Chiropractic & BioMed Central

Review Open Access On the reliability and validity of manual muscle testing: a literature review Scott C Cuthbert*1 and George J Goodheart Jr2

Address: 1Chiropractic Health Center, 255 West Abriendo Avenue, Pueblo, CO 81004, USA and 2Goodheart Zatkin Hack and Associates, 20567 Mack Avenue, Grosse Pointe Woods, MI 48236-1655, USA Email: Scott C Cuthbert* - [email protected]; George J Goodheart - [email protected] * Corresponding author

Published: 6 March 2007 Received: 14 February 2007 Accepted: 6 March 2007 & Osteopathy 2007, 15:4 doi:10.1186/1746-1340-15-4 This article is available from: http://www.chiroandosteo.com/content/15/1/4 © 2007 Cuthbert and Goodheart; licensee BioMed Central Ltd. This is an Open Access article distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/by/2.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited.

Abstract observational cohort studies demonstrated good external Introduction and internal validity, and the 12 randomized controlled A body of basic science and clinical research has been gen- trials (RCTs) that were reviewed show that MMT findings erated on the manual muscle test (MMT) since its first were not dependent upon examiner bias. peer-reviewed publication in 1915. The aim of this report is to provide an historical overview, literature review, Conclusion description, synthesis and critique of the reliability and The MMT employed by chiropractors, physical therapists, validity of MMT in the evaluation of the musculoskeletal and neurologists was shown to be a clinically useful tool, and nervous systems. but its ultimate scientific validation and application requires testing that employs sophisticated research mod- Methods els in the areas of neurophysiology, biomechanics, RCTs, Online resources were searched including Pubmed and and statistical analysis. CINAHL (each from inception to June 2006). The search terms manual muscle testing or manual muscle test were Review used. Relevant peer-reviewed studies, commentaries, and The role of the muscle system in spinal function has reviews were selected. The two reviewers assessed data become increasingly well acknowledged. Manual muscle quality independently, with selection standards based on testing (MMT) as a method of diagnosis for spinal dys- predefined methodologic criteria. Studies of MMT were function has not been well utilized. This paper will categorized by research content type: inter- and intra- present evidence that the MMT can be a legitimate and examiner reliability studies, and construct, content, con- useful evaluation tool for the assessment of the muscu- current and predictive validity studies. Each study was loskeletal and nervous systems. reviewed in terms of its quality and contribution to knowledge regarding MMT, and its findings presented. There are many ways of examining the nervous system and the musculoskeletal system. It has been proposed that Results the term neuromusculoskeletal system be adopted More than 100 studies related to MMT and the applied because examination of the one may reflect the status of kinesiology chiropractic technique (AK) that employs the other [1,2]. The evaluation methods of many manip- MMT in its methodology were reviewed, including studies ulative therapists often focus at either end of the nervous on the clinical efficacy of MMT in the diagnosis of patients system, and this paper suggests that MMT provides a with symptomatology. With regard to analysis there is evi- method of examining both (the central and the periph- dence for good reliability and validity in the use of MMT eral) ends. for patients with neuromusculoskeletal dysfunction. The

