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==Reverted edits== |
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This edit removed a bunch a reviews including a Cochrane review from 2009.[http://en.wikipedia.org/w/index.php?title=Osteoarthritis&diff=549151111&oldid=548850075] Thus I reverted. [[User:Jmh649|<span style="color:#0000f1">'''Doc James'''</span>]] ([[User talk:Jmh649|talk]] · [[Special:Contributions/Jmh649|contribs]] · [[Special:EmailUser/Jmh649|email]]) (if I write on your page reply on mine) 19:47, 7 April 2013 (UTC) |
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::Doc James, that is a heavy handed revert that removed tons of abbreviations and other edits. To simply restore the Cochrane review, let's do it more surgically. Let me look closely at this single edit that you are trying to revert and see why I removed that info.[[User:Sthubbar|Sthubbar]] ([[User talk:Sthubbar|talk]]) 19:55, 7 April 2013 (UTC) |
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:::Doc James, this was near the start of my editing and I think I see the issue. My disagreement with that content is that as I mentioned in the edit comments, it violated NPOV to start listing every medication that has been shown to be ineffective for a particular disease. Unless we also include a complete list of Western medications that have been shown to be ineffective for OA, then why include ineffective "Alt Med" treatments. It appears clear that ineffective "Western" meds are ignored and only effective treatments are listed, so for "Alt Med" I would expect the same treatment. If there is some controversy or extensive debate, like glucosamine, I'll let that slide for now, but from the mention of Vitamin C and stuff, I see no reason to include them. Leave that out.[[User:Sthubbar|Sthubbar]] ([[User talk:Sthubbar|talk]]) |
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:::Doc James, that was in poor form. I put a comment in my I did the revert and further came here to explain. You didn't even leave a comment when do did the revert a second time, or try to come to the talk page. You are undoing tons of work, with no justification.[[User:Sthubbar|Sthubbar]] ([[User talk:Sthubbar|talk]]) 20:04, 7 April 2013 (UTC) |
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::::Justification was provided. [[User:Jmh649|<span style="color:#0000f1">'''Doc James'''</span>]] ([[User talk:Jmh649|talk]] · [[Special:Contributions/Jmh649|contribs]] · [[Special:EmailUser/Jmh649|email]]) (if I write on your page reply on mine) 20:19, 7 April 2013 (UTC) |
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Doc James, you provided some interesting input about glucosamine. I can't find that any of your data conflicts the statement that "1500mg cyrstalline glucosamine sulfate is effective" as stated by the 2012 review. Even the Cochrane mete-analysis can't rule out glucosamine sulfate, which supports the 2012 study. All other negative studies include glucosmaine HCL or heterogenous preperations of glucosamine. |
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Furthermore, as you made a mistake about the removal of the pmid:20847017 Cochrane review, I am reverting to where I left off. I appreciate your editing of the content and improving the quality. |
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::You have removed a number of review articles again including: PMID:21220090 and this Cochrane review PMID:19821296. You have replaced the Cochrane review with an older non systematic review. You have removed the comments on there being a lack of good evidence which was supported by a 2010 review. I disagree with all these changes. The PMID to which you link is the BMJ article. The 2012 review is indeed contradicted by the other review you removed. [[User:Jmh649|<span style="color:#0000f1">'''Doc James'''</span>]] ([[User talk:Jmh649|talk]] · [[Special:Contributions/Jmh649|contribs]] · [[Special:EmailUser/Jmh649|email]]) (if I write on your page reply on mine) 23:28, 7 April 2013 (UTC) |
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Doc James, I'm going to assume good faith, so let me clear up what appears to be your confusion. Here is the situation: |
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1) I made several changes to OA |
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2) You mistakenly assume I removed pmid:20847017 so you reverted most all of my changes |
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3) You added additional content, including PMID:21220090 that I wasn't aware of until just now |
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4) I reverted to #1 to fix your mistake |
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The implication I hear in your comment is that I intentionally removed pmid:20847017 and PMID:21220090. We have already agreed that the former you were mistaken and the later, I wasn't aware because it was an addition after you made the massive revert. |
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As to PMID:19821296, this is for an di proven treatment. The implication is I removed a study disproving this treatment in order to support it. Instead I have completely removed the treatment because the treatment section is not to include every dis proven treatment. If a treatment doesn't work then completely remove it, or put it in the history section if you really want to have that in there. |
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Please stop the reverting. If you want to redo your edit, or I can even redo it for you of PMID:21220090, that's perfectly fine.[[User:Sthubbar|Sthubbar]] ([[User talk:Sthubbar|talk]]) 00:27, 8 April 2013 (UTC) |
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::No that is not at all the case. But let see what a third opinion has to say. [[User:Jmh649|<span style="color:#0000f1">'''Doc James'''</span>]] ([[User talk:Jmh649|talk]] · [[Special:Contributions/Jmh649|contribs]] · [[Special:EmailUser/Jmh649|email]]) (if I write on your page reply on mine) 00:30, 8 April 2013 (UTC) |
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I reverted the latest change because generally the sourcing has been made worse in both recency and authority of works cited. Please discuss and get consensus for these proposed changes one at a time before replacing. <code>[[User:Zad68|<span style="color:#D2691E">'''Zad'''</span>]][[User_Talk:Zad68|<span style="color:#206060">''68''</span>]]</code> 01:25, 8 April 2013 (UTC) |
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Adding - I understand some other good changes were in there like formatting or abbreviations. But the most important thing is the sourcing. Feel free to fix the small things while we discuss the sourcing changes. <code>[[User:Zad68|<span style="color:#D2691E">'''Zad'''</span>]][[User_Talk:Zad68|<span style="color:#206060">''68''</span>]]</code> 01:33, 8 April 2013 (UTC) |
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::I think most of the formatting changes he made are still there. [[User:Jmh649|<span style="color:#0000f1">'''Doc James'''</span>]] ([[User talk:Jmh649|talk]] · [[Special:Contributions/Jmh649|contribs]] · [[Special:EmailUser/Jmh649|email]]) (if I write on your page reply on mine) 01:42, 8 April 2013 (UTC) |
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I restored another removal of well-sourced and correctly-located content, including a 2010 Cochrane review. What could be the justification for the removal of such relevant, well-sourced content? <code>[[User:Zad68|<span style="color:#D2691E">'''Zad'''</span>]][[User_Talk:Zad68|<span style="color:#206060">''68''</span>]]</code> 03:51, 8 April 2013 (UTC) |
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::And he keeps removing what the refs say as in this edit [http://en.wikipedia.org/w/index.php?title=Osteoarthritis&diff=prev&oldid=549286155] [[User:Jmh649|<span style="color:#0000f1">'''Doc James'''</span>]] ([[User talk:Jmh649|talk]] · [[Special:Contributions/Jmh649|contribs]] · [[Special:EmailUser/Jmh649|email]]) (if I write on your page reply on mine) 15:02, 8 April 2013 (UTC) |
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:::Restored "many" after I confirmed that is what the source says. <code>[[User:Zad68|<span style="color:#D2691E">'''Zad'''</span>]][[User_Talk:Zad68|<span style="color:#206060">''68''</span>]]</code> 15:23, 8 April 2013 (UTC) |
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== Zad one more edit == |
== Zad one more edit == |
Revision as of 23:37, 2 December 2013
Medicine: Translation B‑class Top‑importance | ||||||||||||||||
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Zad one more edit
Zad, for consistency, I suggest we remove curcumin from the second sentence of possible treatments and it conflicts with the stronger later study that says there is unclear evidence. OK?Sthubbar (talk) 17:40, 9 April 2013 (UTC)
Changes for 9 April
- "Cat's claw" is a "practical treatment" - overstates what the source says. Source states "Three studies support cat's claw alone or in combination for OA" (Rosenbaum 2010). Suggestion is to restore previous article content "Three studies support the use of cat's claw."
