Talk:Vertebral artery dissection/Archive 1

Interesting source and discussion

Interview of Dr. Michael J Haynes, Chiropractor, PhD.

A few quotes from the interview:

• "The marked over representation of vertebral arteries in the manipulation cases of dissection suggests that underlying arteriopathy is unlikely to be the only factor involved in these cases. The greater stresses that can be applied to vertebral arteries during neck movement compared with carotid arteries is the most likely explanation of these findings, which lends more support to the linkage between SMT and VBS."
• "There have been 2 case control studies, which indicated that rotational stenosis of vertebral arteries is an independent risk factor for vertebrobasilar stroke in general. So here we have further evidence of mechanical factors being involved with vertebrobasilar stroke."
• "If one can accept that minor neck movements can trigger vertebrobasilar strokes in susceptible individuals, it would seem reasonable that forceful neck manipulation involving full rotation of the head, would increase the risk by virtue of greater stresses being applied to the vertebral artery. I have not encountered any research, including the Calgary study by Dr Symons and colleagues, which provides evidence to counter this highly plausible assumption."
• "This complication should not be considered insignificant, firstly because it may not be as rare as many chiropractors would like to believe."
• "In my opinion there is a very high index of suspicion regarding a greater risk with rotational cervical manipulations that involve full rotation of the patient’s head."

-- Fyslee / talk 14:30, 17 June 2008 (UTC)

Removed for discussion

I have removed the following section:

Neck manipulation risk

Spinal manipulation, particularly when employed on the upper spine, is associated with frequent, mild and temporary adverse effects, and can also result in serious complications including vertebrobasilar (VBA) stroke. A 2010 review of published cases found that 26 deaths since 1934 have been recorded after chiropractic neck manipulation typically associated with vertebral artery dissection. A supplementary study in the recent Bone and Joint Decade 2000-2010 "Taskforce on Neck Pain and its Associated Disorders" specifically studied the issue of VBA strokes, and reported the following conclusion,

"VBA stroke is a very rare event in the population. The increased risks of VBA stroke associated with chiropractic and Primary Care Physician visits is likely due to patients with headache and neck pain from VBA dissection seeking care before their stroke. We found no evidence of excess risk of VBA stroke associated (with) chiropractic care compared to primary care".

The study found 818 VBA stroke events recorded for the 109,020,875 person years of observation that were examined for the province of Ontario, Canada, over a 9 year period. In the month prior to these stroke events, 2% (or 16) resulted following the patient having received only chiropractic care, another 2.4% (or 20) of these strokes occurred after the patient had seen both a Primary Care Physician and a chiropractor, and 51% (or 417) of these strokes had occurred after the patient had seen only a Primary Care Physician.

In discussing these results, the authors of the study also noted, "Our results should be interpreted cautiously and placed into clinical perspective. We have not ruled out neck manipulation as a potential cause of some VBA strokes. On the other hand, it is unlikely to be a major cause of these rare events. Our results suggest that the association between chiropractic care and VBA stroke found in previous studies is likely explained by presenting symptoms attributable to vertebral artery dissection".

This is not the way we should be handling such disputes about evidence. Firstly, if neck manipulation is not a common cause then why is more than half the article devoted to the controversy? Furthermore, WP:MEDRS is clear about the quality of sources that we are meant to be using, and long quotes by various pundits and detailed fisking of study data is well outside the boundaries of encyclopedicity. Even the intro has heaps of contradictory claims about neck manipulation.

What I would propose is a section called "Causes" (as WP:MEDMOS would suggest) listing all the causes of vertebral dissection, with a short paragraph about the controversial association with neck manipulation. JFW | T@lk 10:05, 22 November 2010 (UTC)

I am a newbie to W,and I agree with Jfwolff that the entry seems to be getting lop-sided towards the controversy regarding neck manipulation, and that a section called "Causes" would be worthwhile. I think that many, if not all, inclusions in the "Causes" section would need to be described as just being "proposed causes", because according to Rubinstein's systematic review the jury is still out. Perhaps the subject deserves to have material covering most of the headings suggested by MEDMOS, and placed under those headings. I agree that debatable issues should not be included in the introduction.

Maybe, contentious issues can be identified and briefly discussed (2-3 short i.e < = 2 line sentences) with a greater number (< = 10) and variety of appropriate citations. This would illustrate some depth of the controversy without expending much space on issues that tend to be divisive. If this is for the general public, I think that too much jargon is creeping in, e.g "hematoma" could be replaced by "blood clot". 203.171.196.105 (talk) 13:02, 22 November 2010 (UTC)

As I understand it, VAD after neck manipulation is rare, but looking at the subset of patients with VAD, neck manipulation is a common cause, especially in younger patients. I believe much of this material is covered at Chiropractic; I would support a bare-bones medically-oriented treatment here, with the social stuff reserved for that article. A section #Causes with relative rates would be a good presentation; short prose subsections or possibly a table should suffice. - 2/0 (cont.) 21:11, 22 November 2010 (UTC)

Despite views being expressed in this talk about the prominence that has been given to the controversial area of neck manipulation, the entry has reverted to having about half of the content devoted to this, without the change being discussed as JFdwolff had politely asked. I think that the composition of the entry should be much closer to that for carotid artery dissection. That entry identifies some controversial areas, but deals with them briefly. VAPhD (talk) 23:46, 22 November 2010 (UTC)

If others agree that the section is WEIGHTy, please modify the article accordingly. I am not looking for an edit war with QuackGuru. JFW | T@lk 18:32, 23 November 2010 (UTC)

