Letters to the Editor  |   July 2009
Author Affiliations
  • Luke D. Rickards, MOsteo (Australia)
    Research Department, Centre Européen d'Enseignement Supérieur de l'Ostéopathie, Paris and Lyon, France
    Adelaide, Australia
Article Information
Osteopathic Manipulative Treatment / Professional Issues / Osteopathic Cranial Manipulative Medicine / OMT in the Laboratory
Letters to the Editor   |   July 2009
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 381. doi:
The Journal of the American Osteopathic Association, July 2009, Vol. 109, 381. doi:
We have read with great interest the four letters regarding our February article.1 We are encouraged by readers' lack of criticism directed at the actual methodology of our study or at our interpretation of the results. For constructive discussion concerning the subject of our article,1 we refer readers to the excellent editorial by Brian F. Degenhardt, DO,2 in the same edition of JAOA—The Journal of the American Osteopathic Association. 
As scientists, we welcome the submission of any scientific data that would help us to refine our work. Unfortunately, the authors of all four letters have neglected to include references to such data, so we must conclude that they are unaware of any literature that would support their assertions. 
Concern was raised in all four letters regarding the use of manual techniques of osteopathic origin within nonosteopathic professions. We share this concern and lament that manual techniques of osteopathic origin are currently being used by chiropractors, physical therapists, and massage therapists. We did, however, also note in our article1 that these techniques are used by both types of osteopathic practitioners (ie, osteopaths and osteopathic physicians), as defined by the World Health Organization's (WHO) draft report Guidelines on Basic Training and Safety in Osteopathy.3 Although the opening statement of our article1 appears to have been a primary motivating factor for the authorship of the letters, at no point in the article did we imply that osteopathic manipulative procedures should be divorced from the osteopathic paradigm. 
We remind readers that the aim of our study was to assess the effectiveness of training methods typically used in imparting the technical parameters of manual diagnosis and therapy to osteopathy students. We did not attempt to demonstrate that a single magnitude of palpatory pressure is sufficient for all clinical applications of osteopathic cranial manipulation. Providing osteopathy students with an objective “benchmark” for some parameters of a manual technique should not be confused with advocacy of rigid specifications for the application of that manual technique. 
We agree that extensive clinical experience may be necessary to provide optimal manual treatment. However, we consider it plausible that the use of an objective reference standard for biomechanical palpatory parameters may aid and accelerate the transmission of correct application of manual techniques to osteopathy students. The claim that “One cannot measure...a quantifiable amount of pressure to use for a manipulative technique,” as Dr Abu-Sbaih makes, is obviously false, since we have clearly demonstrated in our study1 that this is possible. The usefulness of such measurements within educational and clinical settings remains to be examined, but we strongly disagree with the argument that research in this area cannot yield benefits for the development of osteopathic philosophy and practice. 
Regarding claims that the clinical efficacy of osteopathic cranial manipulation is dependent on patient-specific modifications in palpatory pressure, we suggest that these claims need to be demonstrated by high-quality clinical research before being made.4 Currently, no substantive evidence exists to show that osteopathic cranial manipulation is clinically effective for any condition.5-8 Anecdotal reports and unsupported assertions, such as those included in the four letters, are entirely unsatisfactory for substantiating the clinical efficacy, or the precise role, of individualized alterations in palpatory pressure during osteopathic cranial manipulation. 
We would like to thank the editors of JAOA—The Journal of the American Osteopathic Association for acknowledging the potential applicability of our research to osteopathic medicine and for publishing our article1 after it met full compliance with the JAOA's rigorous peer-review process. 
 Editor's Note: The JAOA received numerous letters on the February publication of “Cranial palpation pressures used by osteopathy students: effects of standardized protocol training” by Rafael Zegarra-Parodi, DO (England), and colleagues (2009;109:79-85)—in fact, the most on one piece in more than 10 years. The JAOA's editors appreciate the passion many of our readers have for osteopathy in the cranial field—and we thank them for the opportunity to address their concerns.
 First, we would like to reassure readers that the article by Zegarra-Parodi et al was reviewed by three world-class experts in the topic area.
 In addition, we would like to reiterate on behalf of the authors that the study investigated a technique—not a treatment. In the first sentence of the fifth paragraph on page 82, Zegarra-Parodi et al wrote: “[Primary respiratory mechanism] `entrainment' models propose that palpation of expression of the [primary respiratory mechanism] at varying levels is dependent on a complex interaction of multiple biological oscillators between the patient and the practitioner.” Nevertheless, the purpose of the study was to determine whether training can minimize variation in palpatory pressure, not to see if every student used the same force on the same patient.
 While it is true that a European-trained osteopath is not the same as an osteopathic physician trained in the United States, both practitioners follow the same basic tenets and use the same manual methods.
 With regard to the importance of demonstrating reduced interoperator variation, though many readers believe that the authors' direction of inquiry is incorrect, others do not agree with this assumption about the study's scientific validity.
 We and the authors acknowledge that the study has flaws. Several limitations are addressed by the authors on page 84 of that study. Others are discussed by Brian F. Degenhardt, DO, our guest editorialist for that issue (2009;109:76-78). Nevertheless, the JAOA will not be retracting the article by Zegarra-Parodi and coauthors.
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 June 8, 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 June 8, 2009.
Directories. Osteopathic International Alliance Web site. Available at: Accessed June 8, 2009.
Moran RW. Osteopathy in the cranial field—moving towards evidence for causality and effectiveness [editorial]. Int J Osteopath Med. 2005;8:79-80.
Green C, Martin CW, Bassett K, Kazanjian A. A systematic review of craniosacral therapy: biological plausibility, assessment reliability and clinical effectiveness. Complement Ther Med. 1999;7:201-207.
Hartman SE, Norton JM. A review of King HH and Lay EM, “Osteopathy in the cranial field,” in Foundations for Osteopathic Medicine, 2nd ed. Sci Rev Alt Med. Fall/winter 2004-2005;8:24-28.
Downey PA, Barbano T, Kapur-Wadhwa R, Sciote JJ, Siegel MI, Mooney MP. Craniosacral therapy: the effects of cranial manipulation on intracranial pressure and cranial bone movement. J Orthop Sports Phys Ther. 2006;36:845-853.
Hartman SE. Cranial osteopathy: its fate seems clear. Chiropr Osteopath. 2006;14:10. Available at: Accessed June 8, 2009.