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Dubious Aspects of Osteopathy

Stephen Barrett, M.D.

Osteopathic physicians (DOs) are the legal equivalents and, in most cases, are the professional equivalents of medical doctors. Although most DOs offer competent care, the percentage involved in dubious practices appears to be higher than that of medical doctors. For this reason, before deciding whether to use the services of a DO it is useful to understand osteopathy's history and the practical significance of its philosophy.

Cultist Roots

Andrew Taylor Still, MD (1828-1917) originally expressed the principles of osteopathy in 1874, when medical science was in its infancy. A medical doctor, Still believed that diseases were caused by mechanical interference with nerve and blood supply and were curable by manipulation of "deranged, displaced bones, nerves, muscles—removing all obstructions—thereby setting the machinery of life moving." His autobiography states that he could "shake a child and stop scarlet fever, croup, diphtheria, and cure whooping cough in three days by a wring of its neck." [1]

Still was antagonistic toward the drug practices of his day and regarded surgery as a last resort. Rejected as a cultist by organized medicine, he founded the first osteopathic medical school in Kirksville, Missouri, in 1892.

As medical science developed, osteopathy gradually incorporated all its theories and practices [2]. Today, except for additional emphasis on musculoskeletal diagnosis and treatment, the scope of osteopathy is identical to that of medicine. The percentage of practitioners who use osteopathic manipulative treatment (OMT) and the extent to which they use it have been falling steadily.

Osteopathy Today

There are 20 accredited colleges of osteopathic medicine and about 44,000 osteopathic practitioners in the United States [3]. Admission to osteopathic school requires three years of preprofessional college work, but almost all of those enrolled have a baccalaureate or higher degree. The doctor of osteopathy (DO) degree requires more than 5,000 hours of training over four academic years. The faculties of osteopathic colleges are about evenly divided between doctors of osteopathy and holders of PhD degrees, with a few medical doctors at some colleges. Graduation is followed by a one-year rotating internship at an approved teaching hospital. Specialization requires two to six additional years of residency training, depending on the specialty. A majority of osteopaths enter family practice.

The American Osteopathic Association (AOA) recognizes more than 60 specialties and subspecialties. AOA membership is required for specialty certification, which forces some practitioners to belong to the AOA even though they do not approve of the organization's policies. Since 1985, osteopathic physicians have been able to obtain residency training at medical hospitals, and the majority have done so. Since 1993, DOs who completed osteopathic residencies have also been eligible to join the American Academy of Family Practice, which had previously been restricted to MDs or DOs with training at accredited medical residencies [3].

Osteopathic physicians are licensed to practice in all states. The admission standards and educational quality are a bit lower at osteopathic schools than they are at medical schools. I say this because the required and average grade-point averages (GPAs) and the Medical College Admission Test (MCAT) scores of students entering osteopathic schools are lower than those of entering medical students [4,5]—and the average number of full-time faculty members is nearly ten times as high at medical schools (714 vs. 73 in 1994) [5]. In addition, osteopathic schools generate relatively little research, and some have difficulty in attracting enough patients to provide the depth of experience available at medical schools [6]. However, as with medical graduates, the quality of individual graduates depends on how bright they are, how hard they work, and what training they get after graduation. Those who diligently apply themselves can emerge as competent.

In January 1995, a one-page questionnaire was mailed to 2,000 randomly selected osteopathic family physicians who were members of the American College of Osteopathic Physicians. About half returned usable responses. Of these, 6.2% said they treated more than half of their patients with OMT, 39.6% said they used it on 25% or fewer of their patients, and 32.1% said they used OMT on fewer than 5% of their patients. The study also found that the more recent the date of graduation from osteopathic school, the lower the reported use [7].

The percentages of DOs involved in chelation therapy, clinical ecology, orthomolecular therapy, homeopathy, ayurvedic medicine, and several other dubious practices appear to be higher among osteopaths than among medical doctors. I have concluded this by inspecting the membership directories of groups that promote these practices and/or by comparing the relative percentages of MDs and DOs. listed in the Alternative Medicine Yellow Pages [4] and HealthWorld Online's Professional Referral Network. The most widespread dubious treatment among DOs appears to be cranial therapy, an osteopathic offshoot described below.