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MMT is the most commonly used method for document- knee, foot, and shoulder pain, and included MMT for the ing impairments in muscle strength. Limited muscle test- evaluation of patients with post-polio syndrome, amyo- ing methods are taught in a number of chiropractic trophic lateral sclerosis, muscular dystrophy, cerebral schools around the world, however in 2006 a major palsy, Down syndrome, mastalgia, hypothyroidism, dys- "stand alone" chiropractic technique that employs MMT insulinism, enuresis and several other disorders of child- for the evaluation of patients known as applied kinesiol- hood. ogy chiropractic technique (AK), turned 42 years old. We propose in this review to look at the research status of After abstracts were selected for relevance and the papers MMT in the manual examination of the nervous system's acquired and reviewed, the literature was sorted according status. The early years of the AK method are related else- to relevance and quality. Inclusion criteria were that the where in detail [3]. The specific protocols and clinical report had a Cohen's kappa coefficient of 0.50 or higher objectives of the technique have been described in previ- (the magnitude of the effect size shown in the study to be ous publications [3-9]. significant) in regards to the intra- and inter-examiner reli- ability, and/or the validity (construct and content validity, AK has therefore been used by a proportion of the chiro- convergent and discriminant validity, concurrent and pre- practic profession for over 42 years and is now used by dictive validity). This selection criteria is consistent with other healing professions. In a survey by the National the one suggested by Swinkels et al for the evaluation of Board of Chiropractic Examiners in 2000, 43.2% of the quality of research literature [15]. Randomized clini- respondents stated that they used in cal trials (n = 12), prospective cohort studies (n = 26), ret- their practices, up from 37.2% of respondents who rospective studies (n = 17), cross-sectional studies (n = reported they used AK in 1991, [10-12] with similar num- 26), case control studies (n = 10), and single-subject case bers reported in Australia [13]. The general public's aware- series and case reports (n = 19) were the types of studies ness of MMT and AK has also been increased worldwide reviewed. Studies with a control group (a randomized by virtue of the patient education program Touch for clinical trial), examiner blinding, and pre- and post-test Health (T4H) designed by an International College of design are indicated in the descriptions of each study. Applied Kinesiology (ICAK) diplomate, John Thie. T4H Duplicates and articles published in non-peer-reviewed was one of the first public self-help programs and there literature were excluded. are claims that it is the fastest growing "body work" pro- gram in the world, used by over 10 million people [14]. Statistical presentations of the data are presented showing the average correlation coefficients of MMT examination For the purposes of this review we define MMT as a diag- upon the different patient populations for each study. nostic tool and AK as a system for its use and based on the findings of the MMT Operational Definitions and History of the Manual Muscle Test In this paper we pose the following questions: 1) "Is the In order to be meaningful, all measurements must be MMT approach worthy of scientific merit?" and 2) "How based on some type of operational definition. An opera- can new diagnostic and treatment techniques employing tional definition is a description of the methods, tools, MMT be critiqued for scientific merit?" and 3) "Does this and procedures required to make an observation (i.e. a evidence add scientific support to chiropractic techniques definition that is specific and allows objective measure- (such as AK) that employ the MMT?" ment). Kaminsky and Fletcher et al provide clinicians with some strategies to critically analyze the scientific merit of Another main objective of this literature review was to manual [16,17]. investigate the evidence for intraexaminer reliability, interexaminer reliability, and validity of MMT in the A basic understanding of operational definitions is assessment of patients. required in order to make judgments about the methods used in articles and to know which research findings Methods should be implemented in practice. For example, how Online resources were searched using Pubmed and should we judge the value of the MMT for the gluteus CINAHL (Cumulative Index to Nursing and Allied Health maximus or gluteus medius muscles in cases of sacroiliac literature). The search terms "manual muscle test", "man- joint pain and dysfunction, knowing that statements ual muscle testing", and "applied kinesiology" found over range from "weakness of the gluteals is usually present in 100 articles in which the MMT was used to document dysfunction of the sacroiliac joint" (Janda 1964) [18] to strength in patients with 17 (primarily pain related) dis- "the results of this study cast doubt on the suitability of eases/disorders, ranging from and sacroil- manual muscle testing as a screening test for strength iac joint pain to neck pain, post-whiplash syndrome, impairments"? (Bohannon 2005) [19].

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Within the chiropractic profession, the ICAK has estab- pressure, i.e., the muscle suddenly becomes unable to lished an operational definition for the use of the MMT: resist the test pressure.

"Manual muscle tests evaluate the ability of the nervous For example in the seated test for the rectus femoris mus- system to adapt the muscle to meet the changing pressure cle, a seated subject is asked to flex his knee toward his of the examiner's test. This requires that the examiner be chest 10 degrees; when that position is reached, the exam- trained in the anatomy, physiology, and neurology of iner applies resistance at the knee, trying to force the hip muscle function. The action of the muscle being tested, as to "break" its hold and move the knee downward into well as the role of synergistic muscles, must be under- extension. The ability of a muscle to lengthen but to gen- stood. Manual muscle testing is both a science and an art. erate enough force to overcome resistance is what is qual- To achieve accurate results, muscle tests must be per- ified by the examiner and termed "Strong" or "Weak." formed according to a precise testing protocol. The fol- lowing factors must be carefully considered when testing The grading system is based on muscle performance in muscles in clinical and research settings: relation to the magnitude of manual resistance applied by the examiner. Scores are ranked from no contraction to a • Proper positioning so the test muscle is the prime mover contraction that can be performed against gravity and can accept "maximal" resistance by the examiner, depending • Adequate stabilization of regional anatomy on the size of the muscle and the examiner's strength. However, in the AK use of MMT the implication of grades • Observation of the manner in which the patient or sub- is limited to an interpretation of 'better' or 'worse', ject assumes and maintains the test position 'stronger' or 'weaker,' and no assumption is made about the magnitude of difference between grades. • Observation of the manner in which the patient or sub- ject performs the test MMT procedures are also commonly employed in clinical neurology as a means of subjectively evaluating muscle • Consistent timing, pressure, and position function. The examiner in the application of force to the subject's resistance evaluates the muscle groups being • Avoidance of preconceived impressions regarding the studied as subjectively "weak" or "strong" on a 5-point test outcome scale [24].