- capsaicin and SAMe - study found them "effective in the management", but don't agree "practical" is a good paraphrase, suggest something like 'capsaicin and SAMe are effective in managing OA'.
- vitamins and ginger, turmeric, omega-3, glucosamie: I'm OK with "There is insufficient evidence", I think it's an improvement.
- chondroitin - "is not recommended", source says "discouraged", maybe we could make our statement a little stronger against
Zad68
17:51, 9 April 2013 (UTC)
- The remove of "three studies" is because this is a direct quote and as I've been told, plagiarism and copyright infringement. Also, I read the rules about using studies and if it is a single study then the language is "A 2010 study says X is a fact.", if it is a review article then it is "X is fact". DJ already reverted when I used the word "effective" and wrote on my talk page that I must paraphrase so I used thesaurus.com and practical is a synonym. I don't see the problem with practical also for Cat's claw. The review article supports the use, period. You can make the chondroitin stronger.Sthubbar (talk) 18:01, 9 April 2013 (UTC)
So reverted back the edit that put cat's claw in the "effective" category... again, the review that covered it didn't go as far as to say 'effective', just that there's some evidence (three studies) to support. Zad68
01:58, 10 April 2013 (UTC)
Why single out cat's claw?
Zad, why do you want to single out cat's claw? The organization of the section I see is:
- Treatments that are the most likely
- Treatments that show some evidence and require more evidence
I am following the criteria "‘Weak evidence’ describes herbs with a single RCT with significant results; ‘promising evidence’ describes herbs with two trials that produced favourable outcomes; ‘moderately strong evidence’ describes herbs with three or more favourable trials." as specified here http://rheumatology.oxfordjournals.org/content/40/7/779.long, which is PMID:11477283, included in the article. We only use 2 categories instead of 3. Category 1 is 3 or more RCT. Category 2 is less than 3 RCT. Cat's claw has 3 RCT so that is why I include it in the first sentence with Capcaicin. Does that make sense?Sthubbar (talk) 02:00, 10 April 2013 (UTC)
- How supportive evidence is of a treatment does not depend just on the number of RCTs done. Doc James (talk · contribs · email) (if I write on your page reply on mine) 05:31, 10 April 2013 (UTC)
- Why is cat's claw being kept out of the first sentence? The abstract says clearly that it is supported as a treatment for OA, so I suggest it be added with the other treatments in the first sentence. The abstract also says nothing about anti-inflammatory properties of cat's claw. I though anti-inflammatory properties was generally associated with RA not OA. Anyway, can we please change the first sentence to include cat's claw and remove the special clause? — Preceding unsigned comment added by Sthubbar (talk • contribs) 03:49, 11 April 2013 (UTC)
- Because De Silva didn't study cat's claw, and Rosenbaum only says "Three clinical trials support the use of cat's claw as an anti-oxidant/antiinflammatory agent". This is stopping short of saying there's enough evidence that it's hands-down effective. I think the current article content reflects the source accurately, don't see a need to change it.
Zad68
02:46, 12 April 2013 (UTC)
- Because De Silva didn't study cat's claw, and Rosenbaum only says "Three clinical trials support the use of cat's claw as an anti-oxidant/antiinflammatory agent". This is stopping short of saying there's enough evidence that it's hands-down effective. I think the current article content reflects the source accurately, don't see a need to change it.
- Why is cat's claw being kept out of the first sentence? The abstract says clearly that it is supported as a treatment for OA, so I suggest it be added with the other treatments in the first sentence. The abstract also says nothing about anti-inflammatory properties of cat's claw. I though anti-inflammatory properties was generally associated with RA not OA. Anyway, can we please change the first sentence to include cat's claw and remove the special clause? — Preceding unsigned comment added by Sthubbar (talk • contribs) 03:49, 11 April 2013 (UTC)
- How supportive evidence is of a treatment does not depend just on the number of RCTs done. Doc James (talk · contribs · email) (if I write on your page reply on mine) 05:31, 10 April 2013 (UTC)
Zad68, <sarcasm>how dare you suggest I do anything illegal! I would never!!</sarcasm>. I will agree to disagree. According to the reports: Phytodolor provides "significant improvement in grip strength", SAMe is "equal to or more effective and better tolerated than the NSAIDs" and SKI 306X provides "significantly lower levels of pain and better function".
To be fair I suggest these two choice:
- Put these statements along with each of the treatments to make them similar to the clarification for cat's claw.
- Leave out this clarification for all items, including cat's claw.
Which seems more reasonable to you?Sthubbar (talk) 03:57, 12 April 2013 (UTC)
Added treatments are from full articles not from abstract
Before reverting the added treatments under dietary supplements, please review the complete articles and discuss here. There are 2 new references from Ernst in 2001 and 2011. This is where much of this info, though not all is coming from.
