BACKGROUND AND OBJECTIVES: Most osteopaths are trained in pediatric care, and osteopathic manipulative treatment (OMT) is available for many pediatric conditions. The objective of this systematic review was to critically evaluate the effectiveness of OMT as a treatment of pediatric conditions.
METHODS: Eleven databases were searched from their respective inceptions to November 2012. Only randomized clinical trials (RCTs) were included, if they tested OMT against any type of control in pediatric patients. Study quality was critically appraised by using the Cochrane criteria.
RESULTS: Seventeen trials met the inclusion criteria. Five RCTs were of high methodological quality. Of those, 1 favored OMT, whereas 4 revealed no effect compared with various control interventions. Replications by independent researchers were available for 2 conditions only, and both failed to confirm the findings of the previous studies. Seven RCTs suggested that OMT leads to a significantly greater reduction in the symptoms of asthma, congenital nasolacrimal duct obstruction (posttreatment), daily weight gain and length of hospital stay, dysfunctional voiding, infantile colic, otitis media, or postural asymmetry compared with various control interventions. Seven RCTs indicated that OMT had no effect on the symptoms of asthma, cerebral palsy, idiopathic scoliosis, obstructive apnea, otitis media, or temporomandibular disorders compared with various control interventions. Three RCTs did not perform between-group comparisons. The majority of the included RCTs did not report the incidence rates of adverse effects.
CONCLUSIONS: The evidence of the effectiveness of OMT for pediatric conditions remains unproven due to the paucity and low methodological quality of the primary studies.
- ADHD —
- attention-deficit/hyperactivity disorder
- AE —
- adverse effect
- CI —
- confidence interval
- CNLDO —
- congenital nasolacrimal duct obstruction
- CP —
- cerebral palsy
- DV —
- dysfunctional voiding
- DWG —
- daily weight gain
- FDT —
- fluorescein disappearance test
- GMFM —
- Gross Motor Function Measurement
- IC —
- infantile colic
- IS —
- idiopathic scoliosis
- ITT —
- intention to treat
- LOS —
- length of hospital stay
- MD —
- mean difference
- OM —
- otitis media
- OMT —
- osteopathic manipulative treatment
- PA —
- postural asymmetry
- RCT —
- randomized clinical trial
- ROB —
- risk of bias
- SR —
- systematic review
- TMD —
- temporomandibular disorder
- UC —
- usual care
Osteopathy is a branch of health care that was founded by A.T. Still during the 19th century in the United States.1 Since then, osteopathy has evolved to encompass 2 distinct professions: nonphysician osteopaths and osteopathic physicians; the former are generally considered practitioners of alternative medicine, whereas the latter group that exists only in the United States has the same standing, training, and regulation as conventional physicians.2
Both nonphysician osteopaths and, to a lesser extent, osteopathic physicians use osteopathic manipulative treatment (OMT) to treat a wide variety of pediatric conditions.3 OMT can be defined as “the therapeutic application of manually guided forces by an osteopathic physician to improve physiologic function and/or support homeostasis that has been altered by somatic dysfunction.”4 According to the Glossary of Osteopathic Terminology, OMT refers to a broad array of manipulative techniques ranging from articulatory to visceral manipulation and includes cranial osteopathy.5 It seems relevant to clarify the difference between chiropractors and (nonphysician) osteopaths. The former “focuses on the relationship between the body’s structure—mainly the spine—and its functioning.”6 Chiropractors primarily perform manipulations of the spine or the limbs with the goal of correcting subluxations,7–9 whereas osteopaths employ mainly (but not exclusively) mobilizations of soft tissues such as fascia, ligaments, and muscles.5 The similarities between the 2 professions are, however, undeniable.
