The ICAK Research Challenge Research for ICAKs Future

1
The ICAK Research Challenge(Research for ICAKs
Future )
Scott C. Cuthbert, DC ICAK USA
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Our Challenge

• To determine the clinical meaningfulness
• of the manual muscle test (MMT) in relationship
  to the subluxation-syndromeAND TO PUBLISH OUR
  FINDINGS!!

• Weve talked about the subluxation and the MMT
  for a century
  
• No one disputes the existence of subluxations
• No one disputes the existence of manual muscle
  tests
  
• The question has always been whether or not
  subluxation (or other neurological lesion) has
  health consequences (i.e., subluxation-syndrome),
  and whether the MMT can detect the presence of
  the subluxation-syndrome

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MMTAlthough DCs have been writing, talking and
theorizing about the MMT since 1964, there has
been far too little rigorous investigation of the
clinical meaningfulness of the traditional AK MMT.
Clinical meaningfulness refers to the practical
value of a concept in directing the doctor to
successful resolution of the health problem the
patient has presented. It is still possible (for
outsiders) that the MMT is a real but not a
clinically meaningful idea in relation to patient
conditions.
4
Old dad Chiro gave us a number of fertile ideas
to explore scientifically we have yet to really
accept the challengeToday more than eleven
decades after chiropractics introduction, we
still cant prove whether subluxation is
clinically meaningful for dozens of the
conditions we treat everyday (this despite
successful practices and the many speculations
and claims we make)
5
Our founding father has given us countless
fertile ideas to explore scientifically we have
yet to really accept the challengeToday, more
than four decades after applied kinesiologys
introduction, we still cant prove -- to many in
our profession -- that AK and MMT are clinically
meaningful for dozens of the conditions we treat
everyday (this despite successful practices and
the many speculations and claims we make)
6
George J. Goodheart, DC, has investigated a
number of factors affecting neurological and
human functioning, relating them all to the MMT,
including

• Nerve dysfunction
• Neurolymphatic dysfunction
• Neurovascular dysfunction
• CSF dysfunction
• Acupuncture-meridian dysfunction

Goodheart GJ. Applied Kinesiology Research
Manuals, Privately published yearly (1964-1998)
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Robert Leach, DC, FICC has reviewed a variety of
contemporary subluxation theories, including

• Segmental dysfunction
• Facilitation
• Nerve compression
• Compressive myelopathy
• Neurodystrophy
• Axoplasmic aberration

Leach RA. The subluxation theories.
4th Edition. Baltimore Lippincott, 2004
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About Dr. Goodhearts and Leachs many
possibilities

• Any or all of these may be valid (or invalid)
• All of these models or theories involve basic
  science questions
  
• None have been adequately tested
• The available research data tells us, as yet,
  relatively little about the presumed CLINICAL
  MEANINGFULNESS of the traditional chiropractic
  subluxation and MMT findings
• To test the clinical meaningfulness of
  subluxation and the MMT we will need to perform
  CONTROLLED CLINICAL TRIALS

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The current state of AK and MMT science

• The scientific community within our profession
  HAS REPEATEDLY challenged the MMT as a mediator
  for the condition-based care provided by DCs
  (i.e., muscle weakness as a mediator of nervous
  system status)
• A number of MMT-relevant studies (including one
  RCT) are underway at Macquerie University in
  Australia, sponsored by ICAK-USA (and elsewhere)
  
• A growing evidence-base has documented the
  predictive power of the MMT for the diagnosis of
  a few specific diseases or conditions (this
  evidence will be reviewed next)
• AK is now 43 years old and our evidence-base is
  still too small!

National University of Health Sciences, formerly
National Chiropractic College
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I am not alone in realizing the limits of our
clinical research validation of the cornerstone
methods of AK

• Charlotte Leboeuf-Yde, DC, MPH, PhD reminded us
  in 1990 (painfully)
  
• A review of the type and scientific quality of
  50 papers published between 1981 and 1987 by the
  ICAK showed none of the papers included adequate
  statistical analysisno valid conclusion could be
  drawn concerning their report of findings.