I do agree, and have made what I think are appropriate modifications. If QuackGuru is unhappy about this then they perhaps need to talk. VAPhD (talk) 14:31, 24 November 2010 (UTC)

Sources

If general expansion of the article is being contemplated, could I perhaps recommend the follow sources? They are compatible with WP:MEDRS, the medicine sourcing guideline:

• PMID 19770343 - Am J Roentgenol, free review of imaging modalities
• PMID 19539238 - Lancet Neurology, review of predisposing factors, diagnosis and outcome
• PMID 19269682 - Thromb Res, review of pathology, epidemiology and management (already cited, but could be used more)
• PMID 19165955 - Curr Opin Neurol, review of supraaortic arterial dissection (carotid and vertebral)
• PMID 18303104 - JNNP, systematic review of treatment

There are no Cochrane reviews specifically for vertebral artery dissection (there is one for carotid dissection). PMID 18195663 is a review focused entirely on the association with cervical manipulative therapy. JFW | T@lk 18:42, 23 November 2010 (UTC)

Manipulation of the Cervical Spine: Risks and Benefits - Richard P Di Fabio

I wonder why this source isn't cited? It's definitely a RS and the most comprehensive I know of:

Abstract

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

Manipulation of the Cervical Spine: Risks and Benefits - Richard P Di Fabio, Physical Therapy, January 1999 vol. 79 no. 1 50-65

Regarding the role of chiropractors, Figure 2 is interesting. Note that this restrospective review took into account mistaken identities from previous studies and thus is quite conservative and accurate. -- Brangifer (talk) 22:50, 24 November 2010 (UTC)

BR, I'm not quite sure how that view squares with other assertions that only MEDRS sources can establish Weight. It seems to be having things both ways a bit. All reliable sources for criticisms of chiropractic but only MEDRS support of it? That might not be your personal take, but given the approach of some editors on this subject it doesn't give that much room for latitude. What do you think? Ocaasi (talk) 07:49, 1 December 2010 (UTC)

I'm not sure what you are concerned about ("that view"), but the Di Fabio reference is a MEDRS source which is already used on Wikipedia. In our articles we use both RS and MEDRS, but they are used differently. Note that MEDRS only applies to factual biomedical and scientific statements, not to many other matters which we are often supposed to include in medical articles. Criticisms of false claims made by chiros and others are often differences of opinion and maybe even political by nature, and are not of specific anatomical or other details requiring MEDRS, so the sources we are required by NPOV to use are not MEDRS, but must still be RS. When chiropractors or others make false claims about supposed benefits of various cures, then if they can't find MEDRS sources to back up their false claims, they can't include them as fact in articles. That seems like an appropriate application of MEDRS. We use it where it applies and don't where it doesn't. Is there some particular matter of concern here? -- Brangifer (talk) 08:06, 1 December 2010 (UTC)

There are numerous higher-quality sources that are much more recent than 1999. I think we are spending too much time on this association, and we are running the risk of WP:WEIGHT here. JFW | T@lk 23:11, 24 November 2010 (UTC)

Keep in mind that weight is determined by the amount of attention (and especially controversy) devoted to the subject in the real world, not by medical statistics and epidemiology. The fact that the chiropractic profession has made such a public fuss about this has created a weight situation in the real world that means we should give this more coverage. They are in massive denial of even the possibility (leaders have outright denied any possibility). If they would have just quietly admitted (like other professions which use manipulation have publicly done) that there is a risk, albeit a small one, there wouldn't be so much fuss about the matter and it would deserve only slight mention. Right now you're trying to minimize a very controversial matter. Don't let epidemiology determine the weight issue. -- Brangifer (talk) 02:22, 25 November 2010 (UTC)

I have now made it very clear, using Ernst as a source, that some in the chiropractic community dispute an association. That is all we can really say about it, and belabouring the point does not serve the scope of the article. JFW | T@lk 02:25, 25 November 2010 (UTC)

Claim lacking context

The following was added:

Dissecting aneurysms of the vertebral artery represent about 4% of all aneurysms.

Aneurysmal dilatation of a dissecting vertebral artery is not unusual (as per Kim & Shulman). I am unsure why we need to cite this statistic, and whether any further context might be helpful. JFW | T@lk 23:13, 24 November 2010 (UTC)

Epidemiology: Underreporting

I think the Epidemiology section needs a bit more since there is much debate about the actual incidence. No one really knows the true incidence, so one study isn't sufficient as a source in that section. Ernst has studied the matter (probably more than anyone else), and here's what he wrote:

• "Our recent survey, however, demonstrated an underreporting rate of 100%.4 This extreme level of underreporting obviously renders estimates nonsensical." [1]

Underreporting should be mentioned in that section. -- Brangifer (talk) 00:03, 25 November 2010 (UTC)

I think that inclusion of this is likely to create problems with WP:WEIGHT too. VAPhD (talk) 01:17, 25 November 2010 (UTC)

How would the addition of one sentence cause such a problem? Right now the section is woefully incomplete and presents one source and one POV, when in fact the evidence is very conflicting in many studies, and the problem of underreporting "renders estimates nonsensical". -- Brangifer (talk) 02:11, 25 November 2010 (UTC)

I had to rephrase the section because I wanted to source it to Kim rather than the previous source. Kim does discuss trends in diagnosis and the possibility of underreporting, and I will be adding this in due course. I see no problems with WP:WEIGHT and am happy to consider any other source that might shed light on the epidemiology of vertebral artery dissection. JFW | T@lk 02:24, 25 November 2010 (UTC)

Good. There are at least two things that need to be dealt with in that section, and one of them is underreporting. That isn't touched on yet, but keep up the good work. Ernst is an expert on the underreporting angle. He may have been the first to do any significant study on the subject and should be used as a source. -- Brangifer (talk) 02:27, 25 November 2010 (UTC)