The prevalence of OMT use in pediatric populations varies throughout the world. Data from the National Health Interview Survey 2007, Child Alternative Medicine survey as well as the Child Core Sample indicated that 2.3 million children (2.3%) in the United States had used OMT or chiropractic manipulation in 2007.10
Numerous clinical trials investigating the effects of OMT in pediatric patients have been conducted; however, no systematic reviews (SRs) evaluating the effectiveness of OMT in pediatrics have been published. The paucity of high quality research in OMT is a critical factor undermining the credibility of the osteopathic profession.11
The objective of this SR is to critically evaluate the effectiveness of OMT as a treatment option for pediatric conditions, by using data from randomized clinical trials (RCTs).
The Preferred Reporting Items for Systematic Reviews and Meta-analyses guidelines were used to lend a reporting framework of this SR.
The present SR included all RCTs investigating the effect of OMT on pediatric conditions. Only children and adolescents ≤18 with a clinical condition were included. Any types of controls were considered admissible. Both published and unpublished RCTs were considered eligible. No gender, time, or language restrictions were imposed. Studies involving the use of OMT in conjunction with other treatments were included. Nonrandomized or uncontrolled trials were excluded. Studies of chiropractic manipulations were also excluded.
Data Source and Search Strategy
The first reviewer (Dr Posadzki) searched the following electronic databases (from their respective inceptions to November 2012): AMED (EBSCO), Cumulative Index to Nursing and Allied Health Literature (EBSCO), Embase (OVID), Medline (OVID), OSTMED.DR, PsycINFO, The Cochrane Library, ISI Web of Knowledge, Osteopathic Research Web, PEDro, and Rehabdata. Details of the Medline search strategy are available in the Appendix. Additionally, the reference lists of the located articles and key SRs of OMT were manually searched for further relevant literature. Hard copies of all retrieved articles were read in full.
All titles and abstracts identified in the electronic database search were screened for relevance. Articles appearing to meet the inclusion criteria were retrieved in full for further evaluation and validation according to predefined criteria. The data screening and selection process were carried out independently by 2 reviewers (Drs Posadzki and Lee). In case of disagreement, a third independent reviewer (Dr Ernst) was asked to decide.
The Cochrane tool was used to assess the risk of bias (ROB) of the RCTs.12 This tool consists of 7 domains: adequate sequence generation, allocation concealment, patient blinding, assessor blinding, addressing of incomplete data, selective outcome reporting, and other sources of bias. Each domain can be scored as follows: H, high ROB; L, low ROB; and U, unclear ROB. Quality assessment process was conducted by 2 independent reviewers (Drs Posadzki and Lee) and subsequently validated by the third reviewer (Dr Ernst). Disagreements about whether a study was of low or high quality were settled through joint discussions.
Data extraction was conducted by 2 reviewers (Drs Posadzki and Lee) by using a predefined form and subsequently validated by another reviewer (Dr Ernst). The following information was extracted from the included trials: first author and year of publication, characteristics of participants, experimental and control interventions, primary outcome measures, main results, author’s conclusions, adverse effects (AEs), conflict of interest, summary of quality score, and RCT’s main limitations.
The posttreatment differences in any type of outcome measures between the intervention and control groups were assessed descriptively. The protocol stipulated that the data should be meta-analyzed if methodological, clinical, and statistical heterogeneity allowed.
Effect sizes were calculated for the effect of OMT on any type of outcome measures. Difference scores between experimental and control groups were calculated by using Cohen’s d formulas.13
Our searches generated a total of 19 509 records, and 17 RCTs met our inclusion criteria (Fig 1). The key data from the included RCTs are presented in Table 1. Table 2 summarizes details of the OMT regimen. A total of 887 pediatric patients were included in the RCTs. The included trials originated from Belgium,14 Germany,15,16 Italy,17,18 Spain,19 Switzerland,20 the United Kingdom,21,22 and the United States.23–30
Duncan et al25 aimed to assess the effectiveness of cranial osteopathy, myofascial release, or both versus acupuncture in 55 children with moderate to severe spastic cerebral palsy (CP). Fifteen children received 10 sessions of OMT, 18 had 30 sessions of acupuncture, and 22 were in the wait-list control arm. After a 24-week period, the authors reported no significant changes in Gross Motor Function Classification System (no P values, no confidence intervals [CIs]), Functional Independence Measure for Children/self care (no P values, no CIs), and Pediatric Evaluation of Disability Inventory/mobility (no P values, no CIs); and significant improvements in the total Gross Motor Function Measurement (GMFM) score (P < .05, no CIs) and in the mobility domain of the Functional Independence Measure for Children (P < .05, no CIs) in the OMT group compared with acupuncture or waiting list controls and concluded that OMT improved motor function in children with moderate to severe spastic CP.
