Talk:Joint manipulation

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Contents 1 Attempts to delete large parts of article 2 Not Small joint manipulation from martial arts 3 Pop sounds 4 Other safety issues? 5 How and whether to separate chiro from non-chiro stuff 6 Condensed safety issues 7 Mobilisation 8 Powell 9 A tricky one... From Dematt's talk page 10 Safety section (continued) 11 Bubbles 12 Appropriate use of Cervical Manipulation 13 return to Coulter 13.1 Overuse? 14 References for whole page (keep at bottom)

[edit] Attempts to delete large parts of article

This is great. Let's take advantage of the fact that we have an electronic encyclopedia and not be so specific in this general Joint Manipulation page. There is much more to joint manipulation that spinal adjustments (which already has its own page and is quite clearly linked to here). Certainly, the work of Osteopaths, et cetera should be discussed, but overall this page should be kept more general concerning the topic of joint manipulation. Let the reader get more specific as they click into linking articles. Levine2112 22:54, 5 November 2006 (UTC)

Yes indeed, but let's be inclusionists, not deletists. We need to cover the subject completely. -- Fyslee 23:06, 5 November 2006 (UTC)

I don't think we can include the entire subject in this one article if we get into every specific of every kind of joint manipulation. Let's keep this page general and keep the specifics for the more specific pages. Not deletionist at all, you see? This is a wiser form of inclusionism if anything, as we are taking better advantage of our digital medium. Levine2112 23:10, 5 November 2006 (UTC)

The specifics of the chiropractic spinal adjustment, IOW what makes it uniquely different and and uniquely chiropractic, belong in its own article, which already exists. All the rest belongs here, although some duplication is alright. Please do not sabotage all my hard work. -- Fyslee 23:14, 5 November 2006 (UTC)

This isn't sabotage and I don't appreciate the insinuation. I am just making these articles "smarter". Why do you want to devote paragraphs of specific information here all about spinal adjustments when we already have this exact information on the spinal adjustment article? Are we to copy all of the info from Physical therapy, Craniosacral, osetopathy, osteopathic medicine, etc. here as well too? No. That's not smart. It makes more sense to discuss the general here and link out to the more specific. You know this, Fyslee. Come on. Levine2112 23:18, 5 November 2006 (UTC)

I do not agree. This article covers the non-subluxation practice of joint manipulation (which includes the spine). It naturally has to make a disambiguation mention of subluxation-based spinal adjustments, but doesnt' concentrate on it. Much of the content here has been adapted and developed especially for this article and is not totally identical. The parts that are identical should be here, and don't necessarily need to be in the spinal adjustment article, since they are not unique to chiropractic. This article covers aspects of the subject that are not covered in the chiropractic article, and applies to all professions who use manipulations/adjustments. The aspects that only apply to chiropractic subluxation-based adjusting are still in that article, and are not dealt with in depth here, if at all. -- Fyslee 23:55, 5 November 2006 (UTC)

Moved from User:Dematt's talk page:

Sorry, Fyslee. What exactly constitutes vandalism? I am making the article smarter. Why be so specific and repeat so much information which can already be found on Spinal Adjustment? Let's keep "your" new article more general and use the space to discuss joint manipulation in general rather than get into one piece of safety specifics about spinal manipulation with an occurence so tiny that you have a better chance of getting struck by lightning. Levine2112 23:24, 5 November 2006 (UTC)

The information is relevant to all professions, not just to chiropractors. Since you won't allow coverage that implicates non-chiropractors as well even on the chiropractic article, then it belongs in the general article for the benefit of non-chiropractors. Now you're trying to bury the information completely. It is well-sourced and you have not provided a single wikipedia policy for your deletions. This is an excuse for POV deletionism. I'm taking this discussion to the article talk page. -- Fyslee 00:17, 6 November 2006 (UTC)

Continuing here:

What are you talking about? This information is clearly stated on the Spinal Adjustment page (where it makes sense). If you actually want to use this space to talk about Joint Manipulation in general, go for it. But don't duplicate material here. Keep the specifics for the specific articles. Levine2112 00:43, 6 November 2006 (UTC)

What specifically are you referring to? There is currently some duplication, and it may be necessary to remove some of it from the spinal adjustment article if it isn't specifically related to chiropractic. This article is more general, and anything that applies to general manipulation principles, and to all professions, can be here. The more specific aspects that are irrelevant to others can be in the specific articles on chiropractic, osteopathy, etc.. I suspect we're talking "past each other," so please be specific right here on the talk page, rather than just making mass deletes, as they are considered vandalism and are an exercise of bad faith towards the hard work of other editors. This article is being constructed, and it doesn't hurt anything for there to be some duplication for awhile. At this phase of development we need to build, not destroy, add, not subtract. -- Fyslee 05:49, 6 November 2006 (UTC)

Still with the accusations of vandalism. Talk about Bad Faith. I've explained to you how my edits were to improve the article. If you are saying that you want to limit the Spinal Adjustment page to just things that specifically relate to Spinal Adjustments, then please remove all of the duplicative saftey information which confuses spinal manipulation with spinal adjustments. Or leave it all there and take it off this page. Either way is fine by me. Having it on the most logical page rather than duplicated is taking advantage of the electronic encyclopedia in the truest sense. You certainly know this with all of your recently wikilinking and "see also" additions. So which will it be? Delete from this article or from Spinal adjustment? Levine2112 09:24, 6 November 2006 (UTC)

It should be possible to read each article separately and get a good description of the subject. Wikilinks are provided as a service for those who seek more in-depth information, but should not be decisive. The article should still provide good coverage without them. That necessarily involves some duplication, which is a common practice here. It's not an either/or situation. We're talking about bytes, not the limitations of paper. The spinal adjustment article is not exclusively about straight chiropractic, so relevant stuff should still be there, including what's relevant to chiropractic as a whole, and not just to a limited group of straights.

We all know about your repeated objections to inclusion of anything regarding the patient safety issue, but that issue concerns all professions using manipulation/adjustments of the upper cervical spine, and since chiropractors do it most and have the highest rate of injuries and deaths on record for that procedure, the information is highly relevant in the spinal adjustment article as well. This is especially relevant in light of your denialism and the denialism going on in the profession. Researchers - including chiropractors - keep repeating that upper cervical adjustments/manipulations aren't worth it and should be avoided. Their warnings are well-documented, as well as the rest of the article, and it is abhorrent POV deletism in violation of Wikipedia policies to try to bury this information. You still haven't used a single Wikipedia policy to justify your deletions. They are clearly (in light of your edit history here at Wikipedia) politically motivated. That's not a bad faith statement, just a statement of fact. You have made many statements showing your strong dislike of complete coverage of this issue, non of them based in Wikipedia policies, but in political arguments. -- Fyslee 11:58, 6 November 2006 (UTC)

What the hell are you talking about? You are really operating on Bad Faith here and creating a terrible straw man argument. My motivation here is to keep Wikipedia smart and to take advantage of the digital medium. I don't object to the inclusion of the safety issue with upper cervical adjustments. My issue is that the supposed serious injury rate associated with the procedure are estimated at less that 1 in a million. It's a tiny risk and hardly conseqeuntial and to dedicate so much space to it on one article in completely imporportionate with the risk and to dedicate even more space to repeat the same information on a second article is frankly just wasteful. Now then, instead of accusing me of being politically motivated, let's take a look at you. You operate an anti-chiropractic site which completely blows this politically-motivated, practically mythological risk out of proportion, you are involved in Neck911 (an anti chiro organization dedicated to blowing this less than 1-in-a-million risk out of proportion), you perform web services for Stephen Barrett who runs chirobase.org (another chiro hate site) and you spam links to NACM, Quackwatch and other anti-chiro sites all over Wikipedia (To name just a small amount of your anti-chiro activities.) Certainly, if there is anyone here with politics as a motivation it is you. Stop being hypocritical. Stop spreading lies and hate and venom (at least here at Wikipedia). If you want policy, I'm sure those three things aren't allowed here. Face the music. Chiropractic is safe! Records form insurance and court cases have constantly shown that chiropractic is the safest portal of entry health care available to the public today. Although no healthcare procedures are 100% safe, chiropractic stands on its record of safety and effectiveness unmatched in healthcare. It has one of the lowest malpractice rates going. Upper cervical adjustments in particular have been shown to have amazing benefits in a profusion of clinical research and studies. The best estimates today put risks of serious injury with chiropractic at less that one-in-a-million. Less than one in a million. Less than one in a million. Meanwhile... 1.5 million people will be hospitalized annually because of iatrogenic (physician caused) reactions, and 100,000 will die. 1,000 people will die this week from complications of surgery that was unnecessary. 1,600 children will die this year from allergic reaction to aspirin, and thousands of people will die this year from anaphylactic reactions to prescribed drugs. Again, chiropractic is safe. Clearly, your anti-chiropractic POV pushing here is completely unacceptable by the terms of Wikipedia policy and just common decency. Please cease and desist your chiro-hate campaign and please stop with the strawman arguments. You don't know me or what I do, so don't question the integrity of my motivations. You are the one with the proven anti-chiroopractic agenda. Levine2112 17:41, 6 November 2006 (UTC)

Let's take this point-by-point:

• I am not "involved in Neck911" in anyway.

Dr. Kissinger (yes, I found out he was behind it) has chosen to copy links from my site. It was his doing.

• I do not "perform web services for Stephen Barrett."

Acting occasionally as assistant listmaster for a discussion list is hardly questionable.

• I do not "spam links to NACM, Quackwatch and other anti-chiro sites all over Wikipedia."

I only place specific links when relevant. That is not spamming. That is standard practice here.

• Low insurance premiums is a non-issue. Just like other professions that don't deal with serious and acute injuries, and diseases requiring radical measures to save lives, chiropractic has relatively low insurance premiums. Nothing new or unique about that.

• The issue here (although you'd like to twist it that way) is not the safety of chiropractic as a profession. No one is questioning that. The issue is patient safety, written about using good sources and research.

• No one is claiming that the risks from cervical manipulation are high in numbers. The risk of getting injured is low. The article makes that clear.

• The consequences when injured are catastrophal. The lucky ones die.