This article should cover underreporting better. It is covered much better here:

Potential for incident underreporting

Statistics on the reliability of incident reporting for injuries related to manipulation of the cervical spine vary. The RAND study assumed that only 1 in 10 cases would have been reported. However, Prof Ernst surveyed neurologists in Britain for cases of serious neurological complications occurring within 24 hours of cervical spinal manipulation by various types of practitioners; 35 cases had been seen by the 24 neurologists who responded, but none of the cases had been reported. He concluded that underreporting was close to 100%, rendering estimates "nonsensical." He therefore suggested that "clinicians might tell their patients to adopt a cautious approach and avoid the type of spinal manipulation for which the risk seems greatest: forceful manipulation of the upper spine with a rotational element." The NHS Centre for Reviews and Dissemination stated that the survey had methodological problems with data collection. Both NHS and Ernst noted that bias is a problem with the survey method of data collection.

A 2001 study in the journal Stroke found that vertebrobasilar accidents (VBAs) were five times more likely in those aged less than 45 years who had visited a chiropractor in the preceding week, compared to controls who had not visited a chiropractor. No significant associations were found for those over 45 years. The authors concluded: "While our analysis is consistent with a positive association in young adults... The rarity of VBAs makes this association difficult to study despite high volumes of chiropractic treatment." The NHS notes that this study collected data objectively by using administrative data, involving less recall bias than survey studies, but the data were collected retrospectively and probably contained inaccuracies.

In 1996, Coulter et al. 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).

"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.'"

None of those sources are secondary sources that would satisfy WP:MEDRS. Again, I don't want to overemphasise a particular niche area for reasons of WP:WEIGHT. JFW | T@lk 11:15, 25 November 2010 (UTC)

"The therapists involved are mostly chiropractors; this predominance is probably due to the fact that these therapists use spinal manipulation more frequently than other practitioners. Most of the incidents reported in case series or surveys had not been previously reported, indicating that under-reporting may frequently be high."

"High levels of under-reporting or recall bias might distort the overall picture generated. Publication bias could have exerted a similar effect. For instance, it is possible that journals of complementary medicine are unlikely to publish findings which might be considered ‘negative’."

Ernst E (2007). "Adverse effects of spinal manipulation: a systematic review". J R Soc Med. 100 (7): 330–8. doi:10.1258/jrsm.100.7.330. PMC 1905885. PMID 17606755. {{cite journal}}: Unknown parameter |laydate= ignored (help); Unknown parameter |laysource= ignored (help); Unknown parameter |laysummary= ignored (help)

The 2007 systematic review is MEDRS compliant. For now I used another source that is also MEDRS compliant. QuackGuru (talk) 06:21, 28 November 2010 (UTC)

Jfdwolff, they don't have to be MEDRS sources since they aren't all dealing with medical facts, but political and controversy issues. This article is unlike most medical articles. We aren't writing a chapter in a pathology textbook. That's not how Wikipedia works. We must cover the whole subject from ALL POV, and because it has been the subject of much controversy, particularly involving the chiropractic community, this article must necessarily discuss that controversy, and it must necessarily involve the use of RS that don't qualify as MEDRS, because the details aren't of a "scientific fact" nature. -- Brangifer (talk) 07:36, 29 November 2010 (UTC)

BR, how are statistical estimations of under-reporting not medical claims? I think MEDRS is somewhat overused in these areas to begin with, but if we're going to use it strictly one way, why the laxity in the other direction? Ocaasi (talk) 07:54, 1 December 2010 (UTC)

The "statistical estimations" that Ernst reports are in a MEDRS. Period. As to "laxity in the other direction", see my answer to you above. We use RS at all times, but we use MEDRS only when they are specifically required. To require MEDRS when RS will do is improper. Is there a specific situation where you feel we're doing this wrong? -- Brangifer (talk) 08:11, 1 December 2010 (UTC)

The controversy is currently well represented in the "causes" section. We cover the incidence of VAD related to chiropractic and the fact that proponents of chiropractic disagree that an association exists. These claims are easily sourced to MEDRS sources so there is no need to bring in any other kind of source. What is your specific objection to the current version? JFW | T@lk 08:37, 29 November 2010 (UTC)

My biggest concern right here is that underreporting isn't covered. Mention of statistics is thus misleading without mention that those statistics give an incomplete and unreliable picture of the situation. -- Brangifer (talk) 18:13, 29 November 2010 (UTC)

There is no direct proof that underreporting is actually happening. Rather, this is based on anecdotal surveys. It is the weakest point of Ernst's paper, and this part of the paper is probably not WP:MEDRS. The more I read the paper the less I find it useful for this article (it might be appropriate for an article on complications after chiropractic). By the way, when we speak of "underreporting", what kind of reporting do we have in mind? To regulatory authorities? Into the medical literature? JFW | T@lk 20:16, 29 November 2010 (UTC)

"There is no proof..."??? What kind of "proof" would be acceptable to you? The kind of reporting would be to on or the other or both. Right now we have many instances where the incident doesn't figure in any statistic, yet there are medical witnesses in the ER and doctor's offices who find these cases. Please suggest a method that would be acceptable as proof. Just because the methods used might be imperfect, they are the best we have and are published in RS, so we should use them. -- Brangifer (talk) 23:49, 29 November 2010 (UTC)