Wyatt et al22 tested the effects of cranial osteopathy on general health and wellbeing, including physical function, in 142 children with CP. In this study, 71 patients received 6 sessions of cranial OMT, and 71 were on the waiting list. At 6-month follow-up, the authors reported no significant between-group differences in GMFM-66 (mean difference [MD] = 4.9 [95% CI: −4.4 to 14.1], no P values), Physical Summary Score (MD = 2.2 [95% CI: −3.5 to 8.0], no P values), and Psychological Summary Score (MD = 3.4 [95% CI: −0.8 to 7.7], no P values) of Child Health Questionnaire and concluded that there was no evidence that cranial osteopathy leads to sustained improvement in motor function, pain, or sleep in children aged 5 to 12 years with CP.
Belcastro et al24 aimed to determine the effectiveness of OMT in 12 patients with bronchiolitis. Three subjects received 3 sessions of OMT, and 9 received postural drainage (no further details were provided). The authors reported no significant between-group differences in number of hospital days or respiratory rates (no statistical tests were reported) and concluded that the study included too few patients to draw any conclusions.
Brady23 aimed to determine whether OMT had an effect on an unknown number of children with moderately severe asthma. The allocation between the arms was not presented. The author reported insignificant changes between the groups in forced expiratory volume in 1 second (P = .982 and P = .081, no CIs) and forced expiratory flow, midexpiratory phase (P = .532 and P = .401, no CIs) and concluded that OMT did not improve pulmonary function or subjective asthma symptoms in pediatric patients.
Guiney et al26 tested OMT in 140 pediatric asthmatic patients. In this study, 90 patients received OMT (details were not provided), and 50 underwent a sham procedure (light touch only). The authors reported significant improvements in peak expiratory flow in the OMT group (no P values [95% CI: 7.3 to 18.7]) compared with controls (no P values [95% CI: −9.8 to 10.4]) and concluded that OMT has a therapeutic effect in this patient population.
Vandenplas et al14 aimed to test whether OMT could reduce the incidence of obstructive sleep apnea. Of the 34 infants in this study, 15 received 2 sessions of OMT, and 13 received 2 sessions of gentle mobilizations over a period of 2 weeks. These authors reported no significant intergroup difference in the decline in the number of obstructive apneas (P = .43, no CIs); and significant (within group) decrease in the number of apneas in the OMT group (P = .01, no CIs) and concluded that OMT may have a positive influence on the incidence of apneas during sleep in infants with a previous history of obstructive apnea, as measured by polysomnography.
Mills et al27 aimed to study effects of OMT as an adjuvant to usual care (UC) in 57 children with recurrent acute otitis media (OM). Of 57 subjects, 25 received 9 sessions of OMT plus UC, and 32 received equal amount of UC only. At 6-month follow-up, the authors reported no significant changes in antibiotics use (P = .13 [95% CI: −0.38 to 0.05]) and audiometrics (no P values [95% CI: −6.10 to 4.16 for final speech awareness threshold]); and significant improvements in the number of episodes of acute OM (MD = −0.14 [95% CI: −0.27 to 0.00], P = .04), mean surgery-free months (P = .01 [95% CI: 0.16 to 1.34]) and normalized tympanograms (MD = 0.55 [95% CI: 0.08 to 1.02], P = .02) in the OMT group compared with controls and concluded that OMT might be beneficial as an adjuvant therapy in children with recurrent acute OM.