I realize there is still conflicting information to be clarified, for example stinging nettle is both listed as promising and not able to be recommended in the first and last paragraph of the section. I think there are other review articles for some of these conflict treatments that we can review.
I will also alphabatize these treatments when I have a mild confidence that these edits aren't just going to be blanket reverted.Sthubbar (talk) 02:27, 10 April 2013 (UTC)
- We typically do not use reviews older than 10 years when newer stuff is available. Thus we should remove the 2001 review.Doc James (talk · contribs · email) (if I write on your page reply on mine) 04:33, 10 April 2013 (UTC)
Why a special page for knee osteoarthrits?
Doc James, I see you have created a special page for osteoarthritis of the knee. I'm curious why a special page. It seems like it will make it more difficult to maintain a consistent information if there is significant overlap with osteoarthritis. This page would make sense to me if on the osteoarthritis page there is a section "osteoarthritis of the knee" and with a link to the new page. Then this new page would only include additional clarification of this particular manifestation of OA and not include duplicate from OA. So, the general question is, why the special page and how to keep both pages in sync?Sthubbar (talk) 12:22, 13 April 2013 (UTC)
- If mean this page knee osteoarthritis it was created by someone else in 2010 Jan [1]. In fact in May of 2010 I tried to redirect it to the main page here [2] and would still be supportive of this option with incorporation of the bit of good content into the main article. Doc James (talk · contribs · email) (if I write on your page reply on mine) 01:48, 14 April 2013 (UTC)
- Doc James, I think I was looking at the history of the talk page that led me to believe you created the page. OK, so you have the same idea I have of putting in the redirect. I guess next is to take it up on the talk page there. Thanks.Sthubbar (talk) 11:36, 14 April 2013 (UTC)
- I notice that there seems to be no activity on the talk page, so probably won't be helpful to start a discuss there. Do you recommend trying to put back in the redirect?Sthubbar (talk) 11:38, 14 April 2013 (UTC)
- If mean this page knee osteoarthritis it was created by someone else in 2010 Jan [1]. In fact in May of 2010 I tried to redirect it to the main page here [2] and would still be supportive of this option with incorporation of the bit of good content into the main article. Doc James (talk · contribs · email) (if I write on your page reply on mine) 01:48, 14 April 2013 (UTC)
OA vs. RA?
Shouldn't the article, including the introduction, define the difference between osteoarthritis and rheumatoid arthritis? (The link to Dorland's is dead.) --Nbauman (talk) 18:57, 22 April 2013 (UTC)
- Yes they stopped offering a free copy of Dorlands a while ago. Doc James (talk · contribs · email) (if I write on your page reply on mine) 03:41, 23 April 2013 (UTC)
Added massage therapy
I also reorganized under Alternative Medicine so the headings there are now: Dietary supplements, Manual therapies, Acupuncture, Electrical stimulation
I moved the content that was under Manual therapies into the two new headings (Acupuncture and E-stim), two sentences on the first and one on the other.
TBH this is the first time I've used journal citations, so please let me know if I did a poor job.
Derekawesome (talk) 20:25, 6 May 2013 (UTC)
- Per WP:MEDRS we try to use secondary sources rather than primary sources. Thus reverted additions. Will look for secondary sources. Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:11, 7 May 2013 (UTC)
- Dillard, JN (2011 Sep). "Use of complementary therapies to treat the pain of osteoarthritis". The Journal of family practice. 60 (9 Suppl): S43-9. PMID 22442759.
{{cite journal}}
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(help) - . PMID 22632691.
{{cite journal}}
: Cite journal requires|journal=
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(help) - The last one is a review of massage. As soon as I have internet that works I will look at it. Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:46, 7 May 2013 (UTC)
- Dillard, JN (2011 Sep). "Use of complementary therapies to treat the pain of osteoarthritis". The Journal of family practice. 60 (9 Suppl): S43-9. PMID 22442759.
- Per WP:MEDRS we try to use secondary sources rather than primary sources. Thus reverted additions. Will look for secondary sources. Doc James (talk · contribs · email) (if I write on your page reply on mine) 07:11, 7 May 2013 (UTC)
Reviews
- [3] Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:14, 6 June 2013 (UTC)
Is before 2009 "older"
It is predictable that the two small and logical edits I have recently made are immediately reverted by Doc James, so let's address them one at a time.
The first one seems so blatantly biased that I'm looking forward to see how people justify reverting the improvement I made.
The term "Older" is used to refer to two studies, one in 2005 and one in 2009.
A quick look at the first 42 references shows 50% of them are from on or before 2009, some of them much earlier.
I will accept characterizing these two 2005 & 2009 studies as "older" if all of the other references from 2009 and before are also qualified as "old" or "older".
Do we have consensus to update this article and qualify every reference from 2009 and before as "old" or "older", or can we take the more rational step and remove this inflammatory characterization from the Dietary Supplements section?Sthubbar (talk) 13:16, 25 September 2013 (UTC)
Glucosamine Sulfate != Glucosamin Hydrochloride
I will assume good faith that Doc James is confused and maybe did not read closely the freely available full text of the reference PubMed 17599746. The current Wiki section says "some others have found it ineffective" where some others refers only to PubMed 17599746 and "it" refers to glucosamine SULFATE. The review article says "no definitive conclusion about efficacy is possible" in reference to glucosamine SULFATE. We have had this discussion before:
No conclusion does NOT equal ineffective No conclusion may mean is effective or is ineffective.
This statement of "ineffective" using PubMed 17599746 as the reference is strictly false. The edit I made removed this and simply moved the reference to the next sentence that says there seems to be a difference between Hydrochloride and Sulfate because this article clearly supports that conclusion as they conclude Hydrochloride "lacks efficacy" which is clearly different than "no conclusion" therefore is supports the idea that there may be a difference between hydrochloride and sulfate. Can we agree that No conclusion does NOT equal ineffective and again restore this edit as well?Sthubbar (talk) 13:24, 25 September 2013 (UTC)
- It is time we remove the old reviews. I will update. Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:32, 25 September 2013 (UTC)
- What is the definition of "old reviews" and does that apply to the complete article or just to the Alt med section? I seem to remember you say before something like before 10 years, and I see references from much more than 10 years all over the article. Are you going to be balanced and remove ALL reviews from the complete article from before a particular date?
