR in this article. Please provide verification. Please explain why the wrong source is being used. The current source is not relevant to this page and is being taken out of context against OR. QuackGuru (talk) 01:00, 3 July 2011 (UTC)

Every statement is sourced to a secondary source (WP:MEDRS compliant) that supports it. There is no OR, and I have no idea what you are banging on about. If you could summarise your points in 2-3 sentences, this will greatly enhance any further discussion. If you are not able to do that, please respect consensus from a large number of other editors (even if it is not WP:TRUTH) and leave this article alone. JFW | T@lk 07:07, 3 July 2011 (UTC)

Every statement is not sourced to a MEDRS compliant source and the sources do not support the text according to V policy. There is mass OR, and you don't seem to get the point. See WP:IDHT.

Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection.[3][original research?] (The text is OR and after I requested V editors were unable to provide V because they can't or don't understand the text failed V.)

The sentence is using a source that is about adverse affects in general but there is a MEDRS compliant source that is specifically about chiopractic and neck manipulation of the VAD specifically. I request V for the first sentence or concede the OR must be removed. QuackGuru (talk) 16:17, 3 July 2011 (UTC)

The current sentence is verifiable by the current source. Speaking of WP:IDHT, would you be happy if the wording was changed from "linked" to "associated", to better match the source? DigitalC (talk) 18:08, 3 July 2011 (UTC)

It is true, I don't get your point. You are sounding like a broken record. For instance, saying "there is mass OR" does not replace the requirement for you to back up this claim with an actual explanation. There is no verifiability problem at all. Despite your claims, "Ernst-death" is not by any means the final word on the association. JFW | T@lk 19:11, 3 July 2011 (UTC)

There is a verifiable problem when you can't verify the text. I made this change to the text that complies with MEDRS while removing the OR. The word "associated" is not accurate. QuackGuru (talk) 21:40, 3 July 2011 (UTC)

I just don't agree. I see "QuackGuru says that the text violates WP:NOR", but I do not actually see any instances of "the text actually violates NOR".

It is not good enough to say that the text violates NOR. If every editor except you says that the text complies with the policy, then it probably does comply, no matter what your personal opinion is. WhatamIdoing (talk) 22:12, 3 July 2011 (UTC)

You can't provide V because the text did fail V. I can provide V for my edit. Is it that hard for you to provide V and comply with policy. Your personal opinion did not verify the text. QuackGuru (talk) 22:16, 3 July 2011 (UTC)

I removed the mass OR. Editors need to stop supporting OR and try to comply with core policies. QuackGuru (talk) 22:31, 3 July 2011 (UTC)

"Many chiropractors claim that, because arterial dissection can also occur spontaneously, causality between the chiropractic intervention and arterial dissection is not proven. However, when carefully evaluating the known facts, one does arrive at the conclusion that causality is at least likely."

• E Ernst (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice. 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715.

I am able to provide V for the sourced text in accordance with V. Please don't restore OR against policy. QuackGuru (talk) 22:34, 3 July 2011 (UTC)

The original text clearly meets WP:V, and you should recognize that you are arguing against consensus on that fact. The sourced used verifies the text. Since you do not like the new wording, I have restored the last stable version. Edit-warring and tendentious editing over this will lead us to WP:ANI. DigitalC (talk) 22:35, 3 July 2011 (UTC)

QuackGuru, you're not getting it. "You say that the text is unverifiable" is not the same thing as "the text actually is unverifiable". I (and others) am telling you that in my opinion, the text is verifiable, as previously written.

If you want me to go along with your story, you need to convince me that it isn't verifiable. You have utterly, completely, and repeatedly failed to do this. From where I'm sitting, your comments sound like someone getting up every morning, banging the table, and screaming, "The sun rises in the WEST, I tell you! I found one source that said the sun rose in the west, and so it does!". Then you expect everyone to agree with you, no matter what. Last I checked, that kind of thing only worked with absolute monarchs.

I simply do not agree with your assertion that the material is unverifiable. As far as I can tell, nobody agrees with your repeated assertions that the material violates the sourcing policies. This means that we have a WP:Consensus (which does not require unanimity) that there is no actual violation of the sourcing policies here. You saying that there's a violation is of no more importance than me saying that I'm going to fly to the moon tomorrow.