• Since the risks can be avoided, there is no excuse for doing it, and that's what the research provided concludes. Even chiropractic researchers say it. -- Fyslee 18:18, 6 November 2006 (UTC)

You do run an anti-chiropractic website and you do perform web services for Stephen Barrett. Saying otherwise is a bald-faced lie.

"The lucky ones dies"? Really?

Based on what research on you saying this. "Since the risks can be avoided, there is no excuse for doing it." Okay, you can avoid choking by not eating, do you recommend that? That's a ridiculous argument. The benefits of chiropractic adjustments is well documented.

Stop your POV-pushing and stop your campaign of hate. Levine2112 19:14, 6 November 2006 (UTC)

Please explain what "web services" I "perform ... for Stephen Barrett." I do no such thing, and even if I did, it would be a privilege and honorable endeavor. Now please provide the evidence or retract your vicious personal attack by calling me a liar. -- Fyslee 20:07, 6 November 2006 (UTC)

Saying that I called you a liar is a gross distortion (something which you have proven yourself adept at). No apology warranted. Stop your POV pushing. Stop accusing me of vandalism. stop accusing me of calling you a liar. Stop your strawman attacks. Stop your soapboxing. Stop operating on bad faith.

Now let's deal with the issue at hand and stop your tangents of accusations. This is an article about "Joint Manipulation". There is already an article about "Spinal Adjusmtent". Perhaps there should also be an article about "spinal manipulation" again. Anyhow, let's reserve the miniscule safety issue with Upper cervical spinal adjustments to the actual spinal adjustments page. It is not noteworthy enough of arisk to include it on the general "Joint Manipulation" page as well. You have profvided plenty of wikilinking, so a researcher on Joint Manipulation will certainly have ample opportunity to go to the SPinal Adjustment page and check out the tiny sliver of a percentage of risk there. Levine2112 20:37, 6 November 2006 (UTC)

Your are being disingenuous. You made several false statements, including that I:

• "perform web services for Stephen Barrett."

To which I replied:

• I do not "perform web services for Stephen Barrett."

You later wrote:

• "...you do perform web services for Stephen Barrett. Saying otherwise is a bald-faced lie."

Well, I had just said "otherwise," so I think I interpreted you pretty correctly (accusing me of lying), so I wrote:

• "Now please provide the evidence or retract your vicious personal attack by calling me a liar."

To which you disingenuously replied (with a denial):

• "Saying that I called you a liar is a gross distortion (something which you have proven yourself adept at). No apology warranted."

Okay, now what is going on here? It sure looks like you were accusing me of lying. I don't think that interpretation is a "gross distortion," and I certainly feel justified in requesting an apology. Please explain yourself, and please explain what "web services" I "perform ... for Stephen Barrett." -- Fyslee 21:19, 6 November 2006 (UTC)

You state clearly above (and have stated many times of Wikipedia before in our dealings) that you are an assistant listmaster for some of Barrett's sites... that sounds like web services to me. You work with Barrett. Face it. You do. You have also been named in a lawsuit with him as a co-defendent. You are also able to summon Barrett up to appear at Wikipedia and have him comment on articles. Stop accusing me of calling you a liar now and take an honest look at yourself and what you have written and what you have done and decide for yourself what you are and what you aren't. I still feel I don't owe you an apology; nor do I want one from you for accusing me on acting on Bad Faith, calling me disingenous, accusing me of acting for political reasons, attacking me using a strawman argument and accusing me of attacking you. I can say that you have a political motive here just by pointing out your anti-chiropractic hate site and all of your work to bash chiropractic by distorting the truth. You want to call that "lying" and say that I am attributing that quality to you, so be it. But you never seen me write it. That would be your speculative opinion and an invention from your own mind. Levine2112 21:30, 6 November 2006 (UTC)

I am one of over 500 members of the Healthfraud Discussion List, a list started by Rebecca Long of the Georgia Skeptics. At some point she asked Barrett to take over her list as the Moderator (he doesn't comment all that often). Later she dropped out completely and he needed someone to watch the list when he was out of town. That's all I do. This has nothing to do with any of his websites, their content, access to them, or anything remotely resembling what you write above:

• "an assistant listmaster for some of Barrett's sites"

You are now blending a discussion list not even started by him, and his websites. To very different matters.

The lawsuit you mention was Negrete's malicious prosecution suit that he promptly withdrew when the judge asked for proof before accepting it. It never went to trial and Negrete, Hulda Clark, and Tim Bolen will be tried for their role soon. None of us had done anything remotely wrong, and it was just an attempt to create an atmosphere of hate towards us, and your mention of it shows it had the intended effect. You should be ashamed of yourself for even mentioning it. It's worse than a non-issue. It was one of the most devious and deceptive things I've ever encountered, total fiction and bald faced lies. That you like to side with Bolen by using it is very telling. Pretty dirty and devious.

You continue to attempt to deny that you accused me of lying. You called my denial a "bald-faced lie." That's calling me a liar, no matter how you want to word it:

• "...you do perform web services for Stephen Barrett. Saying otherwise is a bald-faced lie."

Well, I had just said "otherwise," so I think I interpreted you pretty correctly (accusing me of lying),

If you're not man enough to take responsibility for your own words, so be it. I can't force an apology from you, and a forced one wouldn't be much worth anyway. A true apology includes regret, and that can't be forced either. -- Fyslee 22:14, 6 November 2006 (UTC)

I am neither ashamed of myself nor apologetic towards you. You opinions are your opinions. Essentially, you are now calling yourself a liar. I have never done so. Now you are trying to group me in with Bolen because I cited a lawsuit where you and Barrett were named together as defendants. I was merely pointing out your connection... which you have now clearly established for us. I still don't know why this of any consequence. It seems like a tangent you are continuing to pursue to shift focus away from your intentions for placing distorted, one-sided opinions to this article. I challenge you to produce the results of any human study that backs-up your claims that chiropractic is not safe. All you have is fuzzy, loosely-documented literature reviews. But by all means, please continue this tangent, as I do find it entertaining watching you scramble around demanding apologies and creating strawman arguments. Levine2112 22:33, 6 November 2006 (UTC)

[edit] Not Small joint manipulation from martial arts

You know there are a lot of Mixed martial arts people who would be rather suprised at the defintion given here.Geni 23:57, 5 November 2006 (UTC)

Yes, I'm aware of that. The title is chosen because it's common medical terminology, and the martial arts people may have been aware of that and have made their own article. Maybe there should be a disambiguation link for them. -- Fyslee 00:04, 6 November 2006 (UTC)

Now they have a link. -- Fyslee 06:10, 6 November 2006 (UTC)

[edit] Pop sounds

I had understood these to be (thought to be) cavitation, with the sound being produced not by the opening up of a void, but the snapping shut of it. Some popping or cracking noises are thought to be due to assorted bits of "string" twanging past bits of bone, also. Midgley 01:42, 6 November 2006 (UTC)

Cavitation states that noises are caused by the bubbles collapsing. That seems intuitively sensible, doesn't it? There are references there, i'd suggest that that is a good place for them, and that describing some joint popping as being ascribed to cavitation is more sensible than importing the whole explanation of a physical process into this article as well. Midgley 09:23, 22 November 2006 (UTC)

The (abstract of the) reference offered (Brodeur R., J Manipulative Physiol Ther. 1995 Mar-Apr;18(3):155-64.) looks to me highly unconvincing. Suggesting that there is enough CO2 dissolved in the synovial fluid to provide 80% of 15% of the (increased) joint volume, rather than the bubble being mainly Nitrogen, with CO2 being present at around 4% and N2 at 80% of the total of partial pressures surprises me. (Also as a reference for the bubbles being Nitrogen it is probelmatic, unless th eabstract is inaccurate with respect to the paper. Midgley 01:51, 6 November 2006 (UTC)

That part is taken directly from the chiropractic specific (although it unnecessarily covers general principles about manipulation, which are now covered here) article on spinal adjustment. There the paragraph is just stated, without any source at all. This is the best one I found, but if you have better ones, or if this theory is inaccurate, please provide more information or sources so we can correct this. -- Fyslee 05:41, 6 November 2006 (UTC)

The arithmetic is wrong. The physical chemistry is wrong. The gas dissolved in joint fluid is that in tissue fluid which is that in equilibrium with the body and, via some steps, the atmosphere. CO2 comes out of fizzy drinks when they are shaken, but body fluids release nitrogen. That is why the astronauts degas themselves of nitrogen by breathing pure O2, and why one of the Mercury or Gemini astronauts got knee pain - effectively a low pressure bends. Midgley 09:19, 22 November 2006 (UTC)

And a reference which says "The bubble gas is CO2" isn't very supportive of a statement in the article that says "the bubble gas is N2". Unfair criticism there? Midgley 09:25, 22 November 2006 (UTC)

Don't disagree with you at all. Made some changes that more accurately cite the sources that I saw. It could still use some work, especially the gas "bubble" wording. --Dematt 18:30, 22 November 2006 (UTC)

[edit] Other safety issues?

Are there other safety issues that can be dealt with on this page... especially ones that are more generally about "joint manipulation" rather than one specific kind of manipulation (which is already dealt with in its own article)? Otherwise, I'd recommend deleting the safety section. Less than one in a million for a particular kind of joint manipulation seems non-notable for this article (though enttirely notable fot the Spinal Adjustment article). Anyone besides Fyslee care to comment? Levine2112 19:22, 6 November 2006 (UTC)

I would contend that the safety issues belong here more than they belong in the spinal adjustment article, but they should still receive more than passing mention there. The reason the best coverage belongs here is because this article applies to all professions, while the spinal adjustment article applies specifically to chiropractic.

Limiting coverage exclusively to the spinal adjustment article could be seen as implying that only chiropractors are responsible for injuries and deaths. While the statistics indeed show that the majority of cases involve chiropractors, the risks apply to all professions involved in the use of upper cervical manipulation/adjustment, and therefore all who do so are placing their patients at risk. It is a problem with the technique, more than a problem with which profession is involved.

The only reason more emphasis is often placed on chiropractic is based on these two factors: (1) they are the ones who perform the technique the most, and (2) they are in denial. Their denial makes it even more imperative that their attempts to deny and hide the risks be counteracted. If they would stop these activities, the storm would blow over. Their opposition only draws more attention to the problem, and since they are the ones loudly protesting, it draws attention to their role in the problem, thus making a mountain out of a molehill.