Steele et al29 aimed to describe a research protocol for studying the efficacy of OMT on middle ear effusion after an episode of acute OM in 56 young children. Seven subjects received 5 sessions of OMT plus UC over 30 days, and 27 received UC (antibiotics and surgery). The authors did not report any between-group comparisons and concluded that the OMT protocol can be administered with no serious AEs.
Wahl et al30 aimed to assess the efficacy of Echinacea purpurea and/or OMT for the prevention of acute OM in otitis-prone children. Of the 90 children in the study, 46 received 5 sessions of OMT plus either real or placebo Echinacea, and 44 received sham OMT (palpation of the cranial bones and muscles and other structures) plus either real or placebo Echinacea over 3 months. The authors reported no significant between-group differences in risk of having at least 1 episode of acute OM (relative risk = 0.72 [95% CI: 0.48 to 1.10], P > .05) and concluded that a regimen of up to 5 OMTs does not significantly decrease the risk of acute OM.
Hasler et al20 tested the effect of OMT on trunk morphology and spine flexibility in 20 adolescents with idiopathic scoliosis (IS); 10 received 3 sessions of OMT over 5 weeks, and 10 had no intervention. The authors reported no significant between-group differences in trunk morphology (P = .44, no CIs) and spinal flexibility (P = .43, no CIs) and concluded that there was no evidence to support OMT as an effective treatment of mild adolescent IS.
Monaco et al17 aimed to evaluate the effects of OMT on mandibular kinematics in 28 children with temporomandibular disorders (TMDs). In this study, 14 subjects received OMT (no details provided), and 14 had no intervention. The authors reported no significant changes in maximal closing velocity (no P values, no CIs), opening velocity average (no P values, no CIs), closing velocity average (no P values, no CIs), and maximal mouth opening (P < .07, no CIs); and significant (intragroup) improvements in maximal mouth opening velocity (P < .03, no CIs) in the OMT group and concluded that OMT can induce changes in stomatognathic dynamics, supporting this clinical approach to TMD.
Philippi et al16 aimed to assess the therapeutic efficacy of OMT in 32 infants with postural asymmetry (PA), 16 of whom received 4 sessions of OMT over 1 month and 16 of whom had sham therapy (light touch only). The authors reported significant reductions in PA in the OMT group compared with the sham group (P = .001 [95% CI: 2.0 to 7.3]) and concluded that OMT in the first months after birth reduces the degree of asymmetry in infants with PA.
Bierent-Vass15 tested the hypothesis that OMT is effective for attention-deficit/hyperactivity disorder (ADHD). Of the 77 children included in the study, 50 received 4 sessions of OMT over 2 weeks, and 27 had no such treatment. This author reported <50% of improvement in symptoms, as measured by the Conners Scale, in the OMT group (no statistical tests were reported) and concluded that OMT can have a positive effect on the treatment of children with ADHD.
Cerritelli et al18 tested the effects of OMT on the length of hospital stay (LOS) and daily weight gain (DWG) in 101 premature infants. In this study, 47 infants received OMT + UC (no details provided), and 54 received UC only. The authors reported significant improvements in LOS (P = .03, no CIs) and DWG (P = .03, no CIs) in the OMT group compared with controls and concluded that OMT plays an important role in the management of hospitalized preterm infants.
Hayden and Mullinger21 aimed to investigate the effect of cranial OMT on the pattern of increased crying, irritability, and disturbed sleep associated with infantile colic (IC). Of the 28 infants in this study, 14 received 4 sessions of cranial OMT over 4 weeks, and 14 received no treatment. These authors reported significant improvements in crying (MD = 1.0 [95% CI: 0.14 to 2.19], P < .02) and time spent sleeping (MD = 1.17 [95% CI: 0.29 to 2.27], P < .05) in the treatment group and concluded that cranial OMT can benefit infants with colic.