• Nonpainful contacts – nonpainful execution of the test MMT is employed by physical therapists to determine the grades of strength in patients with pathological problems • Contraindications due to age, debilitative disease, acute and neurologic or physical injuries (strokes, post-polio pain, and local pathology or inflammation" syndromes, fractures, post-surgical disabilities, etc.). The physical therapist's patients are often initially examined In research, the "break test" is the proce- by a medical doctor who supervises the physical thera- dure most commonly used for MMT, and it has been pist's rehabilitation programs that may involve isometric, extensively studied [20-22]. This method of MMT is also isokinetic, and isotonic muscle training regimes for the the main test used in chiropractic, developed originally gradual rehabilitation of muscle function (often involving from the work of Kendall and Kendall [21,23]. instruments and machinery).

In physical therapy the "break test" has the following In the absence of a pathological neurological deficit operational definition [20-22]. The subject is instructed to (pathological deficits were originally what physicians contract the tested muscle maximally in the vector that sought to find using MMT), [25,26] clinical inferences are "isolates" the muscle. The examiner resists this pressure made based upon the result of the MMT. This method of until the examiner detects no increase in force against his MMT is used in both chiropractic and physical therapy to hand. At this point an additional small force is exerted at determine a patient's progress during therapy [3-9,20-23]. a tangent to the arc created by the body part being tested. The initial increase of force up to a maximum voluntary MMT, when employed by AK chiropractors, is used to strength does not exceed 1 sec., and the increase of pres- determine whether manipulable impairments to neuro- sure applied by the examiner does not exceed a 1-second logical function (controlling muscle function) exist. For duration. "Strong" muscles are defined as those that are example, chiropractic management using MMT for a able to adapt to the additional force and maintain their patient with carpal tunnel syndrome could involve assess- contraction with no weakening effect. "Weak" muscles are ment of the opponens policis and flexor digiti minimi defined as those unable to adapt to the slight increase in muscles (innervated by the median and radial nerves),

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and then adjustment as indicated to the carpal bones, the Kendall et al (1993) [21] state: radius and ulna, attention to an inhibited (on MMT) pro- nator teres muscle, adjustment of the cervical or thoracic "As tools, our hands are the most sensitive, fine tuned spines, and evaluation of cranial nerve XI through MMT of instruments available. One hand of the examiner posi- the sternocleidomastoid and upper trapezius muscles. tions and stabilizes the part adjacent to the tested part. Any or all of these factors may require treatment in order The other hand determines the pain-free range of motion to strengthen the inhibited opponens policis and flexor and guides the tested part into precise test position, giving digiti minimi muscles that are evidence of the carpal tun- the appropriate amount of pressure to determine the nel syndrome. This "continuous nervous system" thinking strength. All the while this instrument we call the hand is and testing may allow the identification of contributing hooked up to the most marvelous computer ever created. sites to a pain state. It is the examiner's very own personal computer and it can store valuable and useful information of the basis of The expectation in a chiropractic setting is that the proper which judgments about evaluation and treatment can be therapy will immediately improve muscle strength upon made. Such information contains objective data that is MMT, taking the patient from "weak" to "strong." This is obtained without sacrificing the art and science of manual the reason that in most chiropractic settings, the grading muscle testing to the demand for objectivity." system of muscle evaluation does not have as much signif- icance as it does in physical therapy settings. Chiropractic According to Walther (1988) [23]: therapy may produce rapid responses for the innervation of muscles because the basic therapy required for chiro- "Presently the best 'instrument' to perform manual mus- practic patients is decompression of the nervous system. It cle testing is a well-trained examiner, using his perception is purported that this can be done readily with chiroprac- of time and force with knowledge of anatomy and physi- tic manipulative therapy (CMT) [27-30]. ology of muscle testing."