AOA Hype

Many observers believe that osteopathy and medicine should merge. But osteopathic organizations prefer to retain a separate identity and have exaggerated the minor differences between osteopathy and medicine in their marketing. According to a 1987 AOA brochure, for example: (a) osteopathy is the only branch of mainstream medicine that follows the Hippocratic approach, (b) the body's musculoskeletal system is central to the patient's well-being, and (c) OMT is a proven technique for many hands-on diagnoses and often can provide an alternative to drugs and surgery [9]. A 1991 brochure falsely claimed that OMT encourages the body's natural tendency toward good health and that combining it with all other medical procedures enables DOs to provide "the most comprehensive treatment available." [10] Such statements are consistent with a 1992 AOA resolution that defines osteopathy as:

A system of medical care with a philosophy that combines the needs of the patient with current practice of medicine, surgery, and obstetrics and emphasis on the interrelationships between structure and function and an appreciation of the body's ability to heal itself [11].

A 1994 AOA resolution describes osteopathy as "a complete system of health care and as such is much more holistic than medicine in the classic sense." [11].

The American Osteopathic Association's web site glorifies Andrew Still and asserts that osteopathic medicine has a unique philosophy of care because "DOs take a whole-person approach to care and don't just focus on a diseased or injured part." I consider it outrageous to imply that osteopathic physicians are the only ones who regard their patients as individuals or who provide comprehensive care or pay attention to disease prevention. Another AOA web document states:

Osteopathic physicians frequently assess impaired mobility of the musculoskeletal system as that system encompasses the entire body and is intimately related to the organ systems and to the nervous system. Using anatomical relationships between the musculoskeletal and these organ systems, osteopathic physicians diagnose and treat all organ systems [12].

This statement strikes me as the same sort of baloney chiropractors use to suggest that somehow their attention to the spine will have positive effects on all body processes. Spinal manipulation may produce pain relief in properly selected cases of low back pain [13]. However, OMT has no proven effect on people's general health.

Chelation Therapy

Chelation therapy is a series of intravenous infusions containing EDTA and various other substances. Proponents claim it is effective against atherosclerosis and many other serious health problems. However, no controlled trial has shown that chelation therapy can help any of them. Chelation therapy with EDTA is one of several legitimate methods for treating cases of lead poisoning, but the protocol differs from that used inappropriately for other conditions. To its credit, the AOA has adopted a negative position statement on chelation therapy:

WHEREAS, chelation therapy utilizing calcium disodium edetateis currently labeled by the Food and Drug Administration and recognized by most physicians as medically acceptable only in the management of acute or chronic heavy metal poisoning; now, therefore, be it

RESOLVED, that pending the results of thorough, properly controlled studies, the American Osteopathic Association does not endorse chelation therapy as useful for other than its currently approved and medically accepted uses. Adopted 1985, revised and reaffirmed, 1990, 1995 [11].

The 1998 member referral list of the American College for Advancement of Medicine (ACAM) , the principal group promoting chelation therapy, identifies about 400 MD members and 121 DO members who list chelation therapy as a specialty. These numbers strongly suggest that the percentage of osteopathic physicians doing chelation therapy is about four or five times as high as the percentage of medical doctors doing it. Curiously, Ronald A. Esper, DO, of Erie, Pennsylvania, who was AOA's president in 1998, is an ACAM member and does chelation therapy.

Cranial Therapy

Practitioners of "cranial osteopathy," "craniosacral therapy," "cranial therapy," and similar methods claim that the skull bones can be manipulated to relieve pain (especially of the jaw joint) and remedy many other ailments. They also claim that a rhythm exists in the flow of the fluid that surrounds the brain and spinal cord and that diseases can be diagnosed by detecting aberrations in this rhythm and corrected by manipulating the skull. Most practitioners are osteopaths, massage therapists, chiropractors, dentists, or physical therapists.

Cranial osteopathy's originator was osteopath William G. Sutherland, who published his first article on this subject in the early 1930s. Today's leading proponent is John Upledger, DO, who operates the Upledger Institute of Palm Beach Gardens, Florida. An institute brochure states:

CranioSacral Therapy is a gentle, noninvasive manipulative technique. Seldom does the therapist apply pressure that exceeds five grams or the equivalent weight of a nickel. Examination is done by testing for movement in various parts of the system. Often, when movement testing is completed, the restriction has been removed and the system is able to self-correct [14].

Another Upledger brochure states:

The rhythm of the craniosacral system can be detected in much the same way as the rhythms of the cardiovascular and respiratory systems. But unlike those body systems, both evaluation and correction of the craniosacral system can be accomplished through palpation.