Navarro et al19 aimed to evaluate the efficacy of cranial osteopathy in 30 children with congenital nasolacrimal duct obstruction (CNLDO); 15 infants received 1 session of cranial osteopathy, and 15 received 1 sham treatment (light touch only). The authors reported significant posttreatment improvements (P < .05, no CIs) and no between groups differences at 14 weeks follow-up (P > .05, no CIs) in the fluorescein disappearance test (FDT) and the modified Jones test in the OMT group compared with controls and concluded that cranial OMT is an effective short-term therapy for CNLDO.
Nemett et al28 aimed to determine whether OMT plus UC improves dysfunctional voiding (DV) more effectively than UC alone. Of the 21 children studied, 10 received 4 sessions of OMT, and 11 received UC, which included medications, establishment of timed voiding and evacuation schedules, dietary modifications, behavior modification, pelvic floor muscle retraining, biofeedback training, and treatment of constipation. At 3-month follow-up, the authors reported significant improvement in DV symptoms in the OMT group compared with controls (P = .008, no CIs) and concluded that OMT can improve short-term outcomes in children with DV.
Effect Size of OMT Interventions
In 9 of the 17 RCTs, statistics needed for effect size calculations were not reported. Effect sizes (Cohen’s d) in the remaining trials ranged from 0.03 (small) to 1.288 (large); x̄ = 0.20 (small) (Table 1).
Five of the RCTs included here had a high ROB with regard to adequate sequence generation. Nine trials had a high ROB with regard to allocation concealment. Twelve RCTs had high ROB with regard to patient blinding. Nine RCTs had high ROB with regard to assessor blinding. Six RCTs had a high ROB with regard to addressing of incomplete data and selective outcome reporting. All 17 RCTs had an uncertain ROB from other sources. Thus, the overall quality of the RCTs was poor, and no RCT was free of major methodological limitations. Also, 4 RCTs failed to provide any details about the OMT, making them impossible to be replicated.15,17,18,23
Safety of OMT
Eleven RCTs did not report the incidence rates of AEs.14,15,17–19,21,23–26,28 Four RCTs mentioned that no AEs had occurred.20,22,27,29 Philippi et al16 reported that 4 patients had had aggravation of vegetative symptoms after OMT. Two AEs reported in the study by Wahl et al30 were related to Echinacea and placebo and not to OMT.
The aim of this article was to summarize and critically evaluate the evidence for or against the effectiveness of OMT in pediatric conditions. Seventeen trials were found; 7 of them favored OMT, whereas the remaining 7 revealed no effect, and 3 did not report between-group comparisons. In general, small and biased RCTs favored OMT, whereas the largest and most methodologically sound studies failed to reveal effectiveness. The evidence from RCTs of OMT for treating pediatric conditions is thus limited, weak, and contradictory. Independent replications were available for 2 conditions only: OM and CP; and in both cases the results were contradictory.22,30 Independent replications could not be found for any other conditions. Thus there is no indication for which the effectiveness of OMT has been shown by more than 1 RCT.