Given what I've seen of the sources, I do not think it is reasonable for you to expect to be able to convince me. You are welcome to try, but I guarantee that pounding on the talk page with bold-face rants about massive OR violations will not change my mind. WhatamIdoing (talk) 00:06, 4 July 2011 (UTC)

I am surprised that QuackGuru has not presented us with doi:10.1111/j.1742-1241.2009.02237.x, also by Ernst and also in Int J Clin Pract, which devotes much more attention to the possibility of causality than the later source that we have labeled "Ernst-death". I am personally of the view (as I have made clear all along) that chiropractic is pretty much an established cause of VAD, much like any movement in the neck can cause VAD. The problem we have had is that "Ernst-death" only discusses a few cases of confirmed VAD in the analysis, yet goes on to say that the causality is "likely"; the references for this statement are the source I have just presented, as well as a paper in J Quality Health Care from 2004 that I cannot seem to be able to locate anywhere (does a journal by that name exist?) It follows that we might as well concentrate on the source I have just presented. The new source focuses much more on VAD (rather than deaths due to other causes) and epidemiological proof of causality.

For the purposes of NPOV, we still need to mention that proponents of chiropractic dispute the association in the face of the existing evidence. JFW | T@lk 12:59, 4 July 2011 (UTC)

Coming fresh to this article and talkpage, it seems there is a great deal of talking around the issue here. It would be very helpful if editors advocating specific sources would quote the line(s) from the source that they consider to pertain. This would aid the step from verifiable to verified. Similarly, when objecting to specific sources, if they would clarify why they think that other sources are more reliable. LeadSongDog come howl! 13:37, 4 July 2011 (UTC)

I see at this paper (p.9) there is discussion of difficulties with the citation of the Preston H. Long (2004) paper which can be found here. LeadSongDog come howl! 13:58, 4 July 2011 (UTC)

One of the biggest issues is WP:COATRACK. This article is about VAD, not about chiropractic, and we shouldn't give too much weight to chiropractic at this article. The previous (stable) wording was NPOV and verifiable. Ernst-Death is verifiable as well, but would need to be attributed as his opinion that causation is probable, because other reliable sources say the opposite (see my bold-text post up the page) - including this quote from 2010 ""the weight of the evidence suggests that CMT is not a cause of VADS". By including Ernst's opinion, and then the countering view, we end up giving way too much weight to the issue on this article. DigitalC (talk) 17:10, 4 July 2011 (UTC)

It's not difficult to see that an intervention which transforms a pre-extant condition into a lethal event (as at PMID 19221970) is somewhat different from an intervention which causes that condition. But I doubt anyone is well served by pretending there is no relationship when excellent sources make it clear that there is. If you object to the proportion of the VAD article addressing it, simply reduce to something of the general sort "Spinal manipulation is thought to either cause VAD(ref) or precipitate the release of a clot from an existing VAD,(ref) though practioners dispute this.(ref)" One sentence is certainly not excessive. LeadSongDog come howl! 18:19, 4 July 2011 (UTC)

I don't think anyone is pretending there is no relationship, in fact the previous stable wording indicated that there WAS a relationship ("Chiropractic and other forms of neck manipulation have been linked to vertebral artery dissection"), and we proposed changing "linked" to "associated" to better match the source used. I agree that one sentence is not excessive. The type of sentence that you are proposing (reducing to something general) would be decried as a WP:SYN violation. DigitalC (talk) 23:52, 4 July 2011 (UTC)

Your knowledge of MEDRS is apparent by your support of inclusion of anti-vaccine bullshit into vaccine articles. CAUSES is the right word. In other words, chiropractic CAUSES VAD, per citation from LSD. Linked or associated are perfect weasel words to obfuscate the danger associated with chiropractic, which has little benefit and huge risk to patients. Kind of the opposite of vaccinations. OrangeMarlin ^{Talk• Contributions} 00:40, 5 July 2011 (UTC)