This is a misbegotten strategic public relations nightmare of proportions. Why? Because it causes the public to wonder "Why, oh why, oh why is it so necessary for chiropractors to continually claim that Chiropractic is Safe.? There must be a very real problem with safety or they wouldn't have to protest so loudly." I'm sure chiropractors and their advocates see this differently, but that's how the rest of the healthcare profession and the public sees it.

Like it or not, perception is a very real part of reality and affects it strongly. [1] That perception is what chiropractic needs to deal with. Its credibility can only be restored by facing the problem and taking a pro-active stance, instead of continually standing there like Clinton and claiming "I did not have sexual relations with that woman." A responsible pro-active attitude begets a "forgive and forget" response, while an attitude of denial, spin doctoring, and deception just invites digging for more dirt. Just ask Woodward and Bernstein. -- Fyslee 20:57, 6 November 2006 (UTC)

What this article should be adding is info on all kinds of joint manipulation, for example, do MD's and DO's reduce a subluxated radial head in a child with joint manipulation? What are the risks associated with these manuvers etc. So far what's in this article doesn't justify it's existance, as its a cut and paste of the spinal adjustment article. Why does it have so much on spinal adjustments, and not other types of joint manipulation? Shouldn't it discuss "self manipulation"?--Hughgr 20:16, 6 November 2006 (UTC)

It is originally based on a cut and paste, then modified to make it less chiro-specific, and then expanded with more refs and other documentation. The devil is in the details....;-) The wholesale deletes that were the first reaction didn't take that into account.

Of course the article should discuss all the things you mention. The article is just getting started and more input would be appreciated. It needs to be more than it already is, not less. The argument that because it is rather one-sided at present is not a legitimate argument for deletion, but is actually an argument for supplementing what we have with more complete coverage of missing aspects. As far as spinal manipulation goes, it is a large part of joint manipulation, so it naturally occupies a central role, but other joints can be manipulated. Those who do so can contribute what they know about it. -- Fyslee 21:06, 6 November 2006 (UTC)

I agree with you whole-heartedly, Hughgr. I disagree with Fyslee in his assertion that chiropractic is in denial of the safety risk. If he bothered to look at Chiropractic is Safe then he surely would have seen that they clearly acknowledge the risk and the studies pertaining to that risk. But no matter how you shape it, chiropractic is one of the safest healthcare systems going. Less than one-in-a-million serious complication. That's staggeringly safe. And I suspect that it is even safer than that. Jasvorisiak study of 5 million cervical adjustments with no incidents of serious complication is more likely. Millions of cervical adjustments are performed by chiropractors every month in America alone. where are all of the dead people? Where are all of the stroke victims? This whole stroke scare is clearly (in my opinion) just another attempt to malign chiropractic by its greedy and fearful competitors. If there is any "spin doctoring" going on it is from the chiro-fearing hate groups. Considering all of the anti-chiro websites out there, the bus posters and enormous billboards warning about the so-called "dangers" of chiropractic, all of the twisted lies on all of those venomous discussion boards and silly little blogs and the concentrated efforts of so-caled "chiro-skeptics" to dominate the search engines and fill them with anti-chiropractic propoganda, I think Chiropractic is Safe (a tiny four page website) is a rather modest response to the ridiculous efforts of the fearful, the greedy and the grossly misled. Stop using Wikipedia as a soapbox to spread this lie and gross distortion of the facts. Levine2112 21:17, 6 November 2006 (UTC)

[edit] How and whether to separate chiro from non-chiro stuff

Sections solely dealing with chiropractic should not be in this article, nor should sections dealing solely with the safety of spinal adjustment. Please move those to the chiropractic or spinal adjustment article and possibly leave a pointer here, if relevant. Only the safety and efficacy issues related to manipulation in general should be here. If you don't remove sections which only relate to chiropractic, I will. — Arthur Rubin | (talk) 18:45, 7 November 2006 (UTC)

I agree. However, spinal manipulation safety studies often confuse chiropractic adjustments for manipulations performed by other practitioners. Separating them here will be tricky and I would appreciate your help. Do you also think then that all of the research not specifically dealing with chiropractic adjustments (but rather spinal manipulations in general) should be reomved from the Spinal adjustment page and moved here? Seems to make sense. Fyslee, I believe would prefer removing all of the safety info from Spinal Adjustment and putting it here on Joint Manipulation. What do you think? Levine2112 19:03, 7 November 2006 (UTC)

I have addressed this to some degree above, but will attempt to recap. The risks apply to both procedures, all professions using them, and all patients receiving them, since the only essential difference is the philosophical intention held by (especially straight) chiropractors. The risk is small, but catastrophic when it occurs. Quality control measures will never be effective if the problem is downplayed and ridiculed as unimportant. On the contrary, especially in light of the 100% rate of underreporting found by Ernst, it needs to be examined so we can more fully understand it and just how to prevent it.

The safety portion (a subsection of a necessary "contraindications" section) is just one part of the article, and much more on indications needs to be added, but all the deleting has wasted much time that was intended to be used on doing that.

The "confusion" mentioned above does occur, but it is so small a factor as to make it a red herring. The misattribution problem and it's rarity is covered in this section. It has been shown by Terrett that a few (out of many) cases of injuries have incorrectly been attributed to chiropractors (who still stood for the majority), when others had done it. A later and very large review conducted by Di Fabio, took account of this misattribution error. The results are very interesting, showing that chiropractors still stand for most injuries and practically all deaths. I am a Physical Therapist and trained in SMT, and I definitely do not try to place all blame on chiroractors. On the contrary, I have long proposed that:

A casual glance at these numbers could lead to the partially incorrect conclusion, that manipulation, when performed by a chiropractor, is much more dangerous than when performed by other practitioners. No, that would not be entirely correct. They should be seen more as a reflexion of the fact that manipulation is most often performed by DCs.

Regardless of who performs the manipulation - the more it gets done, the greater the risk. Sooner or later someone is going to get hurt. It needs to be used much more judiciously, by whoever it is that uses it, than most DCs use it today. If a PT or MD were to use spinal manipulation in precisely the same way, extent and frequency that DCs do, they would be exposing their patients to the same risks that chiropractic patients are exposed to every day. The statistics would then reveal more injuries from PTs and MDs.

While the technique itself is potentially problematic, the attitude of most chiropractors towards it makes it doubly so when applied by them.

Here is a conclusion from the summary of Di Fabio's review:

"The literature does not demonstrate that the benefits of MCS outweigh the risks." [2]

Now just where the information is most appropriate is the question. I see it as relevant for both articles, but I can also see the problem of too much duplication (even though it really isn't a problem here, since we're dealing with bytes, not paper). Some should be allowed. This article (and the external links) covers the non subluxation-based practice of joint manipulation (which includes the spine). It naturally has to make a disambiguation mention of subluxation-based spinal adjustments, but doesnt' concentrate on it as a technique or philosophy, only mentioning the needed disambiguation. Much of the content here was originally copied, then adapted and developed especially for this article and is not totally identical. Some of the parts that are identical should be here, and some doesn't necessarily need to be in the spinal adjustment article, since it is not unique to chiropractic. This article covers aspects of the subject that are not covered in the chiropractic article, and applies to all professions who use manipulations/adjustments. It needs more content, not less. The aspects that only apply to chiropractic subluxation-based adjusting are still in that article, and are not dealt with in depth here, if at all. The safety issues apply to both, and therefore should be covered in both articles. At some point in time a separate article can deal even more with those issues. When that happens, some revisions will be called for. -- Fyslee 22:49, 7 November 2006 (UTC)

I think this article puts far too much stock in DiFabio's conclusions and does not fairly representing both sides here... or even the best research. For instance, an extensive commentary on chiropractic care, published in the February 2002 issue of the Annals of Internal Medicine, which is the journal of the American College of Physicians, reviewed more than 160 reports and studies on chiropractic. It states the following with regard to the safety of neck adjustment:

"The apparent rarity of these accidental events has made it difficult to assess the magnitude of the complication risk. No serious complication has been noted in more than 73 controlled clinical trials or in any prospectively evaluated case series to date."

And a Canadian study, published in 2001 in the medical journal Stroke, also concluded that stroke associated with neck adjustment is so rare that it is difficult to calculate an accurate risk ratio. The study was conducted by the Institute for Clinical Evaluative Sciences (ICES) and the authors have stated:

"The evidence to date indicates that the risk associated with chiropractic manipulation of the neck is both small and inaccurately estimated. The estimated level of risk is smaller than that associated with many commonly used diagnostic tests or prescription drugs."

The most recent research into the association between neck adjustment and stroke is biomechanical studies to assess what strain, if any, neck adjustment may place on the vertebral arteries. The preliminary findings of this ongoing work indicate that neck adjustment is done well within the normal range of motion and that neck adjustment is "very unlikely to mechanically disrupt the vertebral artery."

Further the difference between chiropractic spinal adjustments and spinal manipulation performed by others is much more than just intention. It is also a matter of technique. Without question, chiropractic is the most skilled profession when it comes to adjusting the spine. Too often, their techniques are mischaracterized as being high-velocity/high-impact, when in reality the majority of techinques are low-velocity/low-impact to ensure patient safety. Additionally, another reason why chiropractic has enjoyed such an amazing patient safety record is the exhaustive diagnosis procedures which chiropractors perform. While these procedures vary from chiropractic style to another, without question they all put patient safety first.

And here's an extra bonus! Clinical observations of the beneficial influence of spinal manipulation on neurological function have already been noted. Carrick reported that certain procedures, including manipulative techniques, can provide remarkably promising responses in assisting some patients in degrees of recovery from central nervous system (CNS) lesions, including some forms of stroke, coma, and movement disorders such as Parkinson's disease and Friedrich's ataxia. So maybe cervical adjustments can actually help some people recover from strokes! And it's not a hypothetical 1-in-a-million figure... this one has statistical significance. Check it out. I'm sure we'd find this research on Confession of Quackbuster and on Chirobase. Not!