Klinkoski B, Leboeuf C. A Review of the
Research Papers Published by the International
College of Applied Kinesiology from 1981 to 1987.
-- JMPT 1990 (May) 13(4) 190-194.
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But heres a BIGGER kick in the head

• To echo Dr. Leboeuf-Yde, (and despite the
  limited number of PUBLISHED outcome studies
  conducted by ICAK members throughout the years)
  there have been only 12 RCTs in which the value
  of MMT as a predictor of clinical outcomes (e.g.,
  pain, specific disease states, functional
  abilities) was studiedONLY 12

?
Its not that AK and MMT theories are false or
have been disproved, but rather that we havent
often bothered to study their CLINICAL MEANING by
means of scientific experimentation (nor weaker
forms of research)
Leboeuf-Yde C. How real is the subluxation? A
research perspective. JMPT 1998 (Sept) 21(7)
492-4.
12
The ICAK-USAs Orientation to Clinical Research
of AK MMT and the Subluxation Syndrome
13
D.D. Palmer proposed a potentially testable
clinical theory of chiropractic

• adjusting - subluxation-change - decreased
  dis-ease
  
• THIS IS A TESTABLE THEORY!!!
• May be symbolized as A - B - C, where

A stands for the independent variable
(adjusting) B stands for the mediating variabl
e (subluxation) C stands for the clinical outc
ome variables (e.g., pain measured by VAS, number
of dry nights/week in bedwetting kids)
And its NOT rocket science!
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G. J. Goodheart, Jr. proposed a potentially
testable clinical theory of chiropractic

• MMT impairments - correction - decreased
  dis-ease
  
• THIS IS OUR TESTABLE THEORY!!!
• May be symbolized as A - B - C, where

A stands for the independent variable (MMT)
B stands for the mediating variable (AK diagnos
is and then treatment of 1 of 5-factors)
C stands for the clinical outcome variables (e.
g., improved MMT and other AK findings, pain
measured by VAS, ROM, neurologic-autonomic
indicators, number of dry nights/week in
bedwetting kids), i.e. do MMT findings and the
disease-related signs and symptoms demonstrate
covariance?
And this is NOT rocket science!
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Have the ICAK-USA and its membership met the
research challenge, or

• What is the status of the MMT approach in health
  care today?
  
• ?