Consider me stumped. One citation linked by LSD went to a journal that has literally no trace - in my "knowledge of MEDRS" I would say it doesn't qualify. I won't even go into a critical appraisal of that source. The next source LSD linked states that in the majority of the cases they looked at, "there was clear evidence or high probability that the dissection was present prior to the manipulation" and does not say that chiropractic causes VAD. Next, we have Ernst, Apr 2010 which states that "the nature of the association between spinal manipulation and vascular accidents is uncertain and has been hotly disputed for many years" and states that it is "it seems probable that neck manipulation often precedes vascular accidents." Since my reading comprehension is apparently failing me, can you please provide me a quote from a reliable source that states that "chiropractic CAUSES VAD"? DigitalC (talk) 00:31, 6 July 2011 (UTC)

No need to feel bad, it is a bit confusing. The "no trace" journal underwent a name change. It became Patient safety & quality healthcare ISSN 1553-6637 OCLC 57031929 in 2004. The first issue of that new serial here says "Patient Safety and Quality Healthcare has roots in the Journal of Quality Health Care, the peer-reviewed Journal of ABQAURP, the American Board of Quality Assurance and Utilization Review Physicians. The new publication will still be the official journal for ABQAURP..." The name change also seems to have stumped the editor of the NZMJ, as seen here on pages 8-9. You are in good company. LeadSongDog come howl! 03:29, 6 July 2011 (UTC)

Excellent reading comprehension. I never once actually supported the inclusion of that source at Vaccine controversy, indeed I said it should NOT be used. According to the Ernst source, it is probable that chiropractic causes VAD, not that chiropractic DOES cause VAD. Yet we also have sources that say that chiropractic is not a cause of VAD. DigitalC (talk) 01:39, 5 July 2011 (UTC)

We proposed changing "linked" to "associated" to better match the source? The source you are trying to use is about adverse effects in general and is not related to this article. See WP:COATRACK. What is the reason you deleted the text from the related article. Is it because you think MEDRS is wrong or you think there is no relationship? QuackGuru (talk) 02:57, 5 July 2011 (UTC)

Read the edit summary, it is because it was mentioned two sentences before. Also, lets try to keep our discussions on this talk page focused on THIS article, not on other articles. DigitalC (talk) 16:14, 5 July 2011 (UTC)

(←) Can we avoid discussions about vaccines that are clearly not pertinent here and seem to relate more to DigitalC's edits elswhere? With regards to Orangemarlin's comments, we need to remain compliant with NPOV. We can therefore only really say that the evidence suggests a causal relationship, while some dispute this. The "new" Ernst source should be sufficient. JFW | T@lk 05:11, 5 July 2011 (UTC)

Do we have an independent (i.e. non-chiropractor) source that disputes the causality? Otherwise "some dispute" would be weasel. So far as I can see, any substantive dispute comes down to what is being caused: either the VAD itself or else the release of a clot from it. The inconclusive state of the science on that either/or question can be cited. Whichever way the science eventually proves out, the SM has been shown to have lethal consequences, involving VAD, in citable sources. Can we all agree on that much before we start wrangling wording? LeadSongDog come howl! 16:38, 5 July 2011 (UTC)

The current version of the article states that "The association between chiropractic neck manipulation and vertebral artery dissection is disputed by proponents of these treatment modalities." The reference is Ernst2007, because Ernst says in so many words that proponents of chiropractic dispute the association. Good enough? JFW | T@lk 17:54, 5 July 2011 (UTC)

The text is taken out of context and the source is not that relevant to this article. QuackGuru (talk) 18:16, 5 July 2011 (UTC)

Hmmm, the discussion in Ernst2007 says: "In fact, this review shows that the implicated practitioners are not only chiropractors but also surgeons, shiatsu practitioners, ‘bonesetters’ and general practitioners." Indeed, he acknowledges that their skills in such manipulation are not all equal, but still argues for restraining their use in self-limiting conditions. LeadSongDog come howl! 18:50, 5 July 2011 (UTC)

No it's not. Ernst acknowledges the fact that an alternative POV exists, however much he disagrees with it (being the good scientist that he is). It is highly relevant to this article. I don't understand what benefit there might be in suppressing this POV. It would actually be helpful to provide an additional secondary source published by an actual proponent of CSM, to demonstrate beyond doubt that this POV exists. JFW | T@lk 18:32, 5 July 2011 (UTC)