The only actual standard of proof here is actual proof against a gold standard, not a lingering suspicion of absent data. The only evidence Ernst can adduce for underreporting is based on a website and on a lawyer's representation of victims. Causality may not have been proven in any of those cases (however plausible on face value). We already know that 16-28% of VAD is due to chiropractic, and we know that VAD can kill. We do not know whether chiropractic-related VAD is more likely to lead to death than any other kind of VAD. I therefore regard Ernst's point of underreporting of deaths less relevant. Not every death in the world needs to be published in a medical journal (just imagine all the kids dying from malaria). Rather, I think Ernst's point is that chiropractic is of unestablished benefit and proven harm. The collection of mortality data is something for regulators, insurers (why may be reimbursing chiropractic against their benefit) and professional organisations. JFW | T@lk 10:12, 30 November 2010 (UTC)

We must be talking about two different things here, because I don't know what you're referring to when you say "a website and on a lawyer's representation of victims". I'm referring to published reports in peer-reviewed journals, especially these two:

• Spinal manipulation: Its safety is uncertain, Edzard Ernst, CMAJ • January 8, 2002; 166 (1) "Our recent survey, however, demonstrated an underreporting rate of 100%.4 This extreme level of underreporting obviously renders estimates nonsensical." (Referring to the following "recent survey".)

• Full Text: Neurological complications of cervical spine manipulation, Stevinson C, Honan W, Cooke B, Ernst E., J R Soc Med 2001;94:107-10.] This survey reveal vast lack of reporting of cases (about 100%). Who performed the treatments was not documented. Documentation of vast underreporting was the main finding.

• Abstract: Neurological complications of cervical spine manipulation.

Estimates of actual incidence are nonsensical when underreporting is proven. We're not dealing with "a lingering suspicion of absent data". It is proven that data is commonly lacking, and therefore any estimates based on actual reported data are nonsensical because they do not account for underreporting.

The Epidemiology section needs to mention this. Including any numbers of "annual incidence" as we do, without mentioning this is very misleading to our readers. -- Brangifer (talk) 17:49, 30 November 2010 (UTC)

I really don't see why we should dwell on this so heavily. We already mention the fact that 16-28% of VAD is due to manipulation. Are you suggesting that this figure is too low? Again, postal surveys of practicioners are methodologically very weak ways of collecting data. It cannot even be called a registry study.

Let me be very clear: I am not an apologetic for chiropractic, and I want to represent the facts fairly. But I would hate to see this article being used as a WP:COATRACK.

Lastly, stop messing with my indentation please. JFW | T@lk 23:37, 30 November 2010 (UTC)

I'm not questioning the 16-28% matter. I'm just concerned that we don't mention underreporting. It's been studied by the only method available and published for this matter. If you know of a better method that is also published we could use it. Until then we use what is published. I'm not interested in making this a coatrack, just a sentence or two that mentions the problem with underreporting. That doesn't violate weight or coatrack. The wording is already in use in other articles and is copied at the beginning of this section. We could use a synopsis of the first few sentences. -- Brangifer (talk) 03:01, 1 December 2010 (UTC)

Sorry about the indenting thing. I was just following the rules for WP:REFACTOR, but if it bothers you, I'll just have to read more carefully to make sure I don't miss your comments. No offense intended. -- Brangifer (talk) 03:01, 1 December 2010 (UTC)

Overreliance on Kim

Isn't there a bit of a problem with such overuse of one source, especially when it was a study of anticoagulant therapy? How relevant is it to traumatic events like artery dissection? -- Brangifer (talk) 02:14, 25 November 2010 (UTC)

Kim is not a study, it is a review. It is very comprehensive. We will need to expand the "treatment" section to discuss the management of arterial dissection in the context of trauma. When I have expanded the present content, I will be reviewing other sources (particularly the Lancet Neurology review) to fill any gaps and add other viewpoints. JFW | T@lk 02:22, 25 November 2010 (UTC)

Good. Go for it! -- Brangifer (talk) 02:24, 25 November 2010 (UTC)

Reference to Ernst 2010 paper

I think that the inclusion of a discussion of deaths following chiropractic manipulation based on Ernst's paper¹ is problematic because of relevance issues. While Ernst listed 26 case reports of death following "chiropractic" manipulation, only 5 were identified specifically as involving VAD (i.e Sherman 1981, Nielson 1984, Modd 1985, Mas 1989, and Haynes 1994). Furthermore, the Haynes 1994² report explained that a coronial inquest had cleared the chiropractor from any responsibility. A survey³ of authors who had published cases of stroke following "chiropractic" manipulation had found examples where the manipulation was described as being "chiropractic" when the practitioner was not a chiropractor or could not be identified as such, including the Mas 1989 case report.

The mentioning of the the risk/benefit of 'chiropractic" manipulation would be appropriate for entries regarding "chiropractic" or "spinal manipulation", but I doubt that it is for "VAD". While there is an issue of under-reporting of cases, which applies to non-manipulation cases as well, further examples of over-reporting of chiropractic cases have been discussed.⁴The issue regarding neck manipulation cases is complex, which had been explained concisely. Additional material on neck manipulation runs the risk of WEIGHT issues, as previously explained by JFW, especially if it involves a balanced discussion of the Ernst 2010 paper.

References:

1. E Ernst (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice 64 (8): 1162–1165.
2. M.Haynes (1994) Stroke following cervical manipulation in Perth. Chiropr J Aust 4:42-46.
3. AGJ Terrett (1995) Misuse of the literature by medical authors in discussing spinal manipulative therapy. J Manipulative Physiol Ther.18:203-210.
4. A.B. Wenban. (2006) Inappropriate use of the title 'chiropractor' and term 'chiropractic' manipulation in the peer reviewed biomedical literature. Chiropractic and Osteopathy.14:16-23.