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A recent literature review presents the
following information
Research Supporting the Reliability and Validity
of Manual Muscle Testing Chiropractic Osteopat
hy, 2007
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How many RCTs on the MMT have been conducted?
12 Only 12 RCTs on the MMT in nearly 100 years o
f MMT usage by clinicians around the world
12
18
How many reliability studies on the MMT have been
published?
Interexaminer reliability has been reported by
Lilienfeld et al (1954), Blair (1955), Iddings et
al (1961), Silver et al (1970), Florence et al
(1984), Frese et al (1987), Barr et al (1991),
Perry et al (2004), Pollard et al (2005), and
Jain et al (2006) Test-retest reliability has b
een examined by Iddings et al
(1961), Jacobs (1981), Florence et al (1984),
Wadsworth et al (1987), Mendell and Florence
(1990), Hsieh and Phillips (1990), Barr et al
(1991), Florence et al (1992), Lawson and Caruso
(1997), Caruso and Leisman (2000), Perry et al
(2004), Pollard et al (2005), and Jain et al
(2006)
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What is the interexaminer reliability of the MMT
in these studies?
The levels of agreement attained, based upon /-
one grade were high, ranging from 82 to 97
agreement for interexaminer reliability and from
96 to 98 for test-retest reliability.
In 11 of these studies, correlation coefficients
are reported. The coefficients ranged from 0.63
to 0.98 for individual muscle groups, and from
0.57 to 1.0 for a total MMT score (comprised of
the sum of individual muscle grades).
20
In the language of Kappa coefficientsa value
greater than .75 indicates excellent agreement,
a value between .40 and .75 indicates fair to
good agreement, and a value less than .40 equals
poor agreement.
The reliability of MMT has been found to be
excellent in over 20 studies and 3 RCTs!!
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MMT therefore demonstrates excellent
interreliability between examiners.
The reliability coefficients of MMT should be
compared to those for palpation (still the most
widely taught and investigated form of
chiropractic diagnosis)
To quote Leonard John Faye, DC
Interexaminer reliability for palpation has
demonstrated poor agreement, and intraexaminer
findings are generally more reliable.
Fundamentals of Chiropractic, 2003.
Reliability A brief review of the palpation
literature, Faye LJ.
22
So breathe this in
The reliability of MMT has been found to be
excellent in over 20 studies and 3 RCTs
and MMT is more reliable than the most commonly
used method of diagnosis that is still
considered best practice in chiropractic
diagnosis today!!
23
How many RCTs have been conducted on the
prevalence of muscle dysfxn in patients with
spinal pain?
Luckily, there are now at least 100
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HOWEVER!
Despite the wealth of writing on the role of the
muscle system for spinal function in the
chiropractic, physical therapy, and manual
medicine research arenas, as recently as the
1980s MMT as a method of diagnosis for spinal
dysfunction was poorly recognized in orthodox
chiropractic and medical circles.
Cuthbert SC, Goodheart GJ. On the Reliability
and Validity of Manual Muscle Testing A
Literature Review. Chiropractic and Osteopathy
2007.
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Research on the validity of MMT
Validity is defined as the degree to which a
meaningful interpretation can be inferred from a
measurement or test.
Research The Validation of Clinical
Experience, Payton OD. FA Davis, Philadelphia,
1994.
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A common misunderstanding about studying the
validity (clinical meaningfulness) of the MMT
We cant study the validity of the MMT for
subluxation detection because we dont have a
gold standard for determining muscle
weakness. WRONG! Validity (outcome) trials
are precisely what we need to establish a gold
standard for subluxation detection/neurological
dysfunction detection that are amenable to
manipulative methods Where would a gold standa
rd for practice come from if not from validity
trials which include measurement of subluxation
indicators (like the MMT) as well as clinical
outcomes?
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Research on the validity of MMT
Lamb states (1985) that MMT has content validity
because the test construction is based on known
physiologic, anatomic and kinesiologic
principles. A number of other research papers h
ave dealt with the content and construct validity
of MMT in the diagnosis of patients.
     Lamb RI. Manual Muscle Testing. In
Rothstein JM (ed) Measurement in physical
therapy. Churchill Livingstone, New York47-55.
Scapular muscle tests in subjects with
shoulder pain and functional loss reliability
and construct validity, Michener LA, Boardman ND,
Pidcoe PE, Frith AM. Phys Ther. 2005
Nov85(11)1128-38. A comparison of muscle str
ength testing techniques in amyotrophic lateral
sclerosis, Great Lakes ALS Study Group.
Neurology. 2003 Dec 961(11)1503-7.
28
Research on the validity of MMT
Dr. Manohar Panjabi (the worlds most published
human biomechanical researcher) proposes that the
function of muscles should be placed at the
center of a sequence of events that ultimately
results in back pain.
A hypothesis of chronic back pain ligament
subfailure injuries lead to muscle control
dysfunction, Panjabi M. Eur Spine J. 2005 Jul 27.
Panjabis article is very important for those in
the manipulative professions who are evaluating
the existence and consequences of the spinal
subluxation. The key technical factor in this
hypothesis would be the MMT that makes the
detection of the muscular imbalances and spinal
dysfunction cited by Dr. Panjabi identifiable.
29
Research on the validity of MMT
Lund et al (1991) reviewed articles describing
motor function in five chronic musculoskeletal
pain conditions (temporomandibular disorders,
muscle tension headache, fibromyalgia, chronic
lower back pain, and post-exercise muscle
soreness). Their review concluded that the data
did not support the commonly held view that some
form of tonic muscular hyperactivity maintains
the pain of these conditions. Instead, in these
conditions the activity of agonist muscles is
often reduced by pain, even if this does not
arise from the muscle itself.
This literature review describes with fascinating
similarity one of the major hypotheses in AK,
namely that physical imbalances produce secondary
muscle dysfunction, specifically a muscle
inhibition (usually followed by overfacilitation
of an opposing muscle).
The pain-adaptation model a discussion of the
relationship between chronic musculoskeletal pain
and motor activity, Lund, J.P., et al. Canadian
Journal of Physiology and Pharmacology,
199169683-694.
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The convergent and discriminant validity of MMT
Convergent validity exists when a test, as
predicted, demonstrates a strong correlation
between two variables. Discriminant validity
exists when the test, as predicted, demonstrates
a low correlation between two variables. These
tests, when found to have the proper
correlations, lend support to the construct
validity of the method of testing.
Seventeen studies are in the literature that show
excellent convergent and discriminant validity of
MMT.
Cuthbert SC, Goodheart GJ. On the Reliability
and Validity of Manual Muscle Testing A
Literature Review. Chiropractic and Osteopathy
2007.
31
The concurrent validity of MMT
The concurrent validity of MMT has been examined
in studies comparing strength scores obtained
with MMT with strength readings obtained using
quantitative instruments. Eight studies are in t
he literature that show excellent concurrent
validity of MMT.
Cuthbert SC, Goodheart GJ. On the Reliability
and Validity of Manual Muscle Testing A
Literature Review. Chiropractic and Osteopathy
200714-15.
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The predictive validity and accuracy of MMT
Comparing the MMT to supporting evidence that is
obtained at a later date assesses the predictive
validity of MMT. The accuracy of a diagnostic
test is usually determined by examining the
ability of the test to assist clinicians in
making a correct diagnosis. Fourteen studies are
in the literature that show excellent predictive
validity and accuracy of the MMT.
Cuthbert SC, Goodheart GJ. On the Reliability
and Validity of Manual Muscle Testing A
Literature Review. Chiropractic and Osteopathy
200717-19.
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My Lordthe defense rests. Both the reliability
and the validity of the MMT for evaluating
symptomatic patients no longer needs any defense,
it only needs defenders.
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But lets ask How many of these nearly 200
studies are the direct result of ICAK-sponsorship
or ICAK-member authorship?
Too Few!!
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And how many clinical outcome studies have been
published by ICAK Members in the past 40 years?
Too Few!! The answer is 19 (Only 19 papers are
in the peer-reviewed literature about the
treatment outcomes for patients using AK
techniques)
?
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Lets repeat this there are only 19 papers in
the peer-reviewed literature about the treatment
outcomes for patients using AK techniques
This demonstrates a critical need for research
examining the effects of AK chiropractic
technique. This is the area of AK research
lacking the most evidence in the peer-reviewed
published literature. Without evidence from well
designed controlled studies or the sharing of
successful techniques from publishing case
reports, the treatment of patients via AK
technique will remain a nonstandard chiropractic
therapy.
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And The Big Question
The ICAKs Challenge