"Adverse effects of spinal manipulation: a systematic review" is not specifically about VAD at all. There are other relvant sources by the same author that decribes the claim by the proponents. QuackGuru (talk) 18:42, 5 July 2011 (UTC)

That is true, and I have suggested an alternative source above. Which source did you have in mind? JFW | T@lk 18:54, 5 July 2011 (UTC)

Though it is verifiable, I see using the "proponents" text to be POV & weasel wordy. We have peer-reviewed sources that indicate that there is no causal relationship. See above. If we have to expand the content in the article (and thereby give the issue undue weight), we should cite Ernst (or another source) says it is probable that there is a causal relationship, and then perhaps Murphy who says that evidence shows there is no causal relationship (quoted and cited above). DigitalC (talk) 23:45, 5 July 2011 (UTC)

Since there are new editors to the discussion, I will post doi:10.1016/j.clch.2010.02.052, as well as Murphy 2010 C&O, and doi:10.1016/j.jmpt.2008.11.023 - relevant quotes from each were posted in boldface above, but they are definitely worthy background reading for anyone involved in this content dispute. DigitalC (talk) 00:45, 6 July 2011 (UTC)

If we are going to mention the association between chiropractic and VAD, are we also going to mention the association between GP care and VAD? (eg: General practioner care has been linked with vertebral artery dissection) DigitalC (talk) 00:45, 6 July 2011 (UTC)

I'm not sure why we should consider an editorial by chiropractor Donald R Murphy in a chiropractic journal to be anything like comparable to a peer-reviewed systematic review by Ernst. Perhaps you can elaborate on why we should do so.LeadSongDog come howl! 04:04, 6 July 2011 (UTC)

Ad hominem? The fact that he is a chiropractor is irrelevant, he is a expert in the topic area, and on the Clinical Faculty at Brown University School of Medicine. You may call it an editorial, but I would describe it as a peer-reviewed literature review, the type of secondary source we should be using according to WP:MEDRS. We should to so to balance the obvious difference in points of view, to make sure that the article meets WP:NPOV. On the other hand, although Ernst describes his article as a systematic review, I would classify it as a case series, as a systematic review attempts to collect and review all the best evidence on a topic. Limiting the review to case reports causes any higher quality research to be ignored. DigitalC (talk) 16:23, 6 July 2011 (UTC)

I would strongly recommend a review article, ideally in a publication that is not dedicated purely to chiropractic. A source of that kind would be quite useful to represent the divergent views in this area.

With regards to the provenance of "Ernst-death", I agree that it barely meets the criteria for a systematic review, except for the fact that the paper attempts to organise the clinical parameters from all cases (time between CSM treatment received and first symptoms of VAD). There is little scope for statistical analysis, as one would expect from much larger systematic reviews. It is not a case series in the sense that Ernst did not publish his own cases. JFW | T@lk 16:55, 6 July 2011 (UTC)

If we can find a high quality, neutral review article, that would of course be best. However, to balance the opinion of Ernst (a known chiropractic critic), I don't think it is wrong to use an article by a chiropractor. Chiropractic & Osteopathy has since been renamed to Chiropractic & Manual Therapies, is a peer-reviewed scientific journal and is not limited to chiropractic. The name change "should encourage submissions from all professionals interested in manual therapy including chiropractors, osteopaths, physiotherapists, medical doctors and scientists interested in this field" DigitalC (talk) 17:17, 6 July 2011 (UTC)

Ernst's J R Soc Med 2007;100:330-338 doi:10.1258/jrsm.100.7.330 Ernst, E. (2007). "Adverse effects of spinal manipulation: A systematic review". Journal of the Royal Society of Medicine. 100 (7): 330–338. doi:10.1258/jrsm.100.7.330. PMC 1905885. PMID 17606755. shows as a review on Pubmed. In comparison, Murphy's Chiropr Osteopat. 2010 Aug 3;18:22. "Current understanding of the relationship between cervical manipulation and stroke: what does it mean for the chiropractic profession?" Murphy, D. R. (2010). "Current understanding of the relationship between cervical manipulation and stroke: What does it mean for the chiropractic profession?". Chiropractic & Osteopathy. 18: 22. doi:10.1186/1746-1340-18-22. PMC 2922298. PMID 20682039.{{cite journal}}: CS1 maint: unflagged free DOI (link) shows up as an editorial. There is a large difference between an ad-hominem attack and an observation on vested (and to be explicitly fair, declared) interests. It is certainly possible to disagree with Ernst (it happens with great regularity) but his credentials in the application of rigorous scientific methodology to questions in complementary and alternative medicine are beyond doubt, with the publication of more than 1400 papers, including over 400 reviews, in diverse journals. Murphy's body of work just isn't in the same league. LeadSongDog come howl! 19:20, 6 July 2011 (UTC)