Finally, with regards to DiFabio's conclusion that the benefits of cervical manipulation does not outweight the risk, I'd put forth that to castigate or reject spinal manipulative therapy as inappropriate or comparatively dangerous is not only unwarranted, but conveniently overlooks the morbidity and mortality rates of other interventions. Unwarranted sensationalism of cases involving chiropractors threatens to create an impression out of proportion to the actual facts. One wonders what would happen if all medical procedures were subject to the same levels of safety, efficacy, journalistic scrutiny and particularly inaccurate publicity.

Now then, I still think Arthur has a good point. Only the safety and efficacy issues related to manipulation in general should be here. I have said this from the start of my involvement on this article. Joint Manipulation as a topic is far too general to bog down over three-quarters of the article with the hypothetically less than 1-in-a-million safety risk of spinal manipulation. With all of this specific information, we should have a spinal manipulation article to handle all of those hypothetically miniscule statistics. Levine2112 00:18, 8 November 2006 (UTC)

I'm not sure I follow why we would get rid of safety issues with manipulation on this page? Arthur, what is your reasoning? Certainly spinal manipulation is the procedure that has the safety issue no matter who performs it. That seems like a double standard? Though I do think we overdo it on both pages. I think a simple parargraph on both pages is probably all that is needed. I am also concerned that there is a large safety issues section with some citation of research that is not unshakable and I have no problem with that, but there is no benefits section because the research needs to be unshakable before we will allow it. How can this be proportately NPOV? Of course the risks outweigh the benefits if no benefits are considered. Certainly it doesn't take a genius to figure that one out. I have never had a patient have a stroke, but I did have one that had a massive heart attack at 40 while on Vioxx. And I've had one that died in surgery. And yes, I've had some that claim that they were hurt by physical therapists. So sometimes the benefits are the result of not having to undergo other therapies. I have yet to see a study on that, but that doesn't mean it isn't a real consideration. Do we need to think of all of these and put them in the article, or can we just simplify the whole thing and agree that acknowledging that there are safety issues is enough. --Dematt 02:27, 8 November 2006 (UTC)

[edit] Condensed safety issues

Hey guys, this is what is on the Chiropractic Page:

• "The International Chiropractic Association (ICA) suggests that chiropractic is one of the safest health professions and chiropractors have some of the lowest malpractice insurance premiums in the health care industry.^[1] As with all interventions, there are risks associated with spinal manipulation. According to Harrison's, these include vertebrobasilar accidents (VBA), strokes, spinal disc herniation, vertebral fracture, and cauda equina syndrome. A 1996 Danish chiropractic study confirmed the risk of stroke to be low, and determined that the greatest risk is with manipulation of the first two vertebrae of the cervical spine, particularly passive rotation of the neck, known as the "master cervical" or "rotary break."^[2] Estimates of serious complications range from 1 in 400,000 manipulations to 0 in 5 million manipulations. In comparison, there is a 3-4% rate of complications for cervical spine surgery, and 4,000-10,000 deaths per million neck surgeries. ^[3][4]"

Is there anything wrong with just making a statement similar to this? --Dematt 15:24, 8 November 2006 (UTC)

I think that is fine, but perhaps it should be less tailored toward chiropractic adjustments and more tailored toward joint manipulation generally. However, the amount of content seems about perfect. Again, I don't think this is big enough of a risk/issue to dedicate 3/4 of the article to... especially when there is so much more to get into with Joint Manipulation. A simple paragraph, as done on the chiropractic article, should be plenty. Levine2112 17:43, 8 November 2006 (UTC)

If we take out the "chiropractic" stuff:

• "The International Chiropractic Association (ICA) suggests that chiropractic is one of the safest health professions and chiropractors have some of the lowest malpractice insurance premiums in the health care industry.^[1] As with all interventions, there are risks associated with spinal manipulation. According to Harrison's, these include vertebrobasilar accidents (VBA), strokes, spinal disc herniation, vertebral fracture, and cauda equina syndrome. A 1996 Danish chiropractic study confirmed the risk of stroke to be low, and determined that the greatest risk is with manipulation of the first two vertebrae of the cervical spine, particularly passive rotation of the neck, known as the "master cervical" or "rotary break."^[5] Estimates of serious complications range from 1 in 400,000 manipulations to 0 in 5 million manipulations. In comparison, there is a 3-4% rate of complications for cervical spine surgery, and 4,000-10,000 deaths per million neck surgeries. ^[3][6]"

What else? Fyslee? Hughgr? Arthur? ApersOn? --Dematt 17:53, 8 November 2006 (UTC)

I'd agree with that, but there is still too much emphasis on spinal adjusting and nothing on all the other forms of joint manipulation.--Hughgr 18:29, 8 November 2006 (UTC)

Do you have any specifics? --Dematt 18:50, 8 November 2006 (UTC)

The article is still developing, and the way forward is not to delete, but to add what is missing. There can be added more information on techniques, indications, contraindications, etc.. One thing to keep in mind....since this isn't specifically about chiropractic adjusting, there aren't a whole lot of technique names, since other professions (at least medicine and physical therapy) haven't had a history of technique wars [3] [4] and more or less "patented" methods. The education simply concentrates on applying principles and manual skills to the joint biomechanics involved in each case, guided by indications, contraindications, and whatever other modalities might be useful, all done without necessarily using a whole lot of specific names for the originator or whatever. This is where the chiropractic article on spinal adjustment reveals a whole arsenal of specifically branded techniques, some of which don't even affect joint position at all, and yet are called "adjustments." Instrument adjusting is another area of difference. PTs do it the original Palmerian way - by hands only. -- Fyslee 23:11, 8 November 2006 (UTC)

Moving forward will involve adding as well as deleting. The main contention here is that there is too much discussion about one specific kind of manipulation's extremely rare risk factor. This seem like too broad of an article to get that heavy into the specifics of one kind of manipulation which already has its own article. So either before or after we more information that deals with joint manipulations in general, the over-abundance of spinal manipulation information may be deleted. Certainly, as there is a Spinal adjustment article already specifically dedicated to chiropractic's core manipulation, the mention of chiropractic in this article should be breif and lead readers to the Spinal adjustment article for more specific information. I'm not sure of the point you are attempting to make with bringing up techniques and what-not, so let's not go on that tangent and instead concentrate on keeping this article focused on the general topic at hand... joint manipulation. Levine2112 23:40, 8 November 2006 (UTC)

I haven't had the opportunity to read this article or spinal adjustment in depth, but at first glance, the content of both articles does look quite similar. Are the safety issues in joint manipulation pretty much restricted to those done through chiropracty or is it meant to refer to any type of joint manipulation? Andrew73 00:14, 9 November 2006 (UTC)

That is what I was trying to say. I went ahead and created a see also for the safety section in spinal adjustment to the spinal manipulation article. --Dematt 00:16, 9 November 2006 (UTC)

I think that may be the best option proposed thus far. Levine2112 00:20, 9 November 2006 (UTC)

That's what I meant. All this belongs with spinal manipulation. We're getting closer, but we still have to consolidate this information into a well packaged article. --Dematt 00:30, 9 November 2006 (UTC)

That's what Arthur was saying as well. So lets clean out the chior stuff and see what is left. --Dematt 00:43, 9 November 2006 (UTC)

Okay, I cleaned as much chiropractic out as practical, but it looks a little lean so we need to build from here. --Dematt 02:16, 9 November 2006 (UTC)

[edit] Mobilisation

Are we sure that Mobilisaton shouldn't have its own article? --Dematt 01:47, 9 November 2006 (UTC)

I found the reference. So I think I see where you're coming from. --Dematt 02:16, 9 November 2006 (UTC)

Mobilisation could have its own article if anyone is interested. I've got enough to do already. I'm not sure where I found it, but that document is interesting reading. BTW, what is the preferred spelling nowadays - with "s" or "z"? Generally "z" is American and "s" is British, but there are exceptions when it comes to esoteric terminology like medical terms.. -- Fyslee 19:54, 9 November 2006 (UTC)

[edit] Powell

This sentence is in the safety section:

• Powell, et al, have listed six risk factors associated with complications of SMT. These include: "misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine." ^[7]

My concern is that "misdiagnosis, failure to recognize the onset or progression of neurological signs or symptoms, improper technique, SMT performed in the presence of a coagulation disorder or herniated nucleus pulposus, and manipulation of the cervical spine." do not seem to have anything to do with complications of SMT. These speak more to the quality of the examining doctor than the procedure itself. I.e. surely a complication of SMT is not misdiagnosis. If we had the actual article maybe we can decifer a better way of saying this. --Dematt 02:30, 9 November 2006 (UTC)

Okay, after finding the abstract, I see that it is talking about patients that had these conditions and then SMT was used with unsatisfactry results. IOW, contraindications to SMT, rather than complications of SMT. Again, this relates more to the practitioner's diagnostic ability rather than the procedure. I think this is out of place and misleads, though it may have a lot to do with misattribution of risks associated with SMT rather than risks associated with who performed it. Make sense? --Dematt 02:43, 9 November 2006 (UTC)

I see how it could be misunderstood, but that's the precise wording, so before rewording it to make it more clear, we need to figure out just what the authors really mean. I'll give it a try and you tell me if I'm on the right track:

Original: "Powell, et al, have listed six risk factors associated with complications of SMT."

Translation: They found six existing conditions, that, when combined with SMT, increased the risk of complications and unfavorable results. IOW, these often undiscovered conditions are often being treated with SMT, and leading to unexpected and unfavorable results.

What can we learn from this? Well, two of those factors aren't even considered contraindications to SMT by many if not most chiropractors: (1) herniated nucleus pulposus, and (2) manipulation of the cervical spine. IOW they are acting in violation of these cautions and against any best practice guidelines that include these precautions.

Now, just how can we explain that in a simpler manner? I certainly used too many words! -- Fyslee 18:46, 9 November 2006 (UTC)

My probelm with that is that they are saying that SMT is a complicating factor for their neurology practice. That is not the same as saying that herniated disc is a contraindication for SMT. IOW, maybe somebody came in with a herniated disc that had also had SMT. It doesn't say that the SMT did or did not cause the herniated disc, only that it complicated their clinical picture. Either they mispoke and meant contraindicated or they really meant complicated. Since these are probably smart doctors, I think we have to assume they meant complicated. So, being a complcation doesn't really say much. For example; chiropractors say pain medication is a complicating factor in their practices because it usually means longer recovery times and increased risk of unsatisfactory results. That doesn't mean not to take the pain medication, just use the information to prognosticate the recovery potential and time. So the abstract really says more about the complication of the diagnostic process of neurology than that of SMT. The paper itself may give us more, but it is not in the reference.

