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.