I apologize if this was proposed earlier and I missed it, but what about the following source for the theories/research that contradict Ernst: Spine 2008;33(4 Suppl):S123-52.[2]

"Of specific concern are VBA strokes, which are extremely rare, but have been reported to be associated with chiropractic visits. However, the association between chiropractic visits (which frequently include cervical manipulation) and VBA stroke is similar to the association between physician visits and VBA stroke. This suggests that, on average, patients who seek chiropractic care for neck pain or headaches, and who then developed a VBA stroke may have actually been in the prodromal phase of a stroke when consulting the chiropractor; that is, the neck pain or headaches, which lead them to seek care were early symptoms of a VBA stroke......because this increased risk is also seen in those seeking health care from their primary care physician, this association is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke."

Puhlaa (talk) 21:14, 6 July 2011 (UTC)

Reverts against consensus

Both Orangemarlin (talk · contribs) and Noformation (talk · contribs) have now reverted to QuackGuru's version without participating in the discussion. I have asked both to participate in the discussion here. Being mindful of WP:3RR, I will not revert to the consensus version. JFW | T@lk 12:10, 4 July 2011 (UTC)

I have requested protection (diff), because the current oscillation between two versions is - to say the least - unhelpful. JFW | T@lk 12:13, 4 July 2011 (UTC)

Needless to say, the wrong version got protected... Can't be helped. JFW | T@lk 12:35, 4 July 2011 (UTC)

It is disturbing, though not suprising, to see that others are ignoring the consensus developed through discussion, and drive-by reverting rather than helping to find a suitable solution. DigitalC (talk) 17:13, 4 July 2011 (UTC)

<ref name=Ernst-2010>{{cite journal |journal= Int J Clin Pract |year=2010 |volume=64 |issue=6 |pages=673–7 |title= Vascular accidents after neck manipulation: cause or coincidence? |author= Ernst E |doi=10.1111/j.1742-1241.2009.02237.x |pmid=20518945}}</ref>

Cause or coincidence? We are going to find out soon enough when we read it on Wikipedia. QuackGuru (talk) 03:24, 5 July 2011 (UTC)

Not while the article is blocked, we won't. Ironic isn't it? JFW | T@lk 05:07, 5 July 2011 (UTC)

Edit request from Nick Number, 8 July 2011

Please change "[[respiration]]" in the Mechanism section to "[[Respiration (physiology)|respiration]]", as respiration is a disambiguation page. Nick Number (talk) 19:22, 8 July 2011 (UTC)

Done.  Sandstein  06:22, 9 July 2011 (UTC)

Thank you. Nick Number (talk) 20:19, 9 July 2011 (UTC)

Vascular accidents after neck manipulation: cause or coincidence?

QuackGuru, can you supply your proposed wording based on this source, keeping in mind this quote from the background "Therefore the nature of the association between spinal manipulation and vascular accidents is uncertain and has been hotly disputed for many years."? Can you also please describe the methodology of this paper? DigitalC (talk) 18:26, 14 July 2011 (UTC)

After obtaining a full-text version of this source, I have determined that I don't think it is appropriate for use. It is listed as a "perspective", and has no methodology section because it is simply an editorial. DigitalC (talk) 18:53, 14 July 2011 (UTC)

That's odd. Index Copernicus shows it as a review, which it certainly appears to be. It does not present any original research and analyzes results from previous publications against a set of widely accepted published (Bradford-Hill) criteria. It seems eminently usable, although he seems disposed to being rather more forgiving to chiropractic in his concluding para than he might have been on the evidence considered. LeadSongDog come howl! 20:25, 14 July 2011 (UTC)