VAPhD (talk) 01:30, 28 November 2010 (UTC)

I am open to persuation on this one. It does sound a lot like WP:WEIGHT, and should ideally be discussed in the chiropractic article rather than here. By the way, it would be very useful if both QuackGuru and yourself declared any conflicts of interest you might have. JFW | T@lk 02:28, 28 November 2010 (UTC)

Conflict of interest is a subjective area, so I will briefly give my background, so that others may decide if I have a COI. I am a registered chiropractor, with a PhD titled "Ultrasound and biomechanical studies of human vertebral arteries" and a track record in publishing my research in chiropractic and medical internationally peer reviewed journals. While I am a chiropractor, most of my letters to editors of journals (chiropractic and medical) related to this issue have dealt with my concerns about papers written by chiropractor authors. I have major concerns with the papers from some medical authors too, including Prof.Ernst, but have left it to others to comment in the past. I really have sought to have a balanced debate on the subject, and in doing so I think that have irritated some of my chiropractor academic colleagues, including a journal editor.(Generally considered not to be a wise thing to do!)

I am new to WP, but have learned that it aims to provide accurate and balanced information that is not too technical. VAD is the only WP entry that I have contributed to because it is an important clinical issue that I have some expertise in, and I believe that the entry should remain neutral, but could easily become biased without appropriate debate. VAPhD (talk) 04:42, 28 November 2010 (UTC)

Thank you. Well done on your willingness to share your background; it enhances your credibility in this debate. My background is that I am a hospital doctor with an interest in acute neurology and atypical stroke syndromes. My only significant experience with the condition is from the literature. JFW | T@lk 04:49, 28 November 2010 (UTC)

In the section above we have a large review that avoids these problems and takes into account the legitimate concerns expressed by Terrett, so there is no confusion about "who did it": + == Summarise article in accordance with WP:LEAD ==

• Manipulation of the Cervical Spine: Risks and Benefits - Richard P Di Fabio +

There we have record, not of only 26 deaths (years?), but of 32 deaths (1925-1997), and exactly which professional group and type of manipulation was involved. I still think it's unwise to reject this large review. I'm a PT trained and experienced in manual therapies, including spinal manipulation. I have treated patients who survived, some barely, these techniques. (For some strange reason (;-) I never saw those who didn't, but we knew of cases.) We often joked with such patients: "you knocked on Heaven's door and St. Peter wasn't ready for you yet!" Some still had deficits and others had completely recovered. -- Brangifer (talk) 05:09, 28 November 2010 (UTC)

• See WP:MEDRS: Ideal sources for these aspects include general or systematic reviews in reputable medical journals; professional and academic books written by experts in a field and from a respected publisher; and medical guidelines or position statements from nationally or internationally reputable expert bodies.
• See WP:WEIGHT: Neutrality requires that each article or other page in the mainspace fairly represents all significant viewpoints that have been published by reliable sources, in proportion to the prominence of each viewpoint. Giving due weight and avoiding giving undue weight means that articles should not give minority views as much of or as detailed a description as more widely held views.
• This MEDRS compliant source does discuss vertebral arterial dissection associated with manipulation of the spine throughout the systematic review. If this is an issue of WP:WEIGHT then we must give the recent systematic review due weight.
• "What’s known Chiropractic upper spinal manipulation has repeatedly been associated with arterial dissection followed by stroke and, in some cases, death."
• "What’s new The article is the first systematic review of all fatalities reported in the medical literature. Twenty-six deaths are on record and many more seem to have remained unpublished."
• "Vascular accidents after upper spinal manipulation are a well-recognised problem (e.g. 1,2). Dissection of a vertebral artery, caused by extension and rotation of the neck beyond the physiological range of motion, is thought to be the underlying mechanism(2)."
• "This systematic review demonstrates that numerous deaths have been associated with chiropractic. Usually high-velocity, short-lever thrusts of the upper spine with rotation are implicated. They are believed to cause vertebral arterial dissection in predisposed individuals which, in turn, can lead to a chain of events including stroke and death (1,2,26,30)."
• "Reliable estimates of the frequency of vascular accidents are prevented by the fact that underreporting is known to be substantial."
• E Ernst (2010). "Deaths after chiropractic: a review of published cases". Int J Clinical Practice. 64 (8): 1162–1165. doi:10.1111/j.1742-1241.2010.02352.x. PMID 20642715. QuackGuru (talk) 05:33, 28 November 2010 (UTC)

I don't think that VAD due to spinal manipulation is more likely to cause death than VAD due to other causes. The absolute number of deaths reported is small. I therefore think that your additions represent WP:WEIGHT in its purest form. The concern about underreporting does not just affect VAD due to spinal manipulation, and I therefore intend to find a source that addresses the problem in a wider context. You don't need to lecture me on the appropriateness of systematic reviews; I take the credit for removing a number of anecdotal reports (including one you added) and non-MEDRS sources. JFW | T@lk 08:15, 28 November 2010 (UTC)

You don't think that VAD due to spinal manipulation is more likely to cause death than VAD due to other causes is irrelevant when there is a systematic review covering it in accordance with MEDRS. QuackGuru (talk) 08:42, 28 November 2010 (UTC)

That systematic review does not prove that CSM-related VAD is deadlier than other cases of VAD. It is therefore very relevant. You are trying to bring out a conclusion that does not exist. JFW | T@lk 09:19, 28 November 2010 (UTC)

That MEDRS guideline proves this systematic review is appropriate for the article. The text is faithful to the source in accordance with WP:V. QuackGuru (talk) 09:28, 28 November 2010 (UTC)