- BTW 2005 and 2009 are less than 10 years ago. What is your comment to the above section?Sthubbar (talk) 14:21, 25 September 2013 (UTC)
- Furthermore, 17599746 is from 2007, hardly old. The point of this section has nothing to do with the age of the reference it has to do with your insistence that "no conclusion"="ineffective". Please comment on this point.Sthubbar (talk) 14:22, 25 September 2013 (UTC)
- 2007 is more than 3-5 years old and there is newer evidence. The ref stated "Glucosamine hydrochloride is not effective"[4] which we summarized as "while some others have found it ineffective." Doc James (talk · contribs · email) (if I write on your page reply on mine) 15:00, 25 September 2013 (UTC)
- If there are newer reviews that incorporate newer study data or they are otherwise better reviews due to better review methodology, etc., then the older reviews should be removed and the newer reviews used, just as Doc is doing. In such a case it would not be that the older reviews are out of date because of when they were published, but rather that there's now better quality evidence to use.
Zad68
14:36, 25 September 2013 (UTC)
- If there are newer reviews that incorporate newer study data or they are otherwise better reviews due to better review methodology, etc., then the older reviews should be removed and the newer reviews used, just as Doc is doing. In such a case it would not be that the older reviews are out of date because of when they were published, but rather that there's now better quality evidence to use.
- 2007 is more than 3-5 years old and there is newer evidence. The ref stated "Glucosamine hydrochloride is not effective"[4] which we summarized as "while some others have found it ineffective." Doc James (talk · contribs · email) (if I write on your page reply on mine) 15:00, 25 September 2013 (UTC)
- Furthermore, 17599746 is from 2007, hardly old. The point of this section has nothing to do with the age of the reference it has to do with your insistence that "no conclusion"="ineffective". Please comment on this point.Sthubbar (talk) 14:22, 25 September 2013 (UTC)
- BTW 2005 and 2009 are less than 10 years ago. What is your comment to the above section?Sthubbar (talk) 14:21, 25 September 2013 (UTC)
- What is the definition of "old reviews" and does that apply to the complete article or just to the Alt med section? I seem to remember you say before something like before 10 years, and I see references from much more than 10 years all over the article. Are you going to be balanced and remove ALL reviews from the complete article from before a particular date?
- It is time we remove the old reviews. I will update. Doc James (talk · contribs · email) (if I write on your page reply on mine) 13:32, 25 September 2013 (UTC)
You are completely removing references and changing the wording so let's just start a new section as I know we have to take whatever you write.Sthubbar (talk) 21:08, 25 September 2013 (UTC)
- Have you read wp:MEDRS? There's a simple reason for using the more recent reviews than the older ones: the authors of the latter ones were themselves able to read the earlier ones and consider their results. Continuing to use the obsolete sources is in fact wp:UNDUE, except perhaps in a historical section. LeadSongDog come howl! 21:58, 25 September 2013 (UTC)
- LeadSongDog, what you say makes sense if we were talking about a building. So for example if we are designing the 7th floor, we don't have to talk about the existence of floors 1-6 as they must exist because they are supporting the 7th floor. The assumption that because there is a 2012 review article that this 2012 review includes all previous review articles is false. Authors, sometimes because of error, or bias miss or leave out previous review articles. Review articles also can come to different conclusions. Otherwise, only 1 review article would be allowed per topic and it would be whatever is the most recent review article. Obviously, this is not the case, many review articles are used, not just the one with the most recent date. If we allow review articles from 2012, 2008, and 2004, what is the logical reason to deny one from 2000? Your argument sounds to me to be that since the 2000 review is "old" it is included in the more current reviews. But, wait a minute, can't the same be said about the 2004 review? It "must" be included in the 2012 and 2008, and to continue the logic, the 2008 review "must" be included in the 2012 review, so the only logical conclusion for me is either, 1) Only accept the most recent review in 2012 or 2) Do the laborious chore of actually reading all reviews, see if they are overlapping or not and don't choose some arbitrary deadline.Sthubbar (talk) 03:40, 26 September 2013 (UTC)
- Generally you can look at a review or a systematic review and see the primary studies included and (possibly) the older reviews referenced. They may list all the primary studies they looked at, even if they didn't use them, or they might list everything, even stuff they didn't use. Just because a review doesn't happen to mention an older study or review, that doesn't mean it wasn't considered, it just might mean that perhaps the authors didn't feel it was good enough to use. I do not know of any other medical topic on Wikipedia where we go out of our way to use older reviews when there are newer, good-quality ones available. In fact, "use up-to-date evidence" is in the WP:MEDRS guideline. Unless a compelling reason can be given arguing for an exception here not to use the latest reviews, I can't see any policy-based reason to do so. What is so special about this particular topic that it'd be in the best interest of the article to do so?
Zad68
04:24, 26 September 2013 (UTC)- Nothing more here. Next issue is fixing the mischaracterization of the 2012 review article.61.161.199.67 (talk) 06:31, 26 September 2013 (UTC)
- Generally you can look at a review or a systematic review and see the primary studies included and (possibly) the older reviews referenced. They may list all the primary studies they looked at, even if they didn't use them, or they might list everything, even stuff they didn't use. Just because a review doesn't happen to mention an older study or review, that doesn't mean it wasn't considered, it just might mean that perhaps the authors didn't feel it was good enough to use. I do not know of any other medical topic on Wikipedia where we go out of our way to use older reviews when there are newer, good-quality ones available. In fact, "use up-to-date evidence" is in the WP:MEDRS guideline. Unless a compelling reason can be given arguing for an exception here not to use the latest reviews, I can't see any policy-based reason to do so. What is so special about this particular topic that it'd be in the best interest of the article to do so?