It is a review with an emphasis on causality. I support its inclusion, but perhaps with the preface that it is "just a POV". If the proof was absolute, it would have been universally accepted. JFW | T@lk 20:38, 14 July 2011 (UTC)

If it is a review, then it would qualify as a secondary source under WP:MEDRS, and the issue goes back to proposed wording, and also goes to WP:WEIGHT. Most reviews that I read state they are a review, or indicate that in some manner - whereas editorials, which also do not present orgiinal research don't present themselves as reviews. Like this article, this Ernst source is labeled "Perspective" - with no information about the author at the beginning - definitely not like most peer-reviewed scholarly article I am used to. I still think that mentioning the issue very briefly is best, as this article is about VAD, not Chiropractic. I also still don't see any issues with WP:OR or WP:V in the previous, stable, version. DigitalC (talk) 21:22, 14 July 2011 (UTC)

That journal describes "Perspectives" here. I don't see anywhere an indication of whether or not the editors chose peer review in the case of this paper. It does seem a bit of an "odd duck" category, but it clearly is intended as analytic comment on other authors' prior publications, which defines "secondary". It's no Cochrane review, but it's pretty good. LeadSongDog come howl! 21:46, 14 July 2011 (UTC)

Thanks for that find LSD. DigitalC (talk) 23:15, 14 July 2011 (UTC)

So to be clear, I think you believe that this source would meet WP:MEDRS. I believe Murphy 2010 would meet WP:MEDRS, and they have very different conclusions. Per NPOV, we shouldn't present one view instead of the other, and because there is dispute in reliable sources, the sources should be attributed rather than asserted as fact. Do we agree on that? DigitalC (talk) 02:55, 15 July 2011 (UTC)

Take a closer look, the conclusions don't seem all that different. Both accept the correlation. Both say the evidence is inconclusive on causality. It's just that Ernst applies the precautionary principle, while Murphy doesn't.LeadSongDog come howl! 05:45, 15 July 2011 (UTC)

Proposed wording

Editors agreed that the "Perspectives" is better sourcing so I made this change. I propose this wording might resolve this dispute. I gave more WEIGHT to the systematic review than the perspectives source and waited for editors to agree to use this source. What do editors think about the changes? QuackGuru (talk) 21:13, 18 July 2011 (UTC)

Since QG failed to spell out the "proposed" wording on the talk page, and simply edited it in (so much for a collaborative editing environment) - here is the wording QG used:

"Proponents claim that, the association between spinal manipulation therapy and vertebral artery dissection is not proven. However, the causality between chiropractic spinal manipulation and neck manipulation is probable or definite."

The grammar is non-sensical, and even if I change the second sentence to make sense, I feel it fails WP:NPOV because it states one side as fact (Ernst's views) while stating the other view as "proponents claim". I have reverted QG's changes until we can come up with something useable. DigitalC (talk) 00:56, 19 July 2011 (UTC)

I am going to attempt to follow the sources to see if we can come up with something useable.