According to V the 2010 source is a systematic review. If an editor wants to counter this source with another source it must meet MEDRS. Using an older source that is not a specific response or directly disputes the conclusion of the systematic review cannot be a WP:MEDRS compliant source or could create WP:SYNTHESIS. QuackGuru (talk) 20:39, 28 November 2010 (UTC)

You are sounding like a broken record. I know it is a systematic review, I know it is MEDRS/WP:V compliant. The fact that a systematic review exists does not mean that it must be cited. For that we have consensus and dispute resolution. I have not objected to its use (despite a number of problems) but I have objected against its use in the introduction. JFW | T@lk 22:45, 28 November 2010 (UTC)

Someone did object to its use in the body when I had to restore it in the body. You objected to having a concise introduction with three paragraphs. QuackGuru (talk) 23:54, 28 November 2010 (UTC)

You wrote "I have not objected to its use (despite a number of problems) but I have objected against its use in the introduction."

You agreed to its use in this article is appropriate but you have deleted the main point from systematic review again. QuackGuru (talk) 06:46, 29 November 2010 (UTC)

I'm coming round to the view that it cannot be regarded as generally informative on the subject, as it focuses on a very small number of cases over the period for >70 years. As I stated earlier, it would be inappropriate to focus only on the mortality of chiropractic-related VAD. The claim that underreporting exists is also supported by rather circumstantial evidence (surveys of neurologists). To emphasise again: I'm less and less impressed with the source the closer I read it. To emphasise again: I'm trying to rely on the source as little as possible. The main points are already present: that VAD may result from chiropractic and that chiropractic-related VAD constitutes a significant proportion of cases of VAD. I was hoping that you might be prepared to reach some sort of compromise. JFW | T@lk 08:34, 29 November 2010 (UTC)

You deleted what I think was the compromise compared to the previous versions. QuackGuru (talk) 06:42, 1 December 2010 (UTC)

"The frequency for accurate estimates of vascular accidents involving vertebral artery dissection are impeded by substantial underreporting." You also deleted substantial underreporting from Ernst. QuackGuru (talk) 06:58, 1 December 2010 (UTC)

The systematic review should be included per WP:WEIGHT and WP:MEDRS. Per WP:WEIGHT: "Neutrality requires that each article or other page in the mainspace fairly represents all significant viewpoints that have been published by reliable sources, in proportion to the prominence of each viewpoint. Giving due weight and avoiding giving undue weight means that articles should not give minority views as much of or as detailed a description as more widely held views." A systematic review must have its due weight. QuackGuru (talk) 21:34, 5 December 2010 (UTC)

WP:WEIGHT depends on context. Ernst 2007 and 2010 are ideal for the article on Chiropractic or Spinal Manipulation. They are not central to VAD in general and can be mentioned but without a highlight on the study. As MastCell suggested, and as I believe Jfdwolff and VAphd seemed to concur, it suffices to identify the suspected link between chiropractic and VBA, reference Ernst without undue details, and also briefly mention to concern about underreporting. It can be done in one sentence: "Reviews of adverse incidents after spinal manipulation (SM) suggest a connection between SM and VBA.{cite} The connection may be understated due to significant under-reporting.{cite}" Done. Ocaasi (talk) 01:51, 6 December 2010 (UTC)

Your proposal is OR. If editors prefer OR then that would be consensus. QuackGuru (talk) 04:00, 6 December 2010 (UTC)

QG, when you make allegations of policy violations, would you mind giving specific reasons (like an exact phrases or better alternative). If you have a better way to briefly summarize that sentence that is in line with Weight, go for it. Editing involves writing, which involves paraphrasing, which can unintentionally verge on OR--but the edit is in line with the verifiable content of the article, so there's not really an OR issue here. Ocaasi (talk) 04:16, 6 December 2010 (UTC)

Ocaasi was not able to verify the text but if editors prefer OR over sourced text that is consensus. You know the source meets MEDRS. Where is your argument the source is against WEIGHT? QuackGuru (talk) 04:21, 6 December 2010 (UTC)

The other problem with the proposal is that it does not summarise the systematic review and ignores the conclusion. The proposal is vague and does not add anything to the article. QuackGuru (talk) 05:57, 6 December 2010 (UTC)

I will be responding in the "omnibus" thread at the bottom. I suggest we stop this thread to avoid duplication. JFW | T@lk 06:36, 6 December 2010 (UTC)

Summarise article in accordance with WP:LEAD

The lead section (also known as the introduction, lead, or lede) of a Wikipedia article is the section before the table of contents and the first heading. The lead serves both as an introduction to the article and as a summary of its most important aspects.

The lead should be able to stand alone as a concise overview of the article. It should define the topic, establish context, explain why the subject is interesting or notable, and summarize the most important points—including any notable controversies. The emphasis given to material in the lead should roughly reflect its importance to the topic, according to reliable, published sources, and the notability of the article's subject should usually be established in the first few sentences.

While consideration should be given to creating interest in reading more of the article, the lead nonetheless should not "tease" the reader by hinting at—but not explaining—important facts that will appear later in the article. The lead should contain no more than four paragraphs, should be carefully sourced as appropriate, and should be written in a clear, accessible style to invite a reading of the full article.

