The ICAK Research Challenge (Research for ICAK’s Future )

1. The ICAK Research Challenge(Research for ICAK’s Future ) Scott C. Cuthbert, DC ICAK – USA

2. To determine the clinical meaningfulness of the manual muscle test (MMT) in relationship to the subluxation-syndrome…AND TO PUBLISH OUR FINDINGS!! We’ve 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 Our Challenge:

3. 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 chiropractic’s introduction, we still can’t 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 kinesiology’s introduction, we still can’t 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)

7. 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

8. About Dr. Goodheart’s and Leach’s 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

9. 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 hasdocumented 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

10. 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 analysis…no 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.

11. But here’s 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 studied…ONLY 12… • It’s not that AK and MMT theories are false or have been disproved, but rather that we haven’t 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-USA’s 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 variable (subluxation) C: stands for the clinical outcome variables (e.g., pain measured by VAS, number of dry nights/week in bedwetting kids) *And it’s NOT rocket science!

14. 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 diagnosis 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!

15. Have the ICAK-USA and its membership met the research challenge, or… What is the status of the MMT approach in health care today? 

16. A recent literature review presents the following information: “Research Supporting the Reliability and Validity of Manual Muscle Testing” Chiropractic & Osteopathy, 2007

17. How many RCTs on the MMT have been conducted? 12… Only 12 RCTs on the MMT in nearly 100 years of 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 been 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)

19. 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 coefficients…a 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!!

21. 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

24. 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.

25. 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.

26. A common misunderstanding about studying the validity (clinical meaningfulness) of the MMT: • “We can’t study the validity of the MMT for subluxation detection because we don’t 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 standard for practice come from if not from validity trials which include measurement of subluxation indicators (like the MMT) as well as clinical outcomes?

27. 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 have 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 York:47-55. ** 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 Nov;85(11):1128-38. ** A comparison of muscle strength testing techniques in amyotrophic lateral sclerosis, Great Lakes ALS Study Group. Neurology. 2003 Dec 9;61(11):1503-7.

28. Research on the validity of MMT Dr. Manohar Panjabi (the world’s 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. Panjabi’s 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 heldview 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, 1991;69:683-694.

30. 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 the 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 2007:14-15.

32. 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 2007:17-19.

33. “My Lord…the defense rests. Both the reliability and the validity of the MMT for evaluating symptomatic patients no longer needs any defense, it only needs defenders.”

34. But let’s ask: “How many of these nearly 200 studies are the direct result of ICAK-sponsorship orICAK-member authorship…?” Too Few!!

35. 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…) 

36. Let’s 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.

37. The ICAK’s Challenge: And The Big Question: Who will do the research?

38. 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 studies 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 toconductclinical 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 toconductclinical research in their practices.The individual DC, Watkins insisted, was strategically placed to gather and interpret the phenomena of clinical practice.

40. Dr. Goodheart answered Watkin’s call for clinical research in his practice – with astonishing results during the past 69 years (most of it published!). THE ICAK ORGANIZATION(s) AND ITS MEMBERSHIP MUST continue this research in the rigorous, standardized way chiropractic and biomedical research is conducted today.

41. ICAK must aim for greater professional recognition throughout the healing arts by translating Evidence-Based Research into greater political clout & influence for AK:

42. To determine the clinical meaningfulness of the manual muscle test (MMT) in relationship to the subluxation-syndrome…AND TO PUBLISH OUR FINDINGS!! …in order to legitimize and make orthodox AK chiropractic technique for future generations of physicians… The ICAK Research Challenge:

43. The ICAK Research Challenge(Research for AK’s Future ) Thank you for your attention.