I think that it is common knowledge that chiropractors treat disc herniations, the cervical spine and patients with coagulation problems with different types of adjustments, including SMT. You, too, are aware of relative contraindications to SMT, meaning that the doctor needs to take extra care to evaluate and communicate the risks and benefits under these conditions. It doesn't mean they are never to use SMT for them. BTW, were you aware of the study that states that any movement of the cervical spine including cervical manipulation can cause stroke? That would include mobilisation and range of motion tests. Apparently the risks are still less than prolonged aspirin use.

Ultimately, I still don't think it belongs in this article. --Dematt 21:05, 9 November 2006 (UTC)

Yes, relative and absolute contraindications, red flags, etc. are all need to be factored into the big picture in each case. I am familiar with the study (2002) above. I disagree with it on this point:

• "Attempts to identify .... the type of manipulation most likely to result in these complications of manipulation have not been successful."

That's not true. DiFabio's review [5] in 1999 showed rotation to be a strong risk factor. From an anatomical standpoint that makes perfect sense, especially at the uppermost level. Even BJ Palmer recognized that.

"Klougart et al [chiropractic researchers] surveyed 99% of all chiropractors practicing in Denmark .....and they noted that techniques using rotational thrusts were overrepresented in the frequency of injury." (Di Fabio)

We may not be able to predict (by looking at them) which patients are at most risk, but we know which type of manipulations are most risky (rotation with thrust), and which area is most risky (upper cervical). Put that together with Haldemann's cautions, and one can immediately and easily create a much safer environment for patients by avoiding use of those techniques in those regions. -- Fyslee 21:50, 9 November 2006 (UTC)

I totally concur and I think that is pretty much the state of the debate for all of the professions at the moment. Of course, everybody has there eyes and ears open for more information as it develops, but meanwhile, we avoid cervical rotation especially in the upper cervical region and we continue to do our best. --Dematt 22:20, 9 November 2006 (UTC)

[edit] A tricky one... From Dematt's talk page

This edit of yours ends with a wikilink. I've seen this type of linking before (from others) and am wondering about the purpose, if any. I know some chiropractic advocates would like to place all blame for risks on spinal "manipulation" as opposed to spinal "adjustments". What is your thinking on that matter? (Since I see a problem with all such treatment of the upper cervical spine no matter what profession, I basically see no good reason for the wikilink.)

The same problem is evident here, where the section has not only been sanitized of anything that might implicate "adjustments," it uses language that could appear to be designed to (only) implicate "manipulations" (and those who perform them, IOW non-chiros). I know you wouldn't attempt to do that, but we both know that others have done so many times on talk pages and in articles.

I understand and accept that it might be better to do most of the coverage of the safety issues in the "manipulation" article at present (some day another article can take care of the issue, since there is a huge amount of literature on it), but what's left behind is pitiful.

To solve the problem, I suggest some modifications (bold) to existing wording:

and

As with all interventions, there are risks associated with spinal manipulative therapy (SMT), regardless of the profession involved.

These modifications would help to remove the suspicion that the chiropractic article is affected by whitewashing. -- Fyslee 13:46, 18 November 2006 (UTC)

Okay, this is where it seems to be obvious to me, but you seem to have a different POV. This is the differentiation I am trying to make. Maybe you can help me do it more accurately:

• Spinal adjustment and spinal manipulation are two different things. Spinal adjustments can be put in one of three different categories related to spinal manipulation:

1. those that are all spinal manipulation (i.e. straight/specific, gonstead, etc.)
2. those methods that do involve some type of joint manipulation as part of the adjustment, (i.e. Thompson drop table, SOT, etc.)
3. those methods that do not involve joint manipulation in any way whatsoever (i.e. activator, Logan Basic, Cox Flexion/Distraction, etc.) These techniques are not associated with the same risk or benefit discussions as SM.

This is why I keep trying to insert "in chiropractic, spinal adjustments may include spinal manipulation." It is more accurate. I don't see it as whitewashing, but building a more accurate article. IMO, to try and lump them all into SM is not an accurate assessment and is what is leading to some of the arguments related to safety and benefits. That would be like claiming massage and spinal manipulation had the same risks and benefits. That is why I do have a little issue with this change See what I mean?

So if we are going to have a seperate article for spinal manipulation, why would we include the safety issues for spinal manipulation on the spinal adjustment page (or massage page) when we can just put the link on the ones that apply (i.e. #2 and #3)? Which was my reason for the aforementioned link. Please notice that I also do not give SA the same benefit discussion as SM because the research is for SM only. Does that make sense?

--Dematt 01:18, 19 November 2006 (UTC)

Ummmmm, this one is getting too hairy for me to decipher. Too many issues here. Let me try and break it apart and let's take it a little bit at a time. I'm too afraid of misunderstanding you. Let me start by asking and commenting (and numbering them so you can refer to them). I'll even sign each one so you can answer in the appropriate spot!:

(1) My earlier comments about whitewashing don't apply to anything you have done, or at least not to your intentions. You still have my confidence.

Understood. Sometimes it's more a matter of blind spots from POV rather than intentions and is forgivable for all of us. --Dematt 22:04, 19 November 2006 (UTC)

(2) I think I see what you mean about the different types of adjustments. Some involve joint manipulation (with some possibility of safety issues), and others don't. Fair enough. Your differentiation of those matters needs to be made within the spinal adjustment article, and the link to the safety issues discussion at the joint manipulation article could be placed only with those sections.

Yes, that could be clearer. We can work that out. --Dematt 22:04, 19 November 2006 (UTC)

(3) Earlier I notified you about one of my edits. I notified you because I was pretty sure you intended something, and I didn't want to mess that up. There were several changes there, so what specific phrase or part is still problematic? I thought you had fixed it. It sure looks fine to me. -- Fyslee 20:39, 19 November 2006 (UTC)

All's good with that now. --Dematt 22:04, 19 November 2006 (UTC)

(4) Some of the things I mention in the beginning above aren't answered yet. -- Fyslee 20:39, 19 November 2006 (UTC)

Which ones? --Dematt 22:04, 19 November 2006 (UTC)

Now it's your turn! -- Fyslee 20:39, 19 November 2006 (UTC)

Let me know which ones still need to be handled. --Dematt 22:04, 19 November 2006 (UTC)

These are the ones (copied from above, where the context is found):

To solve the problem, I suggest some modifications (bold) to existing wording:

For more in depth discussion of relevant safety issues, see Joint manipulation.

and

As with all interventions, there are risks associated with spinal manipulative therapy (SMT), regardless of the profession involved. -- Fyslee 21:51, 20 November 2006 (UTC)

I'm okay with either sentence. I am concerned about the (1) bold (did you mean it to be bold or was that just for illustration for me). (2) The "regardless of the profession involved" seems to be a little unnecessary because nobody is suggesting otherwise on this article (yet). Right now the article is pretty neutral as far as who performs what, so adding it may inadvertantly add some confusion for the reader, but I am still okay with it. (3) For the "more in depth discussion of relevant safety issues"; this still doesn't differentiate the issues, but is probably good for now. Once we get the details in, we can tweak it to be more correct. --Dematt 01:27, 21 November 2006 (UTC)

I'll put numbers in your message above as reference points for my use below.

(1) The bold was only to help you see what was modified, and definitely not to be used in practice. -- Fyslee 09:34, 21 November 2006 (UTC)

Okay, good;) --Dematt 14:11, 21 November 2006 (UTC)

(2) "Nobody is suggesting otherwise on this article (yet)." No....but it has been suggested several times on the talk pages. There has been an attempt to shift any "blame" away from spinal adjustments (as performed by chiros) and place it on spinal manipulations (as performed by non-chiros), simply because a few cases of misattribution exist. The wording ("regardless....") heads off that diversionary/whitewashing tactic at the pass, and ensures that no one thinks that only chiros or only non-chiros share any risk issues. It's a matter of concern for all professions using upper cervical techniques that actually manipulate the region (that leaves out Activator methods). It's a case of "if the shoe fits..." The safety discussion simply exists, and if the shoe fits, they it gets applied, without it being necessary to necessarily point out someone or group as a big sinner. That occurs "if the shoe fits...," and in my opinion it fits all who do it, and doesn't fit those who don't do it. -- Fyslee 09:34, 21 November 2006 (UTC)

Are there any reliable sources that say non-chiro SM is different than chiro-SM? I think most sources try to make the case that "SA" is different than SM, so I'm not sure that their argument could be excluded with this sentence anyway. My concern is that as the SM article stands now, all professions are in the same boat as far as the reader sees. By adding that sentence, we are actually adding the "doubt" that we are trying to avoid, making the reader say to themselves, "is there a difference between these professions?." It is subtle, and that is why it is okay with me if you want it, but I don't think it really does what we want it to do. --Dematt 14:11, 21 November 2006 (UTC)

We already mention the philosophical difference, and there are straight chiropractic sources that are sourced for that point, if I recall correctly. The modified phrases are for the SA article, not the JM one, because the safety discussion has been brought here. What (or "which") "sentence" are you referring to above (twice)? -- Fyslee 21:19, 21 November 2006 (UTC)

Sorry, - the part of the sentence that I am referring to is: regardless of the profession involved. Right now the article assumes that the risks are for all professions. By adding regardless of the profession involved, we plant the seed that there is a difference. --Dematt 21:49, 21 November 2006 (UTC)

I'm copying your last paragraph to a new section, and will continue there. This is getting too embedded for me to manage. -- Fyslee 22:58, 21 November 2006 (UTC)

(3) Tweaking things in the future may well be relevant, in keeping with "if the shoe fits.". That's fine. -- Fyslee 09:34, 21 November 2006 (UTC)