CranioSacral Therapy is used for a myriad of health problems, including headaches, neck and back pain, TMJ dysfunction, chronic fatigue, motor-coordination difficulties, eye problems, endogenous depression, hyperactivity, attention deficit disorder, central nervous system disorders, and many other conditions [15].

The Upledger Institute also advocates and teaches "visceral manipulation," a bizarre treatment system whose practitioners are claimed to detect "rhythmic motions" of the intestines and other internal organs and to manipulate them to stimulate healing [16].

British osteopath Robert Boyd, who developed a variant he calls Bio Cranial Therapy, claims that it is "extremely helpful" for "chronic fatigue syndrome (CFS); varicosity and varicose ulcers; tinnitus; bladder prolapse; prostate disorders; Meniere's syndrome; cardiovascular disturbances including hypertension, angina; skin disorders (psoriasis, eczema, acne etc); female disorders (dysmenorrhoea, PMS (PMT), menorrhagia etc); arthritis and rheumatic disorders; fibromyalgia and heel spurs; gastric disorders (hiatus hernia, ulceration, colitis); asthma and a range of bronchial disorders including bronchiectasis and emphysema."

The theory underlying craniosacral therapy is erroneous because the cranial bones fuse by the end of adolescence and no research has ever demonstrated that manual manipulation can move the individual bones [17]. Nor do I believe that "the rhythms of the craniosacral system can be felt as clearly as the rhythms of the cardiovascular and respiratory systems," as is claimed by another Upledger Institute brochure [18]. The brain does pulsate, but this is exclusively related to the cardiovascular system [19]. In a recent study, three physical therapists who examined the same 12 patients diagnosed significantly different "craniosacral rates," which is the expected outcome of measuring a nonexistent phenomenon [20].

Osteopathic web sites that espouse cranial therapy can be located by using Google's Advanced Search to lok for "cranial osteopathy" and "Sutherland." The most illuminating source I have found (which no longer appears to be posted) was The Cranial Letter, published quarterly by the Cranial Academy, a component society of the American Academy of Osteopathy. The Summer 1993 issue stated that the Cranial Academy had 989 members. Other issues contained case reports stating that cranial therapy can cause knee pain to disappear within a week (Summer 1992), cure hives (Summer 1993), improve the mental condition of Down syndrome patients (May 1995), and correct crossed eyes (May 1996).

The percentage of osteopaths using cranial therapy is not high, but it apppears to be deeply entrenched within the profession. Many of the osteopathic colleges teach it, and the American Osteopathic Association treats it as legitimate. At least 15 of the 88 items listed in the AOA's 1996 list of "Osteopathic Literature in Print" were written by Sutherland, Upledger, or others who appear to advocate cranial therapy [21]. And in 1998, the AOA's continuing education calendar listed a 40-hour cranial osteopathy course it cosponsored with the American Academy of Osteopathy, which is a practice affiliate of the AOA.

In 2002, two basic science professors at the University of New England College of Osteopathic Medicine concluded:

Our own and previously published findings suggest that the proposed mechanism for cranial osteopathy is invalid and that interexaminer (and, therefore, diagnostic) reliability is approximately zero. Since no properly randomized, blinded, and placebo-controlled outcome studies have been published, we conclude that cranial osteopathy should be removed from curricula of colleges of osteopathic medicine and from osteopathic licensing examinations [17].

The Bottom Line

I believe that the American Osteopathic Association is acting improperly by exaggerating the value of manipulative therapy and by failing to denounce cranial therapy. If you wish to select an osteopathic physician as your primary-care provider, your best bet is to seek one who: (a) has undergone residency training at a medical hospital; (b) does not assert that osteopaths have a unique philosophy or that manipulation offers general health benefits; (c) either does not use manipulation or uses it primarily to treat back pain; and (d) does not practice cranial therapy.

AOA Protests

On January 23, 1998, I received a letter from the AOA's law firm objecting to certain passages in a previous version of this article [22]. Since that time, I have clarified some of the points they raised and added additional information and references. I also invited the AOA to submit a letter for posting and further discussion. Through their attorney, they agreed to do so, but none has arrived so far.

For Additional Information

Reader Comments

An osteopathic student complained about my criticism of the misleading statements the AOA makes about OMT on its web site:

The AOA is not reflective of the majority of osteopathic physicians. To begin with, if one ever hopes to achieve a leadership position in the AOA, one must complete both an osteopathic internship and an osteopathic residency, this effectively eliminates somewhere around 70% of DOs (at least that's the figure tossed around this campus). The remaining 30% of DOs unfortunately includes those who make many questionable claims about OMT. It also includes many excellent physicians. The DOs who continue to make these claims are a very vocal minority; most of us become a little embarrassed when we read this sort of thing.

