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Letters to the Editor / International Journal of Osteopathic Medicine 10 (2007) 80e82 81

Reply to ‘‘The flawed cranial model’’ long-favoured mechanism should be laid to rest, few ap-
preciate thatdwith or without itdthey have no more
For cranial osteopathy, no evidence supports a biologi- evidence for efficacy than did blood letters.
cal mechanism, diagnostic reliability, or efficacy. In this With such a clear and protracted reputation for
letter, I will explain why this failed subspecialty of osteop- unreliability, why does this faith in the intrinsic value
athy persists. When I joined the long-fermenting ‘‘cranial’’ of personal clinical experience persist? Well, sadly,
dispute some years ago, few in the community of practi- human abilities to perceive, interpret, and remember
tioners acknowledged weaknesses of any kind in the fabric moment-to-moment experiences and encounters (in-
of their belief. Therefore, I am pleased to observe that Dr. cluding those in a clinical setting) are limited. For ex-
Maddick and I may not be as far apart as I had thought, ample, a cognitive rule-of-thumb that often gets us in
both judging that Sutherland’s model is ‘‘outdated,’’ ‘‘in- trouble takes the form: if event B follows event A,
congruous,’’ ‘‘untenable,’’ and ‘‘wrong.’’ Although I do then probably B was caused by A. Now, cause does
not believe this is ‘‘known and generally accepted’’ or precede effect, and the first place we should look to ex-
‘‘agreed by most rational observers’’ (at least based on plain an outcome is to events immediately preceding it.
practitioners’ published views), I certainly concur that fur- This does not mean, however, that determining which
ther tests of presumptive underlying mechanisms will be preceding event or events have lead to a particular re-
warranted only if ‘‘the reality of clinical practice’’ first sult will be a simple matter.
can be affirmed. However, our views still diverge regarding In a medical context, perceived symptoms often im-
a matter that hardly could be more important. prove following a treatment. Commonly, patients and
In recent years, Dr. James Norton and I have fully practitioners both are tempted to use the cognitive rule-
and forcefully expressed our carefully researched views of-thumb in assuming that such improvements resulted
on cranial osteopathy and craniosacral therapy.1e5 I directly from the treatment. If motivated to this conclusion
thought I had nothing more to say . until I read Dr. by understandable self-interest then, given the many other
Maddick’s first sentence: ‘‘It is illogical to object to clin- possibilities, it is apparent that our rule-of-thumb has
ical practice because of lack of evidence.’’ I was so taken become magical thinking.6
aback that, to make sure I had interpreted it rightly, I Real, objective, physiological and anatomical symp-
read it again. Many practitioners may greet this curious toms often improve, independent of direct treatment
assertion with a cheer but, as a scientist, I am frustrated effects, due (primarily) to regression to the mean,7,8 the
that this ill-informed conviction still has such power. Al- placebo effect, and the propensity for most maladies to
though tempted to counter many of Dr. Maddick’s improve without intervention. Even more troublesome,
opinions, I will restrict myself to just this one. In the patients and practitioners can be expected to perceive im-
process, I will try to underline what I think remains as provement even when none actually has occurred. Culprits
the most important impediment to the osteopathic pro- here include ‘‘subjective validation,’’ ‘‘demand character-
fession’s full embrace of the enlightened practice of istics’’ of the therapeutic encounter, and other psycholog-
modern medicine: practitioners’ willingness to hang ical phenomena known to accompany the careful and
their professional hats (and their patients’ well-being) caring ministrations of a practitioner.9
on shared perceptions of clinical success . without reli- Such factors, including those influencing perception
able evidence of any kind. of treatment outcomes, have been the bane of objec-
Over the past century, prescientific medicine has been tive, reliable human inquiry for all of recorded history,
recognized for what it was: a millennia-long history of and it is their ubiquity that leddeventuallydto the
magical thinking, guesswork, and failure. For as long development of the system for controlled observation
as humans have struggled to heal other humans, shared and interpretation that we call ‘‘science.’’ Understand-
(but rarely tested) perceptions of clinical success have in- ing when and how we should expect the compromising,
spired both patient and practitioner reliance in untold even crippling, effects of these aspects of every clinical
numbers of what eventually proved to be valueless po- encounter is central to the practice of good medicine
tions and procedures. One example probably will be fa- and should be emphasized in every medical and
miliar to all: to address a surfeit of evil spirits or an allied-health curriculum. If all practitioners were famil-
imbalance in their patients’ four humours, apparent iar with these factors, continued confidence regarding
(but untested) clinical success led caring practitioners the effectiveness of cranial osteopathy and most of
to drain copious quantities of their patients’ blood the other ‘‘alternative’’ medical arts might vanish
with confidence . surely killing many more than they over night.
cured . for millennia. Although some practitioners I have concluded that personal perception of clinical
of cranial osteopathy may realize that Sutherland’s success is a very unreliable indicator of clinical efficacy.