- LeadSongDog, what you say makes sense if we were talking about a building. So for example if we are designing the 7th floor, we don't have to talk about the existence of floors 1-6 as they must exist because they are supporting the 7th floor. The assumption that because there is a 2012 review article that this 2012 review includes all previous review articles is false. Authors, sometimes because of error, or bias miss or leave out previous review articles. Review articles also can come to different conclusions. Otherwise, only 1 review article would be allowed per topic and it would be whatever is the most recent review article. Obviously, this is not the case, many review articles are used, not just the one with the most recent date. If we allow review articles from 2012, 2008, and 2004, what is the logical reason to deny one from 2000? Your argument sounds to me to be that since the 2000 review is "old" it is included in the more current reviews. But, wait a minute, can't the same be said about the 2004 review? It "must" be included in the 2012 and 2008, and to continue the logic, the 2008 review "must" be included in the 2012 review, so the only logical conclusion for me is either, 1) Only accept the most recent review in 2012 or 2) Do the laborious chore of actually reading all reviews, see if they are overlapping or not and don't choose some arbitrary deadline.Sthubbar (talk) 03:40, 26 September 2013 (UTC)
Definition of "Most" and "recent"
Doc James, you have written "Most recent reviews do not show it to be better than placebo." That is a bold statement. My understand of the word most is that if there are x items then anything greater than x/2 could be considered "most". The items in question are "reviews". So, let's count, how many reviews are in that paragraph... Best Bets, PMid 22925619, Pmid 20847017, Pmid 23679910, Pmid 22091473, Pmid 21220090, PMid 22850875, Pmid 18279766, and Pmid 22293240. I count that as 9. So for your statement to be true, then 5 of them must conclude that Glucosamine equal or worse than Placebo. Let's check them out.
- Best Best = "still controversy", so NO, they don't conclude it is equal to placebo. Evidence for effect and for placebo
- Pmid 22925619 = "mild symptomatic relief", so NO not equal to placebo, has effect if it only mild.
- Pmid 20847017 = "do not reduce joint pain or have an impact on narrowing of joint space", YES, one for your side.
- Pmid 23679910 = "may have function-modifying effects", so NO can't say it is equal to placebo
- Pmid 22091473 = "no clear difference between glucosamine and oral NSAIDs", so unless you say NSAIDs=placebo then another for my side.
- Pmid 21220090 = I can't find the full article
- PMid 22850875 = "glucosamine sulfate 1500 mg once daily is therefore recommended" so very much on my side and NOT a placebo
- Pmid 18279766 = "recommendation...glucosamine and/or chondroitin sulphate for symptom relief; glucosamine sulphate, chondroitin sulphate and diacerein for possible structure-modifying effects " again very much NOT placebo.
- Pmid 22293240 = "viable option for the management of OA" so NOT placebo
I count that as 7 clearly show benefit, 1 says is equal to placebo and 1 I can't comment.
Hmm, If I had the power that you do, I would rewrite that as something like "There is overwhelming evidence that some formulations of glucosamine are effective in the treatment of OA."
What do you think?Sthubbar (talk) 21:41, 25 September 2013 (UTC)
- Systematic reviews and meta analysis are a higher quality of evidence than just a plain review. Have changed it to "equal or only slight better than placebo". No one is claiming a large effect and no one finds "overwhelming evidence"
- Pmid 22925619 = " limited to mild symptomatic relief, while a disease-modifying agent for this disease remains elusive."
- Pmid 20847017 = "do not reduce joint pain or have an impact on narrowing of joint space", YES, one for your side.
- Pmid 23679910 = When papers say may this can equally mean may not "showed no pain-reduction benefits after 6 months of therapy."
- Pmid 22091473 = "evidence from a systematic review of higher-quality trials suggests that glucosamine had some very small benefits over placebo for pain"
- Pmid 21220090 = will look
- PMid 22850875 = not listed as a review
- Pmid 18279766 = 2012 "not in the most recent NICE guidelines"
- Pmid 22293240 = old
- Doc James (talk · contribs · email) (if I write on your page reply on mine) 22:37, 25 September 2013 (UTC)
I'm mostly satisfied with how it looks currently, but PMID 23679910 from 2013 (please post PMIDs like this so they can be clicked on) does not exactly conclude no better than placebo, as currently shown in the article. It says unequivocally that that GH (hydrochloride) is no better than placebo, but for sulfate it has a confusingly different message (I don't have access to the full paper): "Pooling data from studies with durations of more than 24 weeks presented a significant combined ES of -0.36 (95% CI: -0.56, -0.17) with an absence of heterogeneity" and concludes "GS may have function-modifying effects in patients with knee OA when administered for more than 6 months". Currently this is cited as [64] in "Most recent reviews found it to be equal to[63][64]", which appears to be an oversight. 0.36 is indeed a decent effect size and usually lack of heterogeneity is good but perhaps this just picked up the three Rottapharm studies, which may be affected by industry bias or, alternatively, by different formulations (according to Reginster 2007). II | (t - c) 01:51, 26 September 2013 (UTC)
- Doc James, thanks for the balanced presentation. @ImperfectlyInformed, unfortunately the drop-down "cite journal" function does not work any more on my system and I don't enjoy memorizing wiki code. BTW, from reading the research it seems absolutely clear to me that Sulfate and HCL are clearly separate treatments, as much as coffee and tea are separate beverages. Most all reviews that show "confusing" results are because they mix the two treatments. All research that I am aware of that clearly separates these two medications shows clear positive response to Sulfate and low or absent response to HCL. The community here seems to think that this borders on "original research", so as long as it is mentioned like it is on the page, I'll leave it to other adventurous readers like myself to actually read the papers.Sthubbar (talk) 02:05, 26 September 2013 (UTC)
- The experts seem mystified by why sulfate would cause a difference (maybe the sulfate itself?) but I dunnno. As far as PMIDs, just write it exactly as I did. PMID [number] and it will be linked (just did it with a couple of yours above). It's best not to get too worked up anyway as the truth comes out over time. II | (t - c) 02:18, 26 September 2013 (UTC)
- Isn't there an OS or RA treatment like sulfazine. It seems reasonable that maybe just taking sulfate, minus the glucosamine is actually what is having the positive affect. I just looked up and sulfate is a salt of sulfuric acid. Maybe we should be recommended OA suffers drink sulfuric acid. Who wants to join that trial?!Sthubbar (talk) 02:34, 26 September 2013 (UTC)
"the National Institute of Clinical Excellence no longer recommends its use"??
Doc James, what am I missing here? I have checked the full text paper for PMID 22293240 and in the Conclusion section it says "it represents a viable option for the management of OA" and "we should consider the use of glucosamine as a combination therapy with other drugs or other nutraceuticals". How does that translate into a "no longer recommends" statement? Amy I looking at the wrong PMID?Sthubbar (talk) 02:16, 26 September 2013 (UTC)
- Oh! I see if I just put PMID in all CAPS followed by the number then the Wiki software will make the link, no need to use the cite tool or memorize wiki code. Got it.Sthubbar (talk) 02:19, 26 September 2013 (UTC)
- "Hence, glucosamine was at first recommended by EULAR and OARSI for the management of knee pain and structure improvement in OA patients, but not in the most recent NICE guidelines". In the abstract. :p Also you might want to move your comment above. II | (t - c) 02:21, 26 September 2013 (UTC)
- OK, I see the NICE guidelines are a different document here http://www.nice.org.uk/CG059 and this is definitely old and if included should be classified as such. These guidelines are being updated and should be released Feb 2014, according to http://www.nice.org.uk/guidance/index.jsp?action=byID&o=13505.