This SR reveals serious methodological limitations in almost all of the RCTs. For instance, only 3 (17%) RCTs had reasonably large sample sizes.18,22,26 Three trials employed patient blinding,14,16,30 and 7 (41%) used blinded assessors.14,16,20,22,25,29,30 Only 4 (23%) RCTs controlled for placebo effects by employing sham procedures,16,19,26,30 and the sham procedure was not credible in 2 of those trials.16,19 Of the 2 RCTs that employed credible sham-interventions, 1 was positive26 and 1 was negative.30 Other sources of bias pertained to the lack of power and sample size calculations,14,15,17,19,24,25,28–30 objective outcome measures,16 equal distribution between study arms,26 or patient compliance with OMT.30 Only 1 (5.8%) RCT used intention to treat (ITT) analyses.16 There were no follow-ups in the majority of the trials.14,16,17,20,21,23–26,28,29 One trial that favored OMT failed to report P values,26 making its conclusions questionable. Two RCTs were available as abstracts only.18,23 Five RCTs (29.4%) were of high methodological quality.16,20,22,25,30 Of those, 1 favored OMT, whereas 4 revealed no effects. Of those high quality trials that arrived at negative conclusions, 3 were executed by investigators not affiliated with osteopathic institutions. Similarly, 4 trials were done by nonosteopaths as lead authors, and all of them were negative.20,22,23,30
In terms of the clinical conditions treated, the populations of individuals were heterogeneous across the included RCTs and included children with ADHD,15 asthma,23,26 bronchiolitis,24 CP,22,25 CNLDO,19 DV,28 IC,21 IS,20 obstructive apnea,14 OM,27,29,30 PA,16 and TMD.17 The control interventions were also heterogeneous, including the use of acupuncture,25 bronchodilators,24 mobilization,14 postural drainage,24 sham therapy,16,19,26,30 UC alone,18,27–29 or no intervention.15,17,20,21 The primary outcome measures were also heterogeneous. The OMTs themselves varied from cranial osteopathy15,19,21,22,25,30 to a combination of wide variety of OMT techniques such as articulation, balanced ligamentous/membranous tension, counterstrain, facilitated positional release, muscle energy, myofascial release, or rib-raising (Table 2). The frequency of OMT sessions varied across RCTs, from a single intervention19 to ten 20- to 60-minute sessions over 24 weeks25 (Table 1). Therefore, due to the clinical and methodological heterogeneity of the data, a meta-analysis would not have been reasonable.
Hayes and Bezilla3 found no OMT-associated complications and concluded that “OMT appears to be a safe treatment modality in the pediatric population”. However, these conclusions are based on a sample that is too small to allow generalizability. It is also possible that OMT-related complications are underreported. Eleven (64%) of the included RCTs failed to report the incidence rates of AEs. This may amount to a serious breach of publication ethics. Authors and journal editors might consider making sure that the situation improves in the future.
In general, reporting of trial methodology and results was often inadequate. To make progress in this area, future studies of OMT should follow the accepted standards of trial design and reporting (eg, CONSORT guidelines).31 Such studies should also have sufficiently large sample sizes based on power calculations, use blinding, follow-ups, ITT data analysis, validated and objective outcome measures, and control for nonspecific effects.
Our review has several limitations that should be considered when interpreting its results. Firstly, even though our searches were extensive, we cannot be entirely certain that all relevant RCTs were located. Secondly, due to the methodological, statistical, and clinical heterogeneity of the included studies, statistical pooling was deemed impractical. Thirdly, publication bias could have prevented negative studies from being published. Fourthly, few RCTs were located for each specific pediatric condition; thus, our conclusions cannot be as confident as we would have liked them to be.
The effectiveness of OMT for pediatric conditions remains unproven. The low methodological quality and paucity of the primary studies is remarkable. More robust RCTs are needed to clarify the many open questions regarding the effectiveness of OMT. Until such data are available, OMT cannot be regarded as an effective therapy for pediatric conditions, and osteopaths should not claim otherwise.