I replied: I would suggest that you and your future colleagues who think that the AOA is making deceptive claims bring pressure on the AOA because it is the only publicly identified spokesperson you seem to have.

Another osteopathic student commented:

I am greatly impressed by your web site. I found out about it from one of my Biochemistry professors who highly recommended it. (I am a first year student.) I am glad to see that you address some of my (and many of my classmates) concerns about the promotion of osteopathy by the AOA in your article. My class has had the usual slogans and propaganda, like "Osteopaths treat the patient not the disease," etc. (implying that the "allopaths" don't, of course) thrown at us from day one. Two members of my immediate family are M.D.'s, and they both find the not-so-subtle disparaging of allopathic medicine by the AOA and the hard-core osteopathic physicians rather amusing.

Another osteopathic student commented:

First and foremost, thank you for your vital and honest web site that I believe helps people navigate the legitimate as well as the questionable modalities available in health care today. With more acceptance of alternative medicine today, it is essential to have a source that holds practitioners accountable to the scientific method.

The following is my assessment of my fist year of osteopathic medical school. Before I begin, I want to make it clear that I believe most D.O.s to be dedicated and competent practitioners who are slightly embarrassed by a sub-section of the profession that overstate the value of OMM and underutilize the methods of modern medicine.

Before entering medical school I was a practicing physician assistant. Even as a top student in PA school I was rejected by all of the allopathic medical schools that I applied to. Because I was accepted to an osteopathic program, I feel that I owe the osteopathic community a debt of gratitude for recognizing my potential to be a great physician.

Within the first few weeks of the commencement of my training, I became more and more concerned with the lack of consideration for basic scientific principles. I was rather shocked when in OMM lab I found myself holding my hands inches above another students abdomen attempting to feel her "energy pulsations." I was amazed at the lengths the Osteopathic faculty would go to explain why data for the efficacy of OMM was so dismal. There were some truly paranoid responses to politely worded inquiries concerning lack of evidence in the literature for osteopathy’s benefits.

I find it disconcerting that I am graded on accurately diagnosing an "inhaled rib" or a slightly "rotated" vertebral body when AOA funded studies involving inter-operator reliability of residency trained OMM specialists can't achieve a significant kappa score.

I can draw more parallels to religion than to medical science in continuing to teach material that has failed to pass muster in controlled clinical studies. I believe that the osteopaths regard A.T. Still so much like a deity that they are unable to disregard any of his 150-year-old notions when they prove unreliable. I am not here to say that no single part of osteopathy is useful in some application; I am simply commenting on my observation that in an attempt to justify a completely separate branch of medicine, the osteopathic community has lost its objectivity.  Osteopaths are so focused on resisting the merging of osteopathy with the mainstream of medical practice that they are quickly losing their credibility as reasonable scientists. Sadly, this sentiment is reflected in the last words of A.T. Still before his death: “Keep it pure boys, Keep it pure.”

A former osteopathic medical school faculty member wrote:

I spent 12 years teaching basic sciences and 7 years as an associate dean at the an osteopathic medical school. However, since the school's faculty came from institutions throughout the United States, I doubt that what I observed differed much from the situation at other osteopathic schools.

Students carried a heavy curriculum in osteopathic manipulative therapy (OMT), beginning in their freshman year. The department of manipulative medicine was completely segregated from the other departments, both in principles and in practice. The osteopathic faculty members in the standard medical departments neither practiced nor taught OMT. Nor did the OMT faculty practice or teach the standard forms of medicine. It was as if OMT was a freestanding form of health care—one that, unlike other departments, was not necessarily bound by scientific foundations. Being a basic science researcher, I have made attempts to set up an animal model to objectively test the claim that certain harmful forms of sympathetic nerve traffic could be altered by spinal OMT. However, I never received any support from the osteopathic faculty in seeing such a study completed. The general attitude of the osteopathic manipulation physicians was, "since we already know it works, why should we bother with proving it."

Cranial therapy was a large component of the manipulative medicine department, both for patient care as well as for teaching the medical students. Interestingly, while the other faculty accepted most forms of OMT even though they did not use them, they did not endorse the use of cranial therapy. Indeed, I heard many criticisms of the practice by the non-OMT faculty. Their objections were the same as mentioned on Quackwatch—that the cranial bones fuse early in infancy, after which no motion of these bones takes place. As you indicate, the alleged sensing of such motion forms the heart of cranial therapy.