- Please either specify the NICE is old and provide the correct reference, or remove completely as you have been doing for the other supportive old reviews and also update the include PMID 22293240 showing support for the use of glucosamine.Sthubbar (talk) 02:30, 26 September 2013 (UTC)
II, and please continue the quote "Consequently, the published recommendations for the management of OA require revision." This reference clearly says that the disagree with these guidelines and they should, and are being updated. It should be very clear that the most current review shows that these old recommendations are not supported by the reference.Sthubbar (talk) 02:38, 26 September 2013 (UTC)
Doc James, I think some more confusing going around. You are right, PMID 22293240 is from 2012 and a great review from my perspective as their conclusions are "it represents a viable option for the management of OA" and "we should consider the use of glucosamine as a combination therapy with other drugs or other nutraceuticals" as stated above. They also stress that the existing guidelines should be updated when they say " the published recommendations for the management of OA require revision." They clearly concluded the current recommendations are out of date and this 2012 is more authoritative. From this date, you decide to quote the 2008 NICE guidelines which this 2012 article clearly says are out of date. Please remove the NICE reference and reframe this reference a supporting the us of glucosamine.Sthubbar (talk) 03:33, 26 September 2013 (UTC)
- But it doesn't support it. It says "At this time, glucosamine hydrochloride cannot be recommended based on the available clinical data. However, there are no clear indications that the effects of the two formulations can be distinguished from each other in terms of biological activity, posology or pharmacokinetics." (emphasis added) and "Therefore, the question of the benefit of glucosamine treatment remains largely unanswered." but also, "glucosamine has low and rare adverse effects". In summary, this article is saying there is no evidence to recommend its use, but because it doesn't appear harmful, it's safe to try it, and if you feel it works for you, great. This is hardly a source that supports it.
Zad68
04:35, 26 September 2013 (UTC)
Zad, we seem to have to go over this point many times. Hydrochloride != Sulfate. Of course they say Hydrochloride doesn't work. You are doing original research when you conclude "this article is saying there is no evidence to recommend its use" and you specifically contradict the conclusion further down in the Conclusion section. Again, I quote the ultimate conclusion above "[glucosamine]it represents a viable option for the management of OA." Period, end of story. This "viable option" is 100% against your original research of "no evidence to recommend its use." Sulfate and Hydrochloride have compelling evidence that they have different behavior with Sulfate showing effect.Sthubbar (talk) 05:03, 26 September 2013 (UTC)
- The point is that the NICE recommendation is out of date. This reference specifically says, as quoted above, that the NICE recommendation is out of date. This reference specifically says GS is a viable option. The wiki page is using this reference to support a position that is 100% opposite of their conclusion. Their conclusion is 1) viable option 2) NICE is out of date.Sthubbar (talk) 05:05, 26 September 2013 (UTC)
- Although you state "Hydrochloride != Sulfate", Henrotin 2012 says (as I already mentioned) "there are no clear indications that the effects of the two formulations can be distinguished from each other in terms of biological activity, posology or pharmacokinetics." and they also state in their Pharmacokinetic studies section, "Glucosamine hydrochloride and sulfate are identical from a chemical and structural point of view. Indeed, both glucosamine sulfate and hydrochloride dissociate in the acidic milieu of the stomach, resulting in the release of glucosamine itself." There's nothing you've provided in your responses that is based in what the article actually says to allow a conclusion to be drawn other than what I stated above.
Of the guidelines discussed in Henrotin 2012 (PMID 22293240), ACR is very old (2000) and the EULARs are old (2003, 2005). NICE and the OARSIs are more up to date, with NICE published February 2008 and the OARSIs dated 2007, 2007, and the latest published 2010 says "update of research published through January 2009". NICE guidelines are influential and authoritative enough that I think we should keep mention of it in the article, and when the new NICE guidelines come out in 2014 we can update this article then. The point of Henrotin 2012's discussion of the evidence base and guidelines is that the guidelines are trending away from recommending glucosamine because the evidence is lacking. They aren't even saying it definitely does not work; rather they are saying there isn't a sufficiently strong evidence base indicating that it does work to make a positive recommendation.
But, I hear your point that those sources are aging; as a compromise how about we mention the dates of the OARSI and NICE guidelines in the article? Proposed content change is: "The Osteoarthritis Research Society International recommends in their 2007-10 guidelines that glucosamine be discontinued if no effect is observed after six months and the National Institute of Clinical Excellence no longer recommends its use in their 2008 guideline."
Zad68
13:49, 26 September 2013 (UTC)
- Although you state "Hydrochloride != Sulfate", Henrotin 2012 says (as I already mentioned) "there are no clear indications that the effects of the two formulations can be distinguished from each other in terms of biological activity, posology or pharmacokinetics." and they also state in their Pharmacokinetic studies section, "Glucosamine hydrochloride and sulfate are identical from a chemical and structural point of view. Indeed, both glucosamine sulfate and hydrochloride dissociate in the acidic milieu of the stomach, resulting in the release of glucosamine itself." There's nothing you've provided in your responses that is based in what the article actually says to allow a conclusion to be drawn other than what I stated above.
Zad, if you want to include the NICE study then just add a reference and leave the sentence as it is. My point is the current sentence is a gross distortion of this reference. One of the conclusions of this review is "glucosamine has low and rare adverse effects, it represents a viable option for the management of OA". Until we come up with a sentence that includes this information, I won't accept the characterization of this reference.Sthubbar (talk) 16:40, 26 September 2013 (UTC)
- ?? There seems to be some disconnect here. We already have a reference for NICE and it's already in the article, and cited appropriately. I was just trying to work with you on the dates, but it sounds like you are now OK with the sources that are cited and their ages, correct? If so, great, we can move forward past that.