In accordance with WP:LEAD I made this change. The lead was too short and was only two paragraphs. QuackGuru (talk) 05:00, 28 November 2010 (UTC)

The addition you made to the lead is disproportionate. It more or less recaps the entire content of the "causes" section. Lead sections don't need to have three or more paragraphs; I can show you a large number of excellent articles that don't. Now if you will please stop reverting and address my points. JFW | T@lk 08:11, 28 November 2010 (UTC)

Your points are that you prefer a short lead that does not summarise the body because you think a large number of excellent articles don't summarise the lead. For this article we should summarise the body to make a better article. QuackGuru (talk) 08:37, 28 November 2010 (UTC)

You are misrepresenting my views. My point is that the addition is too detailed. I thought that would be obvious from my edit summaries. JFW | T@lk 08:43, 28 November 2010 (UTC)

Jfdwolff claimed "Lead sections don't need to have three or more paragraphs; I can show you a large number of excellent articles that don't." If other articles have a short lead that does not mean that should be repeated here. If the addition was too detailed you could of rewrote it. Based on your editing you think there should be only two paragraphs. QuackGuru (talk) 08:55, 28 November 2010 (UTC)

Please refer to my edit summaries, such as: "it would be WP:WEIGHT to go into such detail in the intro - please review any other high-quality medical article - please participate in the discussion on the talkpage about the appropriateness of citing Ernst-death". My primary objection is the excessive detail, and rewriting is not what is needed. You are the one who said that the intro was too long and the article body too short. Please continue to assume good faith, do not presume motives and address my points. JFW | T@lk 09:13, 28 November 2010 (UTC)

Your primary objection is the excessive detail, and rewriting it is not what you think is needed. Then what do you think is needed for the lead. Is it only two short paragraphs or would you like it expanded. I am the one who thinks that the intro is too short and the article body also too short. You continue to delete text and sources I added to the article. QuackGuru (talk) 09:21, 28 November 2010 (UTC)

We are going around in circles. I think the lead is currently the right size, because if it were to get any larger the rest of the article would be {{too short}}, wouldn't it? JFW | T@lk 09:24, 28 November 2010 (UTC)

So you have no intention of helping to expand the short lead because you think "Lead sections don't need to have three or more paragraphs; I can show you a large number of excellent articles that don't." The way you think leads for articles on Wikipedia should be written seems to be against WP:LEAD. QuackGuru (talk) 09:35, 28 November 2010 (UTC)

The issue of the role of neck manipulation is highly contentious. This means that if QuackGuru and others make additions from their perspective, more information is likely to given by myself and others from our perspective, which in turn is likely to generate more detail on this small part of the subject. This applies to the lead section as well as to the other sections, and the effect could be WP WEIGHT in both the lead and main body. My impression is that JFW is very highly experienced in WP, and that his edits, including changes that he has made to my contributions that I've sometimes found unsettling (and vice versa no doubt), seem to be balanced. I think that different parts of it will make some members of both the pro- and anti-neck manipulation groups a bit disgruntled - and that's perhaps a good sign of neutrality. Importantly it is a neutrality that has been achieved concisely, hence avoiding WP WEIGHT issues, and I think is well written. Others may improve it, but not by adding much.

Perhaps it may be worth considering that the Kim statistic of 16-28% of hospital cases implicating neck manipulation is very important. I find such a higher than expected proportion (up to 28%) to be a bit disturbing, and I'm sure that other chiros would do too, but it is a statistic that we seem to have to accept. If much more is added to this part from both pro- and anti- sides, it may dilute the effect of this simple but important statistic. However, it can not determine the issue of risk, and so this is why some mention of the other studies and their limitations is needed here, to provide balance. The addition of the Ernst citation and/or perhaps the deFabio one seem to be offered as some type of counter to this, but it will just trigger another counter from me, and so on. For instance, how do we resolve the dispute about whether the paper by Ernst is a systematic review? I would very much rather that we work collaboratively to achieve consensus. Peace be with you QuackGuru and Bullrangifer, oh and you too JFW. (VAPhD) 202.124.88.86 (talk) 17:15, 28 November 2010 (UTC)

If you want to resolve the query whether others think "Ernst-death" is a systematic review (which it claims to be in the title), then perhaps drop a message on the reliable sources noticeboard. JFW | T@lk 22:45, 28 November 2010 (UTC)

You previously wrote "I know it is a systematic review, I know it is MEDRS/WP:V compliant." QuackGuru (talk) 23:56, 28 November 2010 (UTC)

I did. And I agree that it is exactly what I said it is. But if VAPhD disagrees with that assessment he is fully in his right to discuss it on the relevant noticeboard. Did you hear me say otherwise? JFW | T@lk 03:11, 29 November 2010 (UTC)

Thank you for this, and I will follow it up. The title of the paper is "Deaths after chiropractic: a review of published cases." so "systematic" is not part of the title. Ernst stated that it was a systematic review in the Abstract and the beginning of the Discussion, despite there being no criteria having been set for assessing the quality of the case studies, nor any grading applied to the case studies. WP and Cochrane describe a systematic review as having such, and this is why a systematic review is rated far higher than a general review. His paper was only a compilation of cases drawn from a number of data bases which were then summarized, and from which he drew conclusions. That I think would make it a general review. Just because Ernst stated that his paper is a systematic review doesn't make it true. — Preceding unsigned comment added by 202.124.89.128 (talk • contribs)

The review is systematic in the sense that it collects data from the papers systematically (e.g. the nature of their neurological defect). In that sense I agree that it is systematic. I am much less certain about its suitability for inclusion, as most of the points made in it (e.g. underreporting) are made in other publications, but I would ensure that all the valid points currently sourced to it will continue to be included. JFW | T@lk 05:44, 29 November 2010 (UTC)

I note that the Ernst 2010 reference has been deleted, but please tell me for future reference if WP uses a different criteria for systematic reviews to Cochrane and to the following guide¹:... "Narrative reviews often do not explicitly describe how the reviewers searched, selected and appraised the quality of studies. In contrast, a systematic review includes a comprehensive, exhaustive search for primary studies on a focused clinical question, selection of studies using clear and reproducible eligibility criteria, critical appraisal of studies for quality, and synthesis of results according to a predetermined and explicit method." (VAPhD)

1. M Pai, M McCulloch, JD Gorman, N Pai, W Enanoria, G Kennedy, P Tharyan, JM Colford Jnr. (2004) Systematic reviews and meta-analyses: An illustrated, step-by-step guide. National Med J India.17 (2) 86-95. (This reference was accessed from the "Systematic Review" home page) 203.171.197.184 (talk) 13:58, 29 November 2010 (UTC)

Could I ask you to sign in properly before commenting? The above comments could easily have been from someone impersonating you.