• Therefore the nature of the association between spinal manipulation and vascular accidents is uncertain and has been hotly disputed for many years. (Ernst-2010)
• it seems probable that neck manipulation often precedes vascular accidents. In some instances; however, manipulation might also exacerbate a pre-existing dissection. (Ernst-2010)
• it follows that causality between neck manipulation and vascular accidents is not absolutely certain but very likely. (Ernst-2010)
• Recent evidence has clarified the relationship considerably, and suggests that the relationship is not causal, but that patients with VADS often have initial symptoms which cause them to seek care from a chiropractic physician and have a stroke some time after, independent of the chiropractic visit (Murphy-2010)
• The weight of the evidence currently suggests that the most likely explanation for the occurrence of VADS following CMT is that a patient with neck pain and/or headache arising from the arterial dissection seeks the care of a chiropractic physician or other practitioner of manual therapy for relief from this pain, and sometime after this visit the condition independently progresses to a full stroke. It appears that this progression to stroke occurs as a result of the natural history of VADS, although one has to be open to the possibility that this inevitable progression may be hastened by the CMT, so that it occurs sooner than it would have without CMT (Murphy-2010)
• That is, the weight of the evidence suggests that CMT is not a cause of VADS (although, as stated earlier, it is possible that in incalculably rare cases CMT may precipitate dissection in a person who already has susceptibility to dissection) but is incidental to it, with the link between the two being the presence of neck pain and/or headache(Murphy-2010)
• While current evidence suggests that CMT is associated with but not causally related to VADS, it can be expected that patients with undetected VADS will continue to see chiropractic physicians and it is essential that focused attention be made in an attempt at detection of this uncommon but potentially devastating disorder (Murphy-2010)
• The retrospective case series (Table 3) confirm that spinal manipulation is associated with risks such as vascular accidents and non-vascular complications (Ernst-2007)
• The current understanding, based on the evidence to date, suggests that while there is a clear, though rare, temporal relationship between CMT and VADS, no plausible causal connection can be made (Murphy-2010a-CCP-published convention presentation)
• This suggests that there is no increased risk of VBA stroke after chiropractic care, and that these associations are likely due to patients with headache and neck pain from vertebral artery dissection seeking care while in the prodromal stage of a VBA stroke (Guzman et al. Clinical Practice Implications of the Bone and Joint Decade 2000–2010 Task Force on Neck Pain and Its Associated Disorders. Spine, 2008 33:4S)

It seems clear to me that Ernst is saying "causation is likely" while Murphy is saying "SMT is not a cause of VAD". These are two polar opposite views, linked by one fact - there is an association between SMT and VAD. Temporal? Causal? We don't know yet at this point - but these associations may be due to VBA patients in the promodromal stage presenting to Chiropractors. I think the easiest way to follow WP:NPOV & WP:WEIGHT is to simply state that there is an association. Do we really need to go into the details and start attributing opinions and turn this article into a coatrack? DigitalC (talk) 01:38, 19 July 2011 (UTC)

There is more than just an association according to the peer-reviewed sources. To simply state that there is an association is not accurate. QuackGuru (talk) 21:37, 19 July 2011 (UTC)

Causation is a type of association. Some sources say that SMT likely causes VAD, other sources say SMT does not cause VAD - but either way there is an association. DigitalC (talk) 03:08, 20 July 2011 (UTC)

Causation is definitely a type of association. In fact, it is the most important type of association. WhatamIdoing (talk) 04:53, 20 July 2011 (UTC)

Proposal: Proponents claim that, the association between spinal manipulation therapy and vertebral artery dissection is not proven. However, the causality between chiropractic spinal manipulation/neck manipulation and vascular accidents is probable or definite. In hospital-based studies this was the underlying cause for 16–28% of cases. The reliable estimates for vascular accidents is higher and there is substantial under-reporting. Reports of the association are of weak to moderately strong quality, and many of the reports have methodological flaws.

This proposal is for the Vertebral artery dissection#Traumatic section. The discussion is here at the talk page. See Talk:Vertebral artery dissection#Proposed wording. QuackGuru (talk) 21:37, 19 July 2011 (UTC)

Well, it's the wrong way round. I would start with the observation that some subscribe to the possibility of a link, followed by the observation that the link is disputed. At the moment, this paragraph doesn't flow at all. JFW | T@lk 21:48, 19 July 2011 (UTC)

Which source used in my proposal says possibility of a link. This could be excessive detail for this article. I did keep the proponents view as previously suggested. QuackGuru (talk) 21:56, 19 July 2011 (UTC)

This is obviously an NPOV issue, with various perspectives that all need discussing. For the paragraph to have any degree of logical flow to it, it cannot start with a line that says "They don't believe it's true" without defining what "it" is. At the moment, your proposal makes for confusing content. JFW | T@lk 22:01, 19 July 2011 (UTC)

"They don't believe it's true" is not part of my proposal. It is vertebral artery dissection. "Proponents claim that, the association between spinal manipulation therapy and vertebral artery dissection is not proven." It is defined in the first sentence. QuackGuru (talk) 22:08, 19 July 2011 (UTC)

You've still got it the wrong way round. Think of it logically. If nobody had suggested that there was a link, proponents of CSM would not need to disprove it. This is exactly why the current version is phrased the way it is. JFW | T@lk 22:45, 19 July 2011 (UTC)