The first and more important thing Henrotin states is that glucosamine "cannot be recommended based on the available clinical data" and Henrotin takes pains to point out that there are no important pharmacokinetic differences between the two preparations. I stated all this previously. Making sure you take into account that Henrotin states that the evidence is insufficient to recommend glucosamine, what is your proposal to summarize what the source states?
Zad68
20:08, 26 September 2013 (UTC)
Zad68, where is the NICE reference? I only see the reference to this 2012 review which is not NICE. I have put the NICE URL above and I'll search again in the article and if I can't find it will put it in the page. Here is my suggestion and I'll go ahead and make the update. "Blah blah, NICE doesn't recommend glucosamine[NICE article reference]. Despite difficulty in determining the efficacy of glucosamine it remains a viable treatment option.[This 2012 reference]" We agree, right? The article may still question the efficacy of glucosamine, but they clearly say it is a "viable treatment option".Sthubbar (talk) 01:43, 28 September 2013 (UTC)
- Zad68, you are right, there already was a reference to NICE and I put that reference to the statement about NICE not recommending glucosamine. If any reverts that change with any comments like "better before". I might die laughing on the floor. How can putting a reference that is NOT the study be "better" than the actual study?! Ok, then I added the sentence saying that despite the difficulty of determining the efficacy it is still a viable treatment option.Sthubbar (talk) 01:50, 28 September 2013 (UTC)
How can GH<TM<=GS and GH=GS?!
In reference to PMID 22293240, who can explain the conclusions to me:
GH = Glucosamine Hydrochloride GS = Glucosamine Sulfate TM = Traditional Medicine (commonly used analgesic or nonsteroidal anti-inflammatory drugs)
GH<TM "glucosamine hydrochloride cannot be recommended based on the available clinical data"
TM<=GS "glucosamine sulfate shows an ES superior to (or at least equal to) the commonly used analgesic or nonsteroidal anti-inflammatory drugs"
GH=GS "no clear indications that the effects of the two formulations can be distinguished from each other in terms of biological activity, posology or pharmacokinetics"
Assumptions 1) TM is a recommended treatment 2) If any other treatment is equal to TM, then it is also recommended
So, how can it be that since GH is clearly not recommended, then we have to conclude it is less effective than TM, so GH<TM, and it also clearly says that GS is superior, or at a minimum equal to TM, so GS>=TM, then how in the world can GH=GS?!
At least one of the three conclusions must be wrong (I'm voting for GH=GS).Sthubbar (talk) 02:05, 28 September 2013 (UTC)
- Well, the conclusions in that review are a bit confusing, but the key point to take away is that the quality of the primary clinical studies isn't good enough to draw significant conclusions from, "based on the available clinical data". It's not really surprising: when comparing tiny effects, it's hard to tell which is smaller without huge studies. LeadSongDog come howl! 05:31, 28 September 2013 (UTC)
- LeadSongDog, I agree that the conclusions are confusing. How can you characterize the effects as "tiny" when the conclusion is that Sulfate has an ES (Effect Size) equal to or greater than analgesics or NSAIDS? Do you believe the effect of NSAIDS is tiny?Sthubbar (talk) 00:34, 29 September 2013 (UTC)
- What I believe doesn't enter into it, we use what the best sources say. The paper in question doesn't quantify the NSAID ES at all. It just compares NSAID ES to sulfate ES in one statement (in the conclusions), and there it neglects to say if it refers to ES for pain or ES for joint spacing. In earlier text it simply quantifies various ES ranges for the sulfate and for the HCl, each without reference to NSAIDS. LeadSongDog come howl! 07:11, 29 September 2013 (UTC)
- LeadSongDog, I agree that the conclusions are confusing. How can you characterize the effects as "tiny" when the conclusion is that Sulfate has an ES (Effect Size) equal to or greater than analgesics or NSAIDS? Do you believe the effect of NSAIDS is tiny?Sthubbar (talk) 00:34, 29 September 2013 (UTC)
Educational assignment
Student sandbox
No response from this editor to my query at her sandbox talk page, so I have removed the text for discussion. SandyGeorgia (Talk) 00:36, 6 November 2013 (UTC)
Removed text
The increased vulnerability of osteoarthritis in humans is potentially an evolutionary tradeoff of bipedalism. As early human ancestors evolved into bipeds, morphological changes occurred in the pelvis, hip joint and spine.Cite error: The <ref>
tag has too many names (see the help page). This resulted in the center of gravity being closer to the hip joint increasing specific vulnerability that joint. Also, genetic morphological variations that predispose some humans to OA were likely not selected against because most often, the effects of variation only substantially decrease mobility after the reproductive life stage, therefore, not impacting reproductive success. Evolutionary constraints contribute to OA because the evolution of the basic bone and cartilage joint model evolved long before Homo sapiens. The cartilage did not evolve to last to the advanced age seen in Homo sapiens. An evolutionary understanding of why humans are vulnerable to OA can help improve our understanding of the original circumstances and needs (load, range of motion, etc.) of joints. This contributes to the understanding of what possible impacts behavioral actions many have on human joints which can be applied in a clinical setting.[2]
Discussion
If we can straighten out the sourcing, the proposed text could use some (minor) copyediting, and the last few sentences in the proposed text above are more editorializing than encyclopedic in tone. SandyGeorgia (Talk) 01:21, 6 November 2013 (UTC)
- User:Madelynne Dudas who added this is in user:Sanetti's Darwinian medicine class. I am happy with this article
- Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1302/2048-0105.11.360002, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with
|doi=10.1302/2048-0105.11.360002
instead.
- Attention: This template ({{cite doi}}) is deprecated. To cite the publication identified by doi:10.1302/2048-0105.11.360002, please use {{cite journal}} (if it was published in a bona fide academic journal, otherwise {{cite report}} with
- being used as a source for the above content. The claims being made are in physiology and biology, so I see no reason that this needs to comply with Wikipedia:Identifying reliable sources (medicine) as User:SandyGeorgia asserted. It definitely is a reliable source, and while it is not the review article which SandyGeorgia requested also there would not be any existing review articles for this kind of non-medical subject matter. The article itself is quite good as it reviews a lot of previous publication on the topic. I personally see two problems in this:
- Every sentence should have a citation. On Wikipedia one never knows how content will be re-arranged, so put a citation at the end of every sentence so that the statements can always be matched to the source.
- The author of the source presents his statements as candidate theories, as so much in evolution is. I feel like this material should be presented more as worthy of belief and the views of experts in the field, and less as the certain reality. I say this only because I feel that it would better match the source if it did.