Just jumping in here with this... Considering that we are talking about the tiniest of risks (0.0001% to 0.00001% chance of serious complications), aren't we in fact making a mountain out of a molehill grain of sand by dedicating this much effort and space discussing this in the article? Honestly, I am glad that there is so much research on spinal manipulation safety(enough to fill its own article as suggested above), because it all goes to say that spinal manipulation - when performed by a trained professional - is entirely 99.9999% to 99.99999% safe. I'd prefer we just said this (the truth) then try to put some sort of spin on these numbers. Sure we could say that there is some risk involved... but with a one hundred thousandth of one percent chance of a risk, even the word "some" seems like a massive overstatement. Levine2112 18:07, 21 November 2006 (UTC)

I do agree that this issue is being emphasized for the same reasons that benefits may be emphasized. IOWs, WP should be concerned with getting the unbiased version of benefits and risks. At this point, we have been able to keep the outrageous claims of benefits out, but seem to be catering to overemphasizing claims of the risks. If we are going to allow for so much time on safety, we need to allow for as much time for benefits. Or we can de-emphasize both and just explain what SM is in a NPOV manner. This subject is not that difficult. It has a long and colorful history and is certainly notable. The shear safety of it is one reason it is famous, not infamous. --Dematt 18:58, 21 November 2006 (UTC)

I would say that based on statistical and clinical evidence, it is a more outrageous claim to state that spinal manipulation (as performed by a trained professional) is dangerous or even risky. Though a claim such as spinal manipulation can help infantile colic has only a small amount of support from clinical research [6][7], there is still a higher degree of statistical signifance supporting this claim than what some use to qualify spinal manipulation as a risky procedure. Certainly there is enough supporting evidence for a true objective scientist to conclude that there is a greater than 0.00001% chance that spinal manipulation is beneficial for many conditions and preventive measures. (Once again, 0.00001% is the degree of risk associated with spinal manipulation.) Levine2112 22:14, 21 November 2006 (UTC)

Now would that be spinal manipulation or spinal adjustment? --Dematt 22:23, 21 November 2006 (UTC)

"...it is a more outrageous claim to state that spinal manipulation (as performed by a trained professional) is dangerous or even risky."

That is a straw man argument, because we're only stating that there are risks, and even that they are rare. We're not saying that this is very dangerous (statistically), but it is catastrophal when it does happen. Just ask those who are alive and paralyzed (the dead ones can't be asked). We're discussing risks, what procedures involve the most risk, and the degree of risk (rare). What's wrong with that? -- Fyslee 23:06, 21 November 2006 (UTC)

Then why aren't we just saying:

• "There are risks associated with spinal manipulation. They are rare, but include stroke...." Period.

What's wrong with that? --Dematt 23:16, 21 November 2006 (UTC)

There's nothing wrong with that. I would even quantify the risk as percentages since we have that data. There is a 0.00001% chance of stroke, for instance.

Also, I don't understand Fyslee's "strawman" accussation above. It is outrageous to claim that spinal manipulation is risky. I am not creating a strawman here... for there are lots of people who make this outrageous claim. Neck911 has paid for huge billboards and bus posters proclaiming the so-called "dangers" of chiropractic. Okay, but we haven't mentioned their POV in this article (deservedly so). But we do include Ernst's quote stating that it is debatable whetehr the benefits outweigh the risks. Maybe, he's the object of my argument. What do you think, Fyslee? With a 0.00001% chance of serious injury, would you say that calling spinal maniputation dangerous is an outrageous claim? Levine2112 01:51, 22 November 2006 (UTC)

[edit] Safety section (continued)

(Continued from above, and dealing with this section from the spinal adjustment article. -- Fyslee)

Sorry, - the part of the sentence that I am referring to is: regardless of the profession involved. Right now the article assumes that the risks are for all professions. By adding regardless of the profession involved, we plant the seed that there is a difference. --Dematt 21:49, 21 November 2006 (UTC)

To keep the context of this discussion fresh (for new readers of this discussion), the two (numbered) phrases being discussed are in immediate connection with each other, as can be seen here.

I'm suggesting some modifications to existing wording (the bold part is not intended to be bold in actual usage):

(1) First phrase:

Current:

For safety issues related to spinal manipulation, see joint manipulation.

Modified:

For more in depth discussion of relevant safety issues, see Joint manipulation.

I interpret the Current version above as moving all responsibility for risks and safety issues away from spinal adjustment itself (not just the article), and placing the blame fully on joint manipulation. That's why the modifications (in both sentences).

It says "related to spinal manipulation." It doesn't say "related to spinal adjustment". Readers should (subtly) be alerted to the fact that it is only the in depth discussion that is moved, not the relevance of the subject to both articles. It is still relevant to both articles. Therefore the use of the words "relevant safety issues." The in depth discussion can then dissect the various issues and their relative relevance.

(2) Second phrase:

Current:

As with all interventions, there are risks associated with spinal manipulative therapy (SMT).

Modified:

As with all interventions, there are risks associated with spinal manipulative therapy (SMT), regardless of the profession involved.

I interpret the Current version of (2) in light of the first sentence (1) above, and in light of earlier attempts to place pretty much all blame on non-chiros because of a few cases of misattribution, when in fact the risks apply to all professions "when the shoe fits" (primarily upper cervical rotation with thrust). The modification prevents any misunderstanding.

How about just trying them and see how it looks. It will be easier to understand in its visible context. -- Fyslee 23:00, 21 November 2006 (UTC)

I don't neccessarily consider all the safety issues involved with Spinal Manipulation relevant to chiropractic's spinal adjustment. So I like the first version of the first phrase above better.

For the second phrase above, as this page is specific to just chiropractic's spinal adjustment, I don't think there should be mention about other professions and their versions of spinal manipulation (other than to draw a distinction). Levine2112 01:56, 22 November 2006 (UTC)

You said that in a lot fewer words than I did;) --Dematt 03:44, 22 November 2006 (UTC)

[edit] Bubbles

Good edits on the bubbles. It makes me think of pop tops! I've been developing a neglected section on the alt med article.

You ask about this edit of yours. Is it really necessary? I thought it was already just fine, since it functioned as a differentiation, which is the whole reason for the link. -- Fyslee 21:09, 22 November 2006 (UTC)

I remember pop tops! Don't drink soda with them or you'll blow up!

Okay, you're probably right and I don't think it is any better than the one that is there. --Dematt 00:19, 23 November 2006 (UTC)

[edit] Appropriate use of Cervical Manipulation

Fyslee just made an edit that changed this:

After looking at more than 700 conditions, there was consensus in only 11% of those conditions that cervical manipulation or mobilization was appropriate.

to this:

After looking at more than 700 conditions where it was used, there was consensus that cervical manipulation or mobilization was appropriate in only 11% of those conditions.

To me, this change changes the conclusion reached in this study. I am not sure which conclusion is the correct one, however. Was it that the 5 researches only agreed 11% of the time? Or that they all agreed that only 11% of what they looked at was appropriate? Subtle but essential difference. I don't have the full article in front of me. Any thoughts? Levine2112 19:50, 23 November 2006 (UTC)

Hmmm....I don't have it in front of me either, but I had never even heard of the other possibility. I've always understood it to mean that in 11% of the situations it was the appropriate (indicated) method, IOW 89% of the time it was the wrong treatment (relatively or absolutely contraindicated, or at least inappropriate). If I've interpreted it incorrectly, I certainly hope you guys will correct me! -- Fyslee 21:50, 23 November 2006 (UTC)

I agree we need to find this article. I've tried all night with no luck. I think it is the conservative assumption that "consensus" means that was when all the MDs and DCs agreed (which was 11.1%). This also does not suggest that the procedure was not indicated or contraindicated but merely inappropriate. IOWs, maybe the list included psoriasis then obviously the MDs would not consider manipulation or mobilization appropriate, so this would end up in the inappropriate category. It's not that it is contraindicated, just not appropriate. --Dematt 05:38, 24 November 2006 (UTC)

Here is the link to the RAND monograph. Homola also comments on it here. -- Fyslee 06:28, 24 November 2006 (UTC)

Yeah, I found those, but where's the article with all the numbers? I thought there was an article with all the numbers? It seems we had it before, because I read it and we discussed it. Did we lose the link? --Dematt 13:11, 24 November 2006 (UTC)

Check this out. --Dematt 13:15, 24 November 2006 (UTC)

That link is to the Coulter study for manipulation of the lumbar spine. -- Fyslee 15:52, 26 November 2006 (UTC)

This is a study to study the Coulter study:) It seems to conclude:

1. Principal Findings. While both panels were more likely to rate the indications as inappropriate than appropriate, the single disciplinary panel was more likely to rate an indication as appropriate than the multidisciplinary panel.
2. Conclusion. The composition of a panel clearly influences the ratings and those who use a given procedure in practice, in this case manipulation, are more likely to rate it as appropriate than those who do not use the procedure.

It looks as though they are saying that it is appropriate to question the composition of the panel as well as the process.

What do you think? --Dematt 13:20, 24 November 2006 (UTC)

I found this one discussing the same thing Coulter study for manipulation of the cervical spine, IOW the real subject of this thread, but it's only a short summary. Maybe what you have says more. Anyway, I think the confusion is that you guys were thinking of these matters about agreement among panel members, while the one I've referenced (and Homola as well) speaks of appropriateness numbers. Let's be careful not to confuse them. -- Fyslee 14:30, 24 November 2006 (UTC) (revised Fyslee 15:52, 26 November 2006 (UTC))

This summary has different numbers than what Homola's account of it is. Right?

Over 1400 clinical scenarios (indications) were rated. The panel demonstrated clear agreement on 40% of the indications and clear disagreement on 2% of them. Regarding the appropriateness of cervical manipulation or mobilization for the indications 43% of the indications were rated inappropriate for the intervention with 41% ranking as uncertain and 16% considered appropriate.[8]

That the 5 researchers agreed on the appropriateness on 40% of the indications or only had clear disagreement in 2% of the cases seems to be the most notable figure (and seem to differ from Homola's numbers... or am I missing something?) Levine2112 06:02, 25 November 2006 (UTC)

Yep, it's similar, but not the same numbers and still does not state the authors conclusions about these numbers. --Dematt 14:43, 25 November 2006 (UTC)

Don't give up on this yet. There is something missing and it is our responsibility to get it right. --Dematt 02:36, 25 November 2006 (UTC)

The springing point of this thread is based on a confusion of two different matters, from two different analyses:

1. The subject of the portion of the article in question:

• Appropriateness figures of the 700 situations from the RAND study by Coulter.^[3]

2. Confused with another matter entirely:

• Agreement discussions of the multidisciplinary panel. Those are very different statistics, and are not part of the numbers cited in the article.