I have never heard any attempt by an OMT practitioner to offer a tenable defense to such criticism. To me it almost seemed as if the OMT practitioner felt that the practice could not be defended with ordinary logic since its basis lay somewhere in the metaphysical and that only their gifted hands were able to "sense" the cranial motion.

But the seemingly metaphysical did not stop with the practice of cranial therapy. I know of one case in which a student with an undiagnosed illness consulted one of her OMT mentors who concluded that she had "a "hole in [her] aura."

David E. Jones, Ph.D.

An osteopathic physician in postgraduate training at a university medical center wrote:

I have found my osteopathic school training to be quite equal to that given to my great allopathic colleagues. One of the things I did find disconcerting in my training is what you have pointed out on your site. Osteopathic physicians in training are bombarded with the views that A.T. Still was some kind of god. Most of the people in my class pretty much saw through this and concentrated on the positive aspects of our medical training. I continue to be dismayed at the attitude of the AOA in maintaining a "separate but equal" status for D.O.s. This smacks of an "us versus them" mentality which most mature people have little time for. I and a number of other D.O. colleagues believe that it is time to merge the professions into one cohesive medical discipline. This would allow us to concentrate on caring for our patients with proven modalities as well as produce a stronger lobby for the real danger in medicine: quackery.

Another osteopathic physician wrote:

I just read your article at quackwatch.com regarding the Osteopathic profession. You are, obviously, ill-informed. It's too bad there are still allopaths like yourself who poke fun at our esteemed profession and who do not truly understand how the body works and how healing can be achieved, from within, through proper alignment of the bones, joints, blood vessels, and nerves. Perhaps further research and an open mind would serve you better.

An osteopathic physician from Texas wrote:

ANYONE IGNORANT ENOUGH TO QUESTION THE BENEFITS OF MANIPULATION THERAPY IN 1999 SHOULD HANG THEMSELVES IN THEIR UTILITY CLOSET. 95% OF DOCTORS THAT PRACTICE CHELATION THERAPY ARE M.D.s. CHELATION THERAPY IS 85-95% EFFECTIVE IN ALL PATIENTS THAT TAKE A FULL COURSE OF THERAPY. WHOEVER THE STUPID MOTHERFUCKER IS THAT MADE THIS WEB PAGE SUCKS DICKS AND DESERVES TO DIE OF THROAT CANCER. PLEASE USE ALL MAINSTREAM METHODS TO ATTEMPT TO CURE THE ESOPHAGEAL CANCER I HAVE JUST WISHED ON YOU. I TRULY HOPE THEY HAVE TO REMOVE YOUR MANDIBLE AFTER YOUR RADIATION THERAPY. DIE MOTHERFUCKER!!!!!

Another osteopathic physician responded to the above letter:

I am a double boarded D.O. who completed an M.D. residency. I have never practiced manipulation and agree with much on your web site regarding osteopathy. I am profoundly embarrassed by the above letter from an "Osteopathic Physician in Texas." I would hope that the author is not really a physician, but I fear that he is because of some of his statements. The letter is very inflammatory and does little to expose the frauds of "cranial therapy" and other outlandish practices. If possible, could you consider removing the letter? I feel discussion is needed and the letter will simply drive people away from meaningful discussion.

I replied: Thanks for your note. It's always nice to hear from a rational D.O. The writer identified himself and was listed in the AOA directory. I posted it because most responses I get from D.O.s and students are negative and about 20% are just as nasty.

Another osteopathic physician responded:

I read with interest your article on the dubious aspects of osteopathy. I was disturbed by your note, appended to a letter which, in its turn, responded to the inflammatory and profane comments by a Texas osteopathic physician. Although it disturbs me to hear that such a high percentage of responses by osteopaths are negative—even profane—I am not entirely surprised.

In what seemed to be an effort to build and maintain a separate identity, there was a considerable degree of indoctrination and propagandizing aimed at the students while I was in osteopathic medical training. It is not surprising, therefore, that you should receive such responses from what I would hope to be a vocal minority of the strongest adherents to the "osteopathic faith." For the record, I am in agreement with much of what you have written.

I am pleased that the education I received has enabled me to practice evidence-based Family Medicine alongside my medical peers for the last decade. Graduates of my school perform admirably in postgraduate training alongside graduates of M.D. schools.