When performed by an examiner's hands MMT may not Regardless of the methods or equipment one uses to be just testing for actual muscle strength; rather it may standardize MMT in a clinical or research setting, it is most also test for the nervous system's ability to adapt the mus- important that the test protocol be highly reproducible by cle to the changing pressure of the examiner's test. A nerv- the original examiner and by others. ous system functioning optimally will immediately attempt to adapt a muscle's activity to meet the demands Results of the test. There appears to be a delay in the recruitment Research on the Reliability of the MMT of muscle motor units when the nervous system is func- One way researchers determine if a clinical test is consist- tioning inadequately [66,71-73,82,90,102]. This delay ent and repeatable over several trials is to analyze its reli- varies with the severity of the nervous system's impair- ability. The reliability of a diagnostic method is the ment, and influences the amount of weakness shown dur- consistency of that measurement when repeated. Depend- ing the MMT. ing on the type of measurement that is performed, differ- ent types of reliability coefficients can be calculated. In all Determining the ideal operational definition of a MMT coefficients, the closer the value is to 1, the higher the reli- can be difficult given the large number of test variations ability. For instance, calculating Cohen's kappa coefficient that exist. All of the tests described by Kendall, allows the researcher to determine how much agreement Wadsworth, Goodheart, Walther and others [3,20-23] existed between two or more doctors performing MMT on involve multiple joint movements and handling tech- patients with low back pain. A value greater than .75 indi- niques. This results in a large number of variables that are cates "excellent" agreement, a value between .40 and .75 difficult to control. indicates "fair to good" agreement, and a value less than .40 indicates "poor" agreement [31]. The advantage of the Because of the variability possible during a MMT, several kappa coefficient is that it is a measure of chance corrected studies examining MMT have used specialized instrumen- concordance, meaning that it corrects the observed agree- tation to provide support for the extremity tested and for ment for agreement that might occur by chance alone. standardization of joint position. Throughout its history There are difficulties with the interpretation of kappa and manual muscle testing has been performed by practition- correlation coefficients that have been described by Fein- ers' hands, isokinetic machines, and other handheld stein and Brennan [32,33]. To examine the reliability coef- devices. However, isokinetic machines and dynamome- ficients calculated by the authors of MMT studies, see ters for more objective testing of muscles are still too Table 1. expensive or cumbersome for clinical use, but this equip- ment is useful for research purposes [20-23].

Page 4 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table 1:Characteristics of 10 studies ofthe intraexaminer and Barr et al et Barr Florence etal (2000) Caruso andLeisman al et Escolar Examiner al Perry et Subjects Pollard etal Authors, date 42 43 55 56 (1991) 36 boys 36 (11.7 +/- 3.9years) (1991) 20)* 16patientswith post-polio ** (2004) 20)* 0 outesNovice examiner (5 106volunteers (2005) ** 47 12 children withmuscular (2001) (1992) ** 102 boys 102 aged5 to15 (1992) ** 36 nothing about MMTorAK with Duchenneor Becker 27 volunteerswho knew patients withof signs hip extensor weakness and syndrome;patients 18 without pathology; 26 post-polio syndrome muscular dystrophy. dystrophy years. 12 novice andexperienced experienced examiner (15 years MMT experience) years MMT chiropractic student; chiropractic hsclteait A doub therapists Physical Several examiners Supine MMT of hip hip MMTof Supine examiners Several 2 examiners To show To the difference 2 examiners examiners interexaminer reliability ofmanu s Design Findings andstatistics Findings Design s th year) year) traditional prone test of hip by MMTfor function, range extremities wereevaluated muscle strength in patients Interexaminer reliability of reliabilityof Interexaminer quantitative muscle testing quantitative muscle with Duchenne's muscular To determine reliability of To (QMT, an instrument for an instrument (QMT, effects of prednisone on MMT and dynamometer of motion, and strength. patients with post-polio 2 common muscletests "strong" muscles, using using muscles, "strong" compared to strength trial todocument the between "weak" and extensor musclesin measuring strength) compared toMMT values obtained by obtained values dystrophy (DMD). extensor strength Upper andlower le-blind, multicenter le-blind, multicenter syndrome testing al muscle (RCTs testing indica Deltoid muscle showed Cohen Deltoid muscleshowed proximal muscles the having higher reliabilit "inhibition" or weakness made by examiner corresponding ICC was .80 to .96. Results co was .80to.96.Results ICC corresponding strength in boys with DMD when consecutive evaluations are performed by the same MMT was not as reliable among noviceexaminers as QMT. With adequate training of significant differences inmean muscletorque Study showed that examiners with over 5 over Study showedthatexaminerswith individual muscle strengthgradeswasana individual Good interexaminerreliab that these assessment measures aresufficient Reliability testing showed ex showed Reliability testing strength gradesranged from.80 to.99,with thosegravity-eliminated in the range Reliabilityof muscle strength grades obtained for individualmuscle groupsand of and reproducibility (98.2%) and reproducibility(98.2%) reliability of grades for individual muscle individual for grades of reliability collaborative efforts. efforts. These collaborative Thewere data analyzed using intraclass correlationFor the coefficients (ICCs). sufficient statisticalto power detect chan scoring the highest.that Concludedth MMT in patients with symptomatic post-polio syndromeaffecting hipextensor examiners an interclass correlation coef aninterclasscorrelation examiners interevaluator phase, ICCs for MMT wa MMT ICCs for phase, interevaluator ted by**) ility shownbetweenexperien when their outcomeswere when their cellent agreement (82%). Su agreement (82%). cellent using the dynamometer. kappa value (k 0.62) and psoas muscle showed (k 0.67). results can be usedtodesi can results muscles wasexcellent. physical therapist. e MMT was reliable for assessing muscle was reliable e MMT lyzed usingCohen's weightedKappa.The was corroborated by test pressure analysis y values. Thereliability y values. groups ranged from .65to.93,withthe groups ranged from years experience usi experience years