Since the confusion brings up another topic and brings us off-topic, then it's off track here and that should end that part of the discussion. If you still question the figures cited from the RAND study by Coulter and cited by Homola (we never questioned them before, and there is no reason to question anyone's honesty when citing such a study), then by all means discuss it and leave the other part out, since it's another matter entirely and only confuses the discussion. Continuing in that track amounts to hunting the wrong prey (a straw man). Now that the straw man is identified as the wrong prey, let's get back to hunting the right prey -- if it is really relevant (which it isn't, since there is no real doubt about the numbers). -- Fyslee 12:15, 25 November 2006 (UTC)

Agreed concerning the two different studies and suggest that the other study could be cited as a critique of the research model used. However, I also do have questions about the interpretation of the numbers by Homola, who is using the research in his paper on chiropractic as quackery. He has every right to write whatever he wants in an opinion paper, but we have a higher calling. We have not bothered to find out what the original researchers concluded about their research, yet we use the numbers in a very damning way. We risk lowering ourselves to the level of parrots. We need to make sure the research is correctly stated, regardless of how they turn out. --Dematt 14:12, 25 November 2006 (UTC)

BTW, doesn't Homola cite the same source that we are looking at? Or am I on a totally different page? --Dematt 14:52, 25 November 2006 (UTC)

Yes, he does. That's why the numbers are the same (11.1%), but he also provides the other figures. It would be nice to have the whole RAND monograph. On another topic.....I would also like to get hold of Terrett's study for NCMIC. They used to have it on their site. Do you guys have any idea where I can get it, or where more than small bits are cited? -- Fyslee 15:22, 25 November 2006 (UTC)

I will see what I can dig up. --Dematt 02:03, 26 November 2006 (UTC)

Wow, I'm having trouble getting much of anything. I am no longer able to get on NCMIC or FCER research without membership. Hmm... maybe they had too many unauthorized hits? I'll let you know if I find anything, but not even an abstract for now! --Dematt 03:04, 26 November 2006 (UTC)

[edit] return to Coulter

Fyslee, let me try this a different way. I think you will see what I mean: This is what Homola wrote in his artice to the Archives of family medicine.

"A 1996 study by Coulter et al11 reported that cervical spine manipulation or mobilization may improve range of motion and provide short-term relief for subacute or chronic neck pain and muscle tension headaches. The report concluded that there is not sufficient data to support or refute the use of cervical spine manipulation or mobilization in the treatment of a variety of other conditions, such as cervical curvatures; migraine headache; shoulder, arm, and hand pain; cervical disc herniation; torticollis; infantile colic; and otitis media.

The rate of vertebrobasilar accidents and other complications that occur as a result of cervical spine manipulation was estimated to be 1.46 per 1000000 manipulations. This figure allowed for the possibility that published reports may represent about one tenth of the actual number of accidents.

While the risk of injury or stroke from cervical spine manipulation is low, this risk is unacceptable when cervical manipulation is routinely used as a preventive measure on asymptomatic patients or for conditions for which manipulation is not indicated.

According to the report by Coulter et al, 57.6% of reported indications for cervical manipulation was considered inappropriate, with 31.3% uncertain. Only 11.1% could be labeled appropriate. A panel of chiropractors and medical practitioners concluded that ". . . much additional scientific data about the efficacy of cervical spine manipulation are needed."11"

This is what we have cited for Coulter (which is the same source Homola cites above (11)):

The Appropriateness of Manipulation and Mobilization of the Cervical Spine

By: Ian D. Coulter, Eric Hurwitz, Alan H. Adams, William Meeker, Dan Hanson, Daniel T. Hansen, Robert Mootz, Peter Aker, Barbara Genovese, Paul G. Shekelle

This report presents results from the RAND study on the appropriateness of spinal manipulation and mobilization of the cervical spine. The study was designed to ascertain the clinical criteria for the appropriate use of cervical manipulation and mobilization to treat conditions such as neck pain and headache and to document treatment complications. A review was conducted of more than 500 articles from the medical and chiropractic literature. From this extensive review, a set of indications was created for manipulation and mobilization for neck pain and headaches and for subcategories of patient types. A panel was convened of back-pain experts from the disciplines of orthopedics, chiropractic, family medicine, and neurology to rate for appropriateness the indications for spinal manipulation and mobilization. The panelists rated the set of indications individually and then were convened as a group to rate the same indications following reporting and discussion of the individual ratings. This report presents the results of the final ratings and describes the methodology. It should be of interest to clinicians who perform manipulation and mobilization of the cervical spine, to clinicians who work with patients with cervical problems, and to health researchers and others concerned with the appropriate indications for performing manipulation and mobilization"

This is what we have written:

"There are also concerns about the use of cervical manipulation for conditions in which it is not considered appropriate. In 1996, Coulter et al.^[3] had a multidisciplinary group of 4 MDs, 4 DCs and 1 MD/DC look at more than 700 conditions where it was used. Their job was to evaluate the appropriateness of manipulation or mobilization of the cervical spine in those cases (including a few cases not performed by chiropractors).

"According to the report ... 57.6% of reported indications for cervical manipulation was considered inappropriate, with 31.3% uncertain. Only 11.1% could be labeled appropriate. A panel of chiropractors and medical practitioners concluded that '. . . much additional scientific data about the efficacy of cervical spine manipulation are needed.'"^[8]"

My concerns are:

1. Where did our first sentence come from?

2. Only 11.1% could be labeled appropriate. By whom?- MD group? DC group? Consensus group? The authors?

The information we have is not sufficient to make the statement that we are making. Am I making myself clear? And do you still feel the same way? --Dematt 02:00, 26 November 2006 (UTC)

I have taken the liberty of numbering (so they can be seen in the editing mode) your two points above. Now I'll refer to those numbers:

1. I assume you are referring to this sentence:

• "There are also concerns about the use of cervical manipulation for conditions in which it is not considered appropriate."

That sentence has a long history with many revisions. If it is inaccurate or clumsy, then it can of course be revised.

Nope, I blew it again, this part of the first paragraph:

• In 1996, Coulter et al.^[3] had a multidisciplinary group of 4 MDs, 4 DCs and 1 MD/DC look at more than 700 conditions where it was used. Their job was to evaluate the appropriateness of manipulation or mobilization of the cervical spine in those cases (including a few cases not performed by chiropractors). --Dematt 14:36, 26 November 2006 (UTC)

I don't see this in the cited references. --Dematt 14:38, 26 November 2006 (UTC)

2. I would assume that the authors are quoting the consensus group. We have no reason to doubt that. This is all referring to printed research from 1996, and Homola's reference to it in 1998, all analyzed by thousands of people since then. No one has yet questioned it to my knowledge, so until we can find multiple reliable sources that do so, I think we can relax.

Surely you would not be satisfied with this answer if the shoe was on the other foot. We can work on this while we relax;) --Dematt 14:35, 26 November 2006 (UTC)

If you think that first sentence needs rewording, then let's work on it. -- Fyslee 13:27, 26 November 2006 (UTC)

My mistake, no need to reword first sentence, just first paragraph. --Dematt 14:35, 26 November 2006 (UTC)

Here is the earliest report of the findings I could find (and possibly where some of the original wording originated, since it was an available source):^[9]

RAND FINDS LITTLE JUSTIFICATION FOR NECK MANIPULATION

The Rand Corporation conducted a review of the appropriateness of manipulation and mobilization of the cervical spine employing the same technique it had used to evaluate spinal manipulative therapy for back pain. A panel of nine judges (4 DCs, 4 MDs, and 1 MD/DC) rated cervical manipulation for appropriateness for specified clinical conditions. Each scenario was rated twice--once individually, and then again after a group discussion. A scale of 1 to 9 was used to judge appropriateness based upon the evaluator's opinion of its benefit-risk ratio.

Only 11.1% of 736 indications for cervical manipulation were judged appropriate. The most important finding was the paucity of evidence for the benefit of these procedures. The risks of cervical spine manipulation are well documented. Estimates of risk run from as low as 1 in 40,000 manipulations for mild complications, to 1 in one million for serious complications.

[Coulter, et al. The Appropriateness of Manipulation and Mobilization of the Cervical Spine. Santa Monica, CA, Rand Corp, 1996]

Comment: Although the report discussed the differences between mobilization and manipulation (the latter is more forceful with extension and rotation), there was insufficient attention paid to differences in the risks of these procedures.

NCAHF contends that, since neck stiffness and/or soreness are self-limited, and that there is no important medical benefit to neck manipulation, any risk of stroke or paralysis--no matter how small--is unacceptable. Even if the risk is 1 in one million, the thought of 50,000 chiros nationwide doing 20 to 40 manipulations each working day presents the nightmare of 1-2 patients a day experiencing completely avoidable strokes or paralysis. Given the history of chiropractic silence on its shortcomings, and an ideology that teaches that everyone will benefit from having his or her neck "cracked," NCAHF can only repeat its strong warning against neck manipulation.^[9]

-- Fyslee 16:07, 26 November 2006 (UTC)

Now here is the wording from above:

The Rand Corporation conducted a review of the appropriateness of manipulation and mobilization of the cervical spine employing the same technique it had used to evaluate spinal manipulative therapy for back pain. A panel of nine judges (4 DCs, 4 MDs, and 1 MD/DC) rated cervical manipulation for appropriateness for specified clinical conditions. Each scenario was rated twice--once individually, and then again after a group discussion. A scale of 1 to 9 was used to judge appropriateness based upon the evaluator's opinion of its benefit-risk ratio.

Only 11.1% of 736 indications for cervical manipulation were judged appropriate.

and the current wording:

There are also concerns about the use of cervical manipulation for conditions in which it is not considered appropriate. In 1996, Coulter et al.^[3] had a multidisciplinary group of 4 MDs, 4 DCs and 1 MD/DC look at 736 conditions where it was used. Their job was to evaluate the appropriateness of manipulation or mobilization of the cervical spine in those cases (including a few cases not performed by chiropractors).