Unfortunately, those osteopaths who practice and preach the cranial message and other dubious methodologies still influence students of medicine today, and there are always those who will embrace such things and prey on those searching for the elusive magic bullet.

I appreciate your website and the information you provide. I would have no objection to a merging of professions as mentioned in the article by yourself and others. I feel, biased as I may be, that I received an excellent medical education through my osteopathic medical training, and I hope that time will show that osteopaths as a group will become more respectable with the attrition of some of the older, more "dubious" influences on the profession. I hope, as the numbers of osteopathic practitioners increase, the percentage of those engaged in cranial and chelation nonsense will fall to more nearly match those of the medical profession as a whole (although one would wish it to fall to zero).

I note with professional gratitude that you do not paint all osteopathic practitioners with the quackery brush. I hope this feedback will improve the balance, reducing the percentage of negativity you receive from the osteopathic community. Please keep up the good work. Your site is a very useful tool for my own and my patients' education.

Kindest regards.

Note: Please do not post my name or location. I have the privilege of training osteopathic medical students, and I enjoy imparting reason and discernment in the matter of evidence-based medical practice. Being seen as a "heretic" would impair my ability to continue to serve in this manner.

References

  1. Still AT. Autobiography —with a history of the discovery and development of the science of osteopathy. Reprinted, New York, 1972, Arno Press and the New York Times.
  2. Gevitz N. The D.O.'s: Osteopathic Medicine in America. Baltimore, 1982, The Johns Hopkins University Press.
  3. Gugliemo WJ. Are D.O.s losing their unique identity? Medical Economics 75(8):201-213, 1998. (Clarification regarding AAFP membership published in Medical Economics 75(14):21, 1998.)
  4. Doxey TT, Phillips RB. Comparison of entrance requirements for health care professions. Journal of Manipulative and Physiological Therapeutics 20:86­91, 1997.
  5. Ross-Lee B, Wood DL. Osteopathic medical education. In Sirica CM, editor. Osteopathic Medicine, Past, Present and Future. New York, Josiah Macy Jr. Foundation, 1996, page 95.
  6. Jones DE. Allopathic (M.D.) versus osteopathic (D.O.) medical Schools: Views of a basic scientist with experience in both. Cardiovascular Concepts Web site, accessed 5/21/99.
  7. Johnson SM et al. Variables influencing the use of osteopathic manipulative treatment in family practice. Journal of the American Osteopathic Association 97:80-87, 1997.
  8. Alternative Medicine Yellow Pages. Puyallup, Washington. Futurer Medicine Publishing, Inc., 1994.
  9. Osteopathic medicine: A distinctive branch of mainstream medical care. Undated brochure, distributed in 1987. Chicago: American Osteopathic Association
  10. What is a D.O.? (Brochure) Chicago: American Osteopathic Association, 1991,
  11. AOA Position Papers, Aug 1996. In AOA Yearbook and Directory. Chicago: American Osteopathic Association, Jan 1997, pages 565-588.
  12. Position Paper on Osteopathic Manipulative Treatment (OMT) & Evaluation and Management services. Part II: The Standard of Care for Osteopathic Manipulation and the E&M Service. AOA web site, September 1998.
  13. Gunnar BJ and others. A comparison of of osteopathic spinal manipulation with standard care for patients with low back pain. New England Journal of Medicine 341:1426-1431, 1999.
  14. Discover CranioSacral Therapy. Undated flyer distributed in 1997 by the Upledger Institute.
  15. Upledger CranioSacral Therapy I. Brochure for course, November 1997.
  16. Visceral manipulation. Upledger Institute Web site, accessed Aug 15, 2001.
  17. Hartman SE, Norton JM. Interexaminer reliability and cranial osteopathy. Scientific Review of Alternative Medicine 6(1):23-34, 2002.
  18. Workshop catalog, Upledger Institute, 1995.
  19. Ferre JC and others. Cranial osteopathy, delusion or reality? Actualites Odonto-Stomatologiques 44:481-494, 1990.
  20. Wirth-Pattullo V, Hayes KW. Interrater reliability of craniosacral rate measurements and their relationship with subjects' and examiners' heart and respiratory rate measurements. Physical Therapy 74:908-16, 1994.
  21. Osteopathic literature in print, October 1996. In AOA Yearbook and Directory. Chicago: American Osteopathic Association, Jan 1997, pages 756-757.
  22. Prober, JL. Letter to Dr. Stephen Barrett, January 23, 1998.

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This page was revised on August 18, 2003.