APPENDIX: Detailed Search Strategy for MEDLINE
Osteopath$.ti,ab OR Osteopath$ adj3 manipulat$ OR Osteoapth$ adj3 therap$ OR Osteoapth$ adj3 treatment OR Osteoapth$ adj3 medic$ OR Osteoapth$ ADJ3 (viscera$ OR cranial OR craniosacral OR nervous OR neural OR musculoskelet$ OR nonmusculoskeletal OR non-musculoskelet$).ti,ab OR (manual adj2 therap$).ti,ab OR manual adj2 medic$.ti,ab OR Spencer Technique$.ti,ab OR Jones Technique$.ti,ab OR Strain-Counter Strain.ti,ab OR Positional Release Technique$.ti,ab OR Viscera$ Manipulation$.ti,ab OR Cranial Osteopath$.ti,ab OR Cranio-Sacral Technique$.ti,ab OR Myofascial release.ti,ab OR Soft tissue release.ti,ab OR Muscle energy technique$.ti,ab OR (hand$ adj therap$).ti,ab OR (bone$ adj setter$).ti,ab OR (bodywork adj3 therap$).ti,ab OR (mobili?ation$ adj3 spin$).ti,ab OR (spin$ adj3 adjustment$).ti,ab OR (spin$ adj4 manipulat$).ti,ab OR High velocity thrust$.ti,ab OR Low amplitude thrust$.ti,ab OR HVLA.ti,ab OR Manipulat$ therap$.ti,ab OR Manipulat$ joint$.ti,ab OR Subluxation$.ti,ab OR exp osteopathic medicine/ OR exp manipulation, spinal/ OR exp musculoskeletal manipulations/ OR exp manipulation osteopathic/ OR exp alternative medicine/ OR exp Complementary Therapies/ OR manipulation, osteopathic.sh OR osteopathic medicine.sh OR OMT.tw OR osteopath$.tw
(randomized controlled trial).pt. OR (clin$ adj5 trial$).ti,ab. OR ((singl$ or doubl$ or tripl$ or trebl$) adj5 (blind$ or mask$ or sham)).ti,ab OR random$.ti,ab OR control$.ti,ab. OR prospectiv$.ti,ab. OR exp clinical trial/ OR follow-up studies/or prospective studies/ OR double-blind method/or random allocation/or single-blind method/ OR exp Research Design/
exp Infant/ OR (infant$ or infancy or newborn$ or baby$ or babies or neonat$ or preterm$ or prematur$).tw. OR exp Child/ OR (child$ or schoolchild$ or school age$ or preschool$ or kid or kids or toddler$).tw. OR Adolescent/ OR (adoles$ or teen$ or boy$ or girl$).tw. OR Minors/ OR Puberty/ OR (minor$ or pubert$ or pubescen$).tw. OR exp Pediatrics/ OR (pediatric$ or paediatric$).tw. OR exp Schools/ OR (nursery school$ or kindergar$ or primary school$ or secondary school$ or elementary school$ or high school$ or highschool$).tw.
1 AND 2 AND 3
The authors would like to thank Tae-Woong Moon for retrieving full text versions of the articles.
- Accepted April 18, 2013.
- Address correspondence to Paul Posadzki, PhD Medical Research Division, Korea Institute of Oriental Medicine, 461-24, Jeonmin-dong, Yuseong-gu, Daejeon 305-811, South Korea. E-mail:
Dr Posadzki has participated in the concept and design, analysis and interpretation of data, and in drafting and revising of the article; Dr Lee has participated in analysis and interpretation of data and revising of the article; and Dr Ernst has participated in data interpretation and revising of the article.
FINANCIAL DISCLOSURE: The authors have indicated they have no financial relationships relevant to this article to disclose.
FUNDING: Drs Posadzki and Lee were supported by KIOM (K13400).
- ↵World Health Organization. Benchmarks for training in traditional/complementary and alternative medicine. Benchmarks for training in osteopathy. Available at: www.who.int/medicines/areas/traditional/BenchmarksforTraininginOsteopathy.pdf. Accessed December 12, 2012
- ↵The American Association of Colleges of Osteopathic Medicine. Glossary of osteopathic terminology. Available at: www.aacom.org/resources/bookstore/Documents/GOT2011ed.pdf. Accessed December 12, 2012
- ↵National Center for Complementary and Alternative Medicine. Chiropractic: an introduction. Available at: http://nccam.nih.gov/health/chiropractic/introduction.htm. Accessed April 8, 2013
- ↵Cochrane Oral Health Group. The Cochrane Collaboration’s tool for assessing risk of bias. Available at: http://ohg.cochrane.org/sites/ohg.cochrane.org/files/uploads/Risk%20of%20bias%20assessment%20tool.pdf. Accessed April 8, 2013
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- ↵Consolidated Standards of Reporting Trials Statement. Available at: www.consort-statement.org/consort-statement/. Accessed December 10, 2012
- Copyright © 2013 by the American Academy of Pediatrics