Although apparently not understood by most practi-
tioners of cranial osteopathy, this is particularly relevant
DOI of original article: 10.1016/j.ijosm.2007.03.002. to that field for the following reasons:
82 Letters to the Editor / International Journal of Osteopathic Medicine 10 (2007) 80e82

1. No properly controlled, scientific studies of outcomes optimistic. This is one of the admittedly rare occasions
support any form of ‘‘cranial’’ treatment. That is, that I hope I am wrong.
practitioners’ perceptions of success lack the only
foundation suitable to the 21st-century practice of
References
medicine.
2. Mechanisms favoured by practitioners (including Su- 1. Hartman SE, Norton JM. Interexaminer reliability and cranial os-
therland’s) are biologically anomalous. That is, when teopathy. Sci Rev Altern Med 2002;6:23–34.
compared against long- and widely understood hu- 2. Hartman SE, Norton JM. Craniosacral therapy is not medicine.
man biology, they not only are invalid but . well, Phys Ther 2002;82:1146–7.
3. Hartman SE, Norton JM. A review of King HH and Lay EM,
they’re prescientific and strange.
‘‘Osteopathy in the cranial field,’’ in Foundations for osteopathic
3. Over the many and independent published reports, medicine, 2nd ed. Sci Rev Altern Med 2004e2005;8:24–8.
measurement reliabilities are tiny and many are less 4. Hartman SE. Should osteopathic licensing examinations test for
than zero. That is, whatever individual practitioners knowledge of cranial osteopathy? Int J Osteopath Med 2005;8:153–4.
are feeling, there is little indication that any two are 5. Hartman SE. Cranial osteopathy: Its fate seems clear. Chiropr Osteo-
pat 2006;14(10). <http://www.chiroandosteo.com/content/14/1/10>.
palpating the same physiological phenomenon. This
6. Zusne L, Jones WH. Anomalistic psychology: a study of magical
does not inspire confidence that ‘‘cranial’’ diagnosis thinking. 2nd ed. Hillsdale, NJ: Erlbaum; 1988. p. 13e32.
or treatment possibly could be effective. 7. McDonald CJ, Mazzuca SA, McCabe Jr GP. How much of the
placebo ‘‘effect’’ is really statistical regression? Stat Med 1983;2:
Not just limited scientific evidence for efficacy, but 417–27.
8. Streiner DL. Regression toward the mean: its etiology, diagnosis,
none. Not just limited mechanistic understanding, but
and treatment. Can J Psychiatry 2001;46:72–6.
none. Not just limited diagnostic reliability, but none. 9. Beyerstein BL. Social and judgmental biases that make inert treat-
Under the circumstances, ongoing contentions of effi- ments seem to work. Sci Rev Altern Med 1999;3:20–33.
cacy are extraordinary claims that should be considered
seriously only if accompanied by extraordinary proof. Steve E. Hartman
Until such is forthcoming, other skeptics and I will be Department of Anatomy,
obliged to adhere to the paraphrase of an old aphorism: College of Osteopathic Medicine,
If it walks like a failed technique and quacks like a failed University of New England,
technique, probably it is a failed technique. Biddeford, ME 04005, USA
Perhaps many practitioners are loath to question Tel.: þ1 (207) 602 2431; fax: þ1 (207) 602 5931.
their collective perceptions of clinical success because E-mail address: shartman@une.edu
they are not aware of how faulty human cognition can
be; perhaps many are so heavily invested, both profes- 11 April 2007
sionally and personally, that they are reluctant to
let evidence guide them. I want to believe that the oste- 1746-0689/$ - see front matter Ó 2007 Elsevier Ltd. All rights reserved.
opathic community soon will be ready to move on from doi:10.1016/j.ijosm.2007.04.001
its prescientific past, but I confess that I am not