Can we use one of them (NCAHF or current), or should we come up with a third version to use? -- Fyslee 16:18, 26 November 2006 (UTC)

The NCAHF is terribly slanted and highlights the ridiculous hole in all of these safety accusations against chiropratic neck manipulations. If there were 1 to 2 incidents a day of stroke and/or paralysis, then there is no way chiropractic could keep it a secret. Even if there was 1 or 2 a week... or even 1 or two a month... or even one or two a year. The fact is, millions upon millions of neck adjustments are performed by chiropractors every day and there has never been a direct incident-based correlation made... just estimates made that are used and abused by anti-chiro propagandists.

I really don't think we should be putting any emphasis at all on the RAND/Coulter studies. None of us have shown that we understand what the report is saying about appropriateness or safety and I think this just shows that it is not conclusive enough to be deemed worthy of encyclopedic mention. Levine2112 18:55, 26 November 2006 (UTC)

Good find! I do wish it came from somewhere besides NCAHF (they are rather biased:) so we could at least get a NPOV. I'm still wondering what the studies actual design and conclusions were. I'll keep looking, too. --Dematt 20:35, 26 November 2006 (UTC)

They are reporting a legitimate study. As long as we reference it, there should be no problem. Now is there any problem remaining with the wording of that first paragraph? -- Fyslee 22:18, 26 November 2006 (UTC)

Even still it is their opinion of the findings rather than the findings themselves. It would be beter to just have the findings themselves rather than a very slanted interpretation. Again, I think we should do away with the whole thing. It is overblowing a minimal and really says nothing about appropriateness. Levine2112 23:00, 26 November 2006 (UTC)

As far as we know, the purpose may have been to see if MDs and DCs agreed on the uses appropriate for SM and they agreed only under 11.1% of the 739 conditions. That would make a lot more sense and I could understand that. Something tells me we are repeating bad information. --Dematt 23:41, 26 November 2006 (UTC)

I fear that this questioning of the numbers is a form of OR. The numbers have been around for ten years, and yet this is the first place they are questioned! The study used a standard method used by RAND and other organizations and used many times before on other subjects. This wasn't even the first time it was used on a chiropractic-relevant subject. It had immediately previously been used on low back pain. The study did not discuss the agreement-disagreement aspects. That was a later study, and not part of this discussion. It isn't our job to question the results or suppress them if we don't like them. It's legitimate research and can just be presented, without taking sides. That's our job. -- Fyslee 06:28, 27 November 2006 (UTC)

If this isn't about the agreement-disagreement, then what is the report saying? I still remain of the opinion that we don't have a clear idea of what these numbers mean. No supression going on here. And I can't say whether or not I like this study, because I am in the dark about what it means. Until we know what this report is distinctly about, we would remiss in presenting it here. Levine2112 09:39, 27 November 2006 (UTC)

It's very simple - the multidisciplinary group agreed and published their findings - that 57.6% of reported indications for cervical manipulation was considered inappropriate, with 31.3% uncertain. Only 11.1% could be labeled appropriate.

A later study about that study method analyzed the different patterns of agreement/disagreement between a multidisciplinary group and another group composed only of chiropractors. That was a different study of a different matter. The original study represents the united and agreed conclusions of the original multidisciplinary group, 50% of whom were chiropractors. It would be OR for us to second guess them. -- Fyslee 12:03, 27 November 2006 (UTC)

There are so many unanswered questions about that research. I.e., If 57.6% were agreed to be inappropriate - does that mean even DCs didn't think it was appropriate? If that is the case, then why aren;t we stating it that way - or that 42.6% were considered appropriate by DCs? etc. etc.. I mean, without knowing what these numbers were in reference to, we can make them say anything we want. Could NACHF and Homola do that? I think so. --Dematt 16:42, 27 November 2006 (UTC)

This is the point I've been trying to make. That's for doing it so succinctly. We need to verify from the source what this all means and if it is significant enough for the article. Levine2112 18:00, 27 November 2006 (UTC)

Keep in mind that this article isn't primarily about chiropractic. The spinal adjustment article is. Of course the RAND study does involve DCs, since they provide 94%(?) of manipulations (and probably 96%(?) of cervical manipulations, and 98%(?) of upper cervical manipulations). (Those statistics are changing.) But the RAND study was not limited to DCs, but to all cervical manips, so it's relevant for this article.

The specific context for the use of this RAND study is the "concerns about the use of cervical manipulation for conditions in which it is not considered appropriate." The opinion of the multidisciplinary group (half of whom were DCs) is what's cited. That way we avoid a POV problem. The other study ("spinal manipulation for low back pain") studies the differences of opinion between the multidisciplinary group (includes DCs) and another group (only DCs). It also includes discussions of the universal principles involved in this type of study (also used for the cervical manipulation study). It then concludes that the multidisciplinary approach is best for determining questions of overuse (appropriateness):

• "Ultimately, however, the important comparison will be between panel ratings of appropriateness and necessity and patient outcomes. Until this is possible, mixed panels will be preferable when the purpose is coming to consensus about overuse of a procedure. The result here will be a reduction in inappropriate care. However, in those instances where the problem is underuse of a procedure, as measured by necessity, a mixed panel could have the opposite effect and further contribute to underuse." [9]

If anyone noticed another subject ("measured by necessity"), then the current study does mention that:

• ". . . much additional scientific data about the efficacy of cervical spine manipulation are needed."^[3][8]"

The question of necessity is intimately connected with the question of efficacy. But this is another subject not relevant to this section. Emphasis above added by Fyslee 20:38, 27 November 2006 (UTC)

It then concludes that the multidisciplinary approach is best for determining questions of overuse (appropriateness):

It did not conclude that, it compares that... BIG difference. IOWs insurance companies might want to look at multidisciplanary panels, but that does not necessarily mean it is accurate. Have to go, but read that last part again. --Dematt 21:08, 27 November 2006 (UTC)

 ? I'm not sure what you mean. Here it is again. It starts by mentioning three factors (I'll number them) that currently can't be compared:

• "Ultimately, however, the important comparison will be between panel ratings of (1) appropriateness and (2) necessity and (3) patient outcomes. Until this is possible, mixed panels will be preferable when the purpose is coming to consensus about overuse of a procedure. The result here will be a reduction in inappropriate care." [10]

Since it can't compare them, it just states what it can about an aspect relevant to the subject of the study (bold above). -- Fyslee 23:57, 27 November 2006 (UTC)

I understand what you are saying, but the information that discusses the value of this type of panel is in the three paragraphs before the one you've quoted. Check them out (bold is mine):

• The other major conclusion from this article is that the composition of the panel clearly influences the ratings. Those who do not use a procedure, such as manipulation, are more conservative in what they will rate as appropriate for the procedure, and are less likely to be in agreement about this issue than those who use the procedure in their practice. Further, an increase in the percentage of indications rated appropriate by a panel may have a drastic effect on the measurement of appropriate and inappropriate care. In the study by Leape et al. (1992), an additional 10 percent of indications rated appropriate resulted in an increase from 38 percent, based on the mixed panel, to 70 percent based on the specialist panel, in the ratings of the patient files.

• Depending on how one views the purpose of a panel, and whether the panel should err on the side of caution, this is either an argument in favor of multidisciplinary panels or an argument against them. RAND traditionally has favored multidisciplinary panels. The logic for this has been that the spectrum of disease is unlikely to be experienced by a single category of practitioner. Further, the stage at which they encounter the disease will vary considerably from general to specialty practice. Certain types of patients will present to different types of physicians. Furthermore, those who perform a procedure have both a professional bias in favor of it (if not, presumably they would not be performing it) and a financial incentive to support its use. The results presented here contribute additional information on the effect of a variation in panel membership for two panels whose recommended indications were more similar than in previous studies. These results will contribute further to the debate over the composition of panels.

• In the absence of a gold standard, however, it is not possible to judge whether a specialist or a mixed panel is better. The most we can say is that they differ. Two areas of further research may partially resolve this problem. In the first, the ratings can be compared to the literature. For spinal manipulation there is now a sufficient number of clinical studies (including random controlled trials) to allow a meta-analysis (Shekelle, Adams, Chassin, et al. 1992). A second possibility is to compare the ratings to the newly published AHCPR guidelines for treatment of low back pain (Bigos, Bowyer, and Braen 1994).

• Ultimately, however, the important comparison will be between panel ratings of appropriateness and necessity and patient outcomes. Until this is possible, mixed panels will be preferable when the purpose is coming to consensus about overuse of a procedure. The result here will be a reduction in inappropriate care. However, in those instances where the problem is underuse of a procedure, as measured by necessity, a mixed panel could have the opposite effect and further contribute to underuse.

Notice, they did not conclude that a mixed panel was the best way to determine appropriateness of care. In fact that said, "..it is not possible to judge." All they can say is that if you want to reduce the use of any type of care, use a mixed panel... There is more in the pages before that as well, but you get the point. IOWs, if you want to find out the lowball number for whatever reason, use a mixed panel. If you want to find out the highball number, use a specialist panel. The truth is somewhere in between. Right? We can't use the lowball numbers and try to pass it off as fact. Just because Homola and NCAHF did, does not mean that we should. However, if we want to use it, we should at least give the highball number as well. In the absense of that, maybe it would be better not to have it at all. --Dematt 02:06, 28 November 2006 (UTC)

The only way I can see us using this "not appropriate/overuse" study in this article would be to include everything which you have written above to qualify the mixed panel's findings. I think that this would get way to cumbersome and once again, since we are dealing with an infinitessimal fraction of percentage of risk, including this much here would be giving too much weight to an extremely minor hypothetical point. Levine2112 19:52, 28 November 2006 (UTC)

[edit] Overuse?

There are also concerns about overuse, specifically about the use of cervical manipulation for conditions in which it is not considered appropriate.

There are concerns of overuse of manipulation? Whose concerns are these? Who doesn't consider the conditon for use appropriate? Basically this sentence is a poor summary of what is to follow. Let's let the text speak for itself. And considering that none of us have given a clear explanation of this, I don't think a summary is appropriate. Overall, I agree with Dematt above. We should not use this confused study at all. Levine2112 04:04, 28 November 2006 (UTC)

[edit] References for whole page (keep at bottom)