Who will do the research?
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In the future AK practitioners interested in the
validation of AK procedures for the world outside
of our organization must consider the following
WE need to publish adequately written case
reports and clinical trials. WE need to perform s
tudies using appropriate methodological designs.
WE need to publish those reports and studies in
peer-reviewed, indexed journals.
WE need to get outside the ICAK box and comfort
zone!
39

C.O. Watkins, DC, chairman of the board of
directors of the National Chiropractic
Association in 1942-43, urged chiropractors to
conduct clinical research in their
practices.The individual DC, Watkins insisted,
was strategically placed to gather and interpret
the phenomena of clinical practice.
C.O. Watkins, DC, chairman of the board of
directors of the National Chiropractic
Association in 1942-43, urged chiropractors to
conduct clinical research in their
practices.The individual DC, Watkins insisted,
was strategically placed to gather and interpret
the phenomena of clinical practice.
40
THE ICAK ORGANIZATION(s) AND ITS MEMBERSHIP MUST
continue this research in the rigorous,
standardized way chiropractic and biomedical
research is conducted today.
Dr. Goodheart answered Watkins call for clinical
research in his practice with astonishing
results during the past 69 years (most of it
published!).
41

ICAK must aim for greater professional
recognition throughout the healing arts by
translating Evidence-Based Research into greater
political clout influence for AK
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The ICAK Research Challenge

• To determine the clinical meaningfulness
• of the manual muscle test (MMT) in relationship
  to the subluxation-syndromeAND TO PUBLISH OUR
  FINDINGS!!

• in order to legitimize and make orthodox AK
  chiropractic technique for future generations of
  physicians

43
The ICAK Research Challenge (Research for AKs
Future )
Thank you for your attention.