Ernst outlines his methodology in reasonable detail. I agree that methodological critique is less, but in case reports that is often very difficult and Ernst concedes that details were sometimes lacking. I don't want this discussion to continue here; it would be much better if the reliable sources noticeboard could be involved. JFW | T@lk 20:16, 29 November 2010 (UTC)

For some reason I am having occasional technical difficulties in signing in properly, and am finding it hard to post on the reliable sources noticeboard. I do not want to debate the issue. VAPhD (talk) 01:21, 30 November 2010 (UTC)

OK, no problem. JFW | T@lk 10:12, 30 November 2010 (UTC)

Point of order

Is everybody happy with the entire rest of the article, except the lead?

You're supposed to write the lead after everything else, since it's logically impossible to "summarize" what doesn't exist. If you're still working on the rest of the article, then I strongly advice you to stop fussing with the lead for now and resolve the main text. WhatamIdoing (talk) 01:35, 1 December 2010 (UTC)

I summarised the Vertebral artery dissection#Causes section in the WP:LEAD after the section was expanded. I don't see any reason to delete a concise summary from the lead. QuackGuru (talk) 06:30, 1 December 2010 (UTC)

You added too much detail. The intro already covers trauma, spontaneous dissection and mild trauma. Mentioning rare underlying causes (Ehlers-Danlos) is not reasonable, nor is a whole discussion about the methodology of studies of chiropractic. I honestly wish you'd concede this point. JFW | T@lk 10:13, 1 December 2010 (UTC)

Development section

The body does not have a Development section. QuackGuru (talk) 05:46, 29 November 2010 (UTC)

Is it meant to? WP:MEDMOS does not require it. JFW | T@lk 05:59, 29 November 2010 (UTC)

Development of what? The VAD? This is dealt with under pathophysiology already. Doc James (talk · contribs · email) 02:29, 1 December 2010 (UTC)

"After the tear, blood enters the tunica media within the arterial wall leading to a clot formation that can block blood flow to the back part of the brain and spinal cord."

Having a section on the initial development of VAD might be too much detail for this aticle. Is there enough information in the body about the development of the tear leading to a blood clot. QuackGuru (talk) 07:54, 1 December 2010 (UTC)

Yes. In the "mechanism" section that I wrote. Did you read it? JFW | T@lk 10:08, 1 December 2010 (UTC)

WP:DUE, manipulation and VAD

We state 16–28% of VAD may be due to manipulation. Thus most are not. They occur spontaneously at a rate of 1 to 1.5 per 100,000. They may occur in possibly 1 per 100,000 neck manipulations. And 1% of serious neck trauma cases. Thus well much literature agrees that manipulation is a possible cause it does not appear to be the main cause.

I agree with JFD that it should not be mentioned in the lead but dealt with in the body of the article. Ernst is a well know and respected researcher of alt med. Thus his reviews are appropriate. But based on my editorial judgment belongs in the body of the article. My COI is on my user page. Doc James (talk · contribs · email) 02:25, 1 December 2010 (UTC)

IIRC, the Canadian study concluded it was a the major cause in individuals under 45 years of age. Otherwise I agree that it doesn't have to be mentioned in the lead, at least not until it is properly developed in the body. Then we can see if it's worth mentioning in the lead. -- Brangifer (talk) 02:53, 1 December 2010 (UTC)

Can you give a link for that? Does it give a percentage? How did it come to this conclusion? Doc James (talk · contribs · email) 06:18, 1 December 2010 (UTC)

I did find the "under 45" figure many places, probably quoting from this Stroke reference: Rothwell DM, Bondy SJ, Williams I. Case control study of chiropractic manipulation and stroke. Stroke 2001 (5) 1054-1060. Some places say it's a "major cause" and others a "leading cause". I'll refactor my comment above to soften it.

Here is a statement from 62 Canadian neurologists where they express concern that "patients with posterior circulation strokes under the age of 45 are 5 times more likely than controls to have visited a chiropractor within one week of the event 14." You can read their statement and the references they use:

• Statement of Concern to the Canadian Public from Canadian Neurologists Regarding the Debilitating and Fatal Damage Manipulation of the Neck May Cause to the Nervous System

Interestingly, this published statement was issued at a time when a major lawsuit was being filed by a family whose daughter, Laurie Jean Mathiason, had died after a neck manipulation. Immediately following the manipulation, she convulsed on the table and her head actually began turning blue. She went into a coma and died. The lawyers for the Canadian Chiropractic Association were on their toes and very aggressive. When this statement was published, each of the neurologists was contacted by those lawyers and threatened with a lawsuit if they didn't retract their support for the statement. Brangifer (talk) 07:43, 1 December 2010 (UTC)

Is any of this immediately relevant here? We are already discussing it as one of the causes in a fair amount of detail, ensuring NPOV by stating that there is an opposing view. From the above sources, is there anything that is going to make this article better? JFW | T@lk 10:06, 1 December 2010 (UTC)