Letters to the Editor  |   July 2009
Author Affiliations
  • Mark E. Rosen, DO
    The Cranial Academy, Indianapolis, Ind
Article Information
Medical Education / Osteopathic Manipulative Treatment / Osteopathic Cranial Manipulative Medicine
Letters to the Editor   |   July 2009
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 380-381. doi:
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 380-381. doi:
To the Editor:  
Osteopathy in the cranial field provides an important contribution to the practice of medicine as a clinical application of osteopathic principles. The educational rigor, knowledge base, and skill development required to practice osteopathy in the cranial field are unparalleled. The osteopathic medical profession sets standards and carries responsibilities that are unsurpassed by other kinds of practitioners of manual techniques. 
So it was with great interest that I read the original contribution on “cranial palpation pressures” by Rafael Zegarra-Parodi, DO (England), MEd, and colleagues.1 I was initially very pleased to see a cover article in the JAOA discussing palpation of cranial anatomic function. Research is essential in providing evidence-based support for the practice of osteopathic medicine. 
However, the article by Zegarra-Parodi et al1 is fraught with problems. 
Particularly problematic is the article's opening statement, “Cranial manipulation, or craniosacral therapy, is a widely practiced technique used by osteopathic physicians, foreign-trained osteopaths, chiropractors, physical therapists, and massage therapists.”1 Equating all manual practice regardless of its origin provides insurance companies with a rationale for refusing reimbursement of osteopathic physician services. Furthermore, publishing this article in the JAOA implies an American Osteopathic Association endorsement of equal status for all practitioners who may place their hands on the body. 
As Brian F. Degenhardt, DO,2 noted in his accompanying editorial, 40 minutes of training is profoundly insufficient as preparation for developing examiner reliability in palpatory techniques. 
As a research fellow in osteopathic manipulative medicine while an osteopathic medical student at Michigan State University College of Osteopathic Medicine in East Lansing, I spent many months and countless hours working with William L. Johnston, DO, in interexaminer reliability studies. We actively calibrated our touch and refined our palpatory tests for the specific purpose of ensuring palpatory synchronization. We did not begin our research study until we were certain that we were capable of attending to identical palpatory cues in the testing environment. 
Given the limited preparation provided for each examiner in the study by Zegarra-Parodi et al,1 it is understandable that differences in findings between “trained” and “untrained” examiners could not be demonstrated. 
As Dr Degenhardt2 also indicated, it is inappropriate to define a standardized pressure in the application of osteopathic manipulative treatment (OMT). 
Effective practice of OMT requires an application of forces that match inherent forces within each individual patient. As the therapeutic process is engaged, the inherent forces within the patient will fluctuate, thus requiring the operator to constantly moderate applied forces. This is the very reason that extensive training is essential for the effective practice of osteopathy in the cranial field. 
The fundamental set of assumptions underlying the research protocol used by Zegarra-Parodi et al1 bears little resemblance to the actual practice of osteopathic medicine. 
Further, the assumptions and the quality of the research protocol used by Zegarra-Parodi and colleagues1 call into question the appropriateness of this article. I would appreciate greater rigor being exerted in the future by the JAOA editors in the vetting of materials for publication. 
Zegarra-Parodi R, de Chauvigny de Blot P, Rickards LD, Renard E-O. Cranial palpation pressures used by osteopathy students: effects of standardized protocol training. J Am Osteopath Assoc. 2009;109:79-85. Available at: Accessed May 19, 2009.
Degenhardt BF. New horizons for research and education in osteopathic manipulative medicine [editorial]. J Am Osteopath Assoc. 2009;109:76-78. Available at: Accessed May 19, 2009.