title: Reliability of Diagnosis and Clinical Efficacy of Cranial Osteopathy: A Systematic Review.
abstract: BACKGROUND
  In 2010, the World Health Organization released benchmarks for training in osteopathy in which they considered cranial osteopathy as an important osteopathic skill. However, the evidence supporting the reliability of diagnosis and the efficacy of treatment in this field appears scientifically weak and inconsistent.
  
  
  OBJECTIVE
  To identify and critically evaluate the scientific literature dealing with the reliability of diagnosis and the clinical efficacy of techniques and therapeutic strategies used in cranial osteopathy.
  
  
  METHODS
  Relevant keywords were used to search the electronic databases MEDLINE, PEDro, OSTMED.DR, Cochrane Library, and in Google Scholar, Journal of American Osteopathy Association and International Journal of Osteopathic Medicine websites. Searches were conducted up to end June 2016 with no date restriction as to when the studies were completed. As a complementary approach we explored the bibliography of included articles and consulted available previous reviews dealing with this topic.
  
  
  METHODS
  Regarding diagnostic processes in cranial osteopathy, we analyzed studies that compared the results obtained by at least two examiners or by the same examiner on at least two occasions. For efficacy studies, only randomized-controlled-trials or crossover-studies were eligible. We excluded articles that were not in English or French, and for which the full-text version was not openly available. We also excluded studies with unsuitable study design, in which there was no clear indication of the use of techniques or therapeutic strategies concerning the cranial field, looked at combined treatments, used a non-human examiner and subjects or used healthy subjects for efficacy studies. There was no restriction regarding the type of disease.
  In our electronic search we found 1280 references concerning reliability of diagnosis studies plus four references via our complementary strategy. Based on the title 18 articles were selected for analysis. Nine were retained after applying our exclusion criteria. Regarding efficacy, we extracted 556 references from the databases plus 14 references through our complementary strategy. Based on the title 46 articles were selected. Thirty two articles were not retained on the grounds of our exclusion criteria.
  
  
  METHODS
  Risk of bias in reliability studies was assessed using a modified version of the quality appraisal tool for studies of diagnostic reliability. The methodological quality of the efficacy studies was assessed using the Cochrane risk of bias tool. Two screeners conducted these analyses.
  
  
  RESULTS
  For reliability studies, our analysis leads us to conclude that the diagnostic procedures used in cranial osteopathy are unreliable in many ways. For efficacy studies, the Cochrane risk of bias tool we used shows that 2 studies had a high risk of bias, 9 were rated as having major doubt regarding risk of bias and 3 had a low risk of bias. In the 3 studies with a low risk of bias alternative interpretations of the results, such as a non-specific effect of treatment, were not considered.
  
  
  CONCLUSIONS
  Our results demonstrate, consistently with those of previous reviews, that methodologically strong evidence on the reliability of diagnostic procedures and the efficacy of techniques and therapeutic strategies in cranial osteopathy is almost non-existent.
authors.affiliation: CORTECS team, Univ. Grenoble-Alpes, Grenoble, France.|Critical Thinking Research Federation, Univ. Grenoble-Alpes, FED 4270, Grenoble, France.
authors.forename: Albin
authors.initials: A
authors.lastname: Guillaud
authors.affiliation: CORTECS team, Univ. Grenoble-Alpes, Grenoble, France.|Critical Thinking Research Federation, Univ. Grenoble-Alpes, FED 4270, Grenoble, France.
authors.forename: Nelly
authors.initials: N
authors.lastname: Darbois
authors.affiliation: CORTECS team, Univ. Grenoble-Alpes, Grenoble, France.|Critical Thinking Research Federation, Univ. Grenoble-Alpes, FED 4270, Grenoble, France.
authors.forename: Richard
authors.initials: R
authors.lastname: Monvoisin
authors.affiliation: ThEMAS team, TIMC-IMAG laboratory, UMR CNRS-UGA 5525, Grenoble, France.|School of Physiotherapy, Grenoble-Alpes University Hospital, Grenoble, France.|Critical Thinking Research Federation, Univ. Grenoble-Alpes, FED 4270, Grenoble, France.
authors.forename: Nicolas
authors.identifier: http://orcid.org/0000-0001-5034-0802
authors.initials: N
authors.lastname: Pinsault
mesh_terms: D003933:Diagnosis; D006801:Humans; D026301:Manipulation, Osteopathic / Q000379:methods*; D015203:Reproducibility of Results; D012886:Skull