- Thanks, please respond to both my comments and Sandy's. I think with a bit of response this material could be re-integrated back into the article. Please also get feedback from your classmate here - I see that your class is reviewing each other's articles. Blue Rasberry (talk) 14:51, 20 November 2013 (UTC)
- User:Madelynne Dudas who added this is in user:Sanetti's Darwinian medicine class. I am happy with this article
I think the source is very weak. Bone Joint 360 is an obscure journal. That is not to say that there are no theories of evolutionary impact on lower limb osteoarthritis the same way there are sources for venous insufficiency and degenerative spinal disease. I would like to encourage the editor to find a stronger source in a textbook or review in an indexed journal. The current source has 42 sources, some of which might potentially be used to support this content. JFW | T@lk 14:41, 21 November 2013 (UTC)
Thank you for feedback. It was incredibly helpful. I am in the process of placing my revised text in my sandbox. Madelynne Dudas (talk) 03:54, 26 November 2013 (UTC)
Revised Text for Evolutionary Considerations
The increased vulnerability of osteoarthritis in humans is potentially an evolutionary tradeoff of bipedalism along with other relatively recent evolved traits. [3] This is represented in the prominence of osteoarthritis is a specific few joints such as the first metatarsophalangeal joint.[4] As early human ancestors evolved into bipeds, morphological changes occurred in the pelvis, hip joint and spine.[5] This resulted in the center of gravity being closer to the hip joint increasing specific vulnerability to the joint because the gait of modern Homo sapiens is more energy efficient then some recent ancestors.[6] Also, genetic morphological variations that predispose some humans to osteoarthritis were likely not selected against because most often, the effects of variation only substantially decrease mobility after the reproductive life stage, therefore, not impacting reproductive success. [7] Evolutionary constraints contribute to osteoarthritis because the evolution of the basic bone and cartilage joint model evolved long before Homo sapiens. [8]Madelynne Dudas (talk) 18:05, 2 December 2013 (UTC)
- Can you please format the refs in the same style as discussed at WP:MEDHOW. It will make it easier for us to look at the refs. Also they should generally be from the last 5 years. More than 10 years is too old. Doc James (talk · contribs · email) (if I write on your page reply on mine) 19:17, 2 December 2013 (UTC)
Removed again
Madelynne Dudas I've removed the text again; please do not re-add it without gaining consensus. Both Jmh649 and Jfdwolff have expressed concern about the sourcing. Some are very old, others are weak, and if you would please format them correctly, the rest can be more easily evaluated. You can plug the PMID into this citation filling template to get a citation template. I corrected the citations for you in the version below; please view the text in edit mode so you can understand how to cite text. SandyGeorgia (Talk) 23:25, 2 December 2013 (UTC)
Evolutionary considerations
The increased vulnerability of osteoarthritis in humans is potentially an evolutionary tradeoff of bipedalism along with other relatively recent evolved traits.[9] This is represented in the prominence of osteoarthritis is a specific few joints such as the first metatarsophalangeal joint.[9] As early human ancestors evolved into bipeds, morphological changes occurred in the pelvis, hip joint and spine.[10] This resulted in the center of gravity being closer to the hip joint increasing specific vulnerability to the joint because the gait of modern Homo sapiens is more energy efficient then some recent ancestors.[11] Also, genetic morphological variations that predispose some humans to osteoarthritis were likely not selected against because most often, the effects of variation only substantially decrease mobility after the reproductive life stage, therefore, not impacting reproductive success.[12] Evolutionary constraints contribute to osteoarthritis because the evolution of the basic bone and cartilage joint model evolved long before Homo sapiens.[13]
- ^ . PMID 20232616.
{{cite journal}}
: Check|pmid=
value (help); Cite journal requires|journal=
(help); Missing or empty|title=
(help) - ^ Cite error: The named reference
Hopgervorst
was invoked but never defined (see the help page). - ^ Hutton, C.W. (1987). “Generalized Osteoarthritis: An Evolutionary Problem?” The Lancet 329(8548): 1463–1465. PMID: 2885455.
- ^ Hutton, C.W. (1987). “Generalized Osteoarthritis: An Evolutionary Problem?” The Lancet 329(8548): 1463–1465. PMID: 2885455.
- ^ Hogervorst, T., Bouma, HW, de Vos, J.(2009). “Evolution of the hip and pelvis.” Acta Orthop Suppl. 80(336):1-39.PMID: 19919389.
- ^ Wang, W., Crompton,R., & Li, Y. (2003). “Energy transformation during erect and ‘bent-hip, bent-knee’ walking by humans with implications for the evolution of bipedalism.” Journal of Human Evolution 44(5): 563-579. PMID: 12765618.
- ^ van der Kraan, P., van den Berg, W. (2008). “Osteoarthritis in the context of ageing and evolution: Loss of chondrocyte differentiation block during ageing.” Ageing Research Reviews 7(2):106–113. PMID: 18054526.
- ^ Taylor MP, Wedel MJ. (2013). “The effect of intervertebral cartilage on neutral posture and range of motion in the necks of sauropod dinosaurs.” PLoS One 8(10): e78214. PMID: 24205163.
- ^ a b Hutton CW (1987). "Generalised osteoarthritis: an evolutionary problem?". Lancet. 1 (8548): 1463–5. PMID 2885455.
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ignored (help)CS1 maint: multiple names: authors list (link) - ^ Wang WJ, Crompton RH, Li Y, Gunther MM (2003). "Energy transformation during erect and 'bent-hip, bent-knee' walking by humans with implications for the evolution of bipedalism". J. Hum. Evol. 44 (5): 563–79. PMID 12765618.
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ignored (help)CS1 maint: multiple names: authors list (link) - ^ van der Kraan PM, van den Berg WB (2008). "Osteoarthritis in the context of ageing and evolution. Loss of chondrocyte differentiation block during ageing". Ageing Res. Rev. 7 (2): 106–13. doi:10.1016/j.arr.2007.10.001. PMID 18054526.
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ignored (help) - ^ Taylor MP, Wedel MJ (2013). "The effect of intervertebral cartilage on neutral posture and range of motion in the necks of sauropod dinosaurs". PLoS ONE. 8 (10): e78214. doi:10.1371/journal.pone.0078214. PMC 3812996. PMID 24205163.
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