Is Walker suggesting VAD causes SMT? If so, there would be no direct danger. The danger lies rather with the reverse possibility. I think what we're looking for is "Proponents of spinal manipulation therapy claim that its association with vertebral artery dissection is not proven to be causal." To my reading of Ernst, he agrees with this too, but urges caution (prescreening of risk) on the grounds that the possibility of SMT causing VAD cannot be dismissed. In other words, he thinks it might be safe but it is not shown to be safe. Of course it would be nearly impossible to get ethical approval for a trial that could address the remaining question unless there was a benefit to offset the risk, so there may be a stalemate. — Preceding unsigned comment added by LeadSongDog (talk • contribs)

I thought I was being sufficiently clear. What QuackGuru wants to achieve (apparently) is let the "causality" POV have the last word. Therefore, he starts with the claim that there is "no causal link", followed by the arguments against this. But in reality the paragraph would flow better if we started - as we do currently - with the claim of causality, followed by the dissenting opinions. I don't think Ernst disagrees that there is dissent, but to disagree with a proposition you first need to articulate the proposition (and not in the way QG is trying to do, in a near-ungrammatical convoluted way). JFW | T@lk 16:04, 20 July 2011 (UTC)

I am fine with switching the order of the sentences and rewriting my initial proposal as long as the text still meets NPOV and we use the current evidence rather than the older Ernst ref. QuackGuru (talk) 21:47, 20 July 2011 (UTC)

QuackGuru has been banned from chiropractic- and pseudoscience-related subjects for one year. I suggest that we consider this particular discussion "closed", and that any further discussion (on these or any other points) be handled in a new section. WhatamIdoing (talk) 22:17, 24 July 2011 (UTC)

I have made two edits that will hopefully not be too controversial.

Firstly, I have added a reference to the Guzman article, as this clarifies why proponents of CSM dispute the causality between CSM and VAD.

Secondly, I have replaced Ernst-2007 with Ernst-2010 (doi:10.1111/j.1742-1241.2009.02237.x) as it is more specifically aimed at this very association, and makes an attempt to satisfy the Bradford Hill criteria in defending its stance with regards to causality.

I very much hope this satisfies all viewpoints. JFW | T@lk 01:45, 25 July 2011 (UTC)

I still have issues with this text. First, I still believe we are giving WAY too much weight to the issue, turning it into a bit of a coatrack. If you were to pick up a peer-reviewed review article on VAD, would you expect it to mention the chiropractic link, and if so how much mention would it give? Second, while it meets WP:V I don't like the weasel-wording of "disputed by proponents". What we know for sure is that there is an association. This should be reported in the article. If there is consensus to add more detail/weight to the issue, we can add Ernst 2010 to state that Ernst believes there is a causative relationship, but an article by Murphy suggests that the relationship is not causal. We have mulitple sources. If we need to use them to satisfy WP:NPOV, lets do it. My main POV is that we should only have one sentence on the association, but I'm not sure that there is consensus for that. DigitalC (talk) 15:21, 25 July 2011 (UTC)

I had the feeling you were going to be unhappy. If 16-28% of all cases are associated with CSM then there is definitely no problem with WP:WEIGHT - it currently takes up about 20% of all the content related to "causes". From your perspective I can understand why it might be good to bury the whole thing in a single terse sentence, but there is an entire literature on the subject that we simply cannot skim over.

I have tried my best to satisfy WP:NPOV, which should be the overriding principle. How about you suggest a rewording, and we'll see if me and others can live with that. JFW | T@lk 15:28, 25 July 2011 (UTC)

I will take some time to review the sources and see what I can come up with. Obviously there is no consensus to back off on the weight, so I will work on rewording. I don't want to bury the whole thing, I want to give it the amount of weight that a neutral source on VAD would give it. DigitalC (talk) 15:45, 25 July 2011 (UTC)

Neutral sources on VAD, such as Kim and Debette, give a fair amount of airtime to the CSM debate, because there is quite a lot of literature about it. I would be interested to hear the opinion of other users now that our pal QC is gone. JFW | T@lk 00:11, 26 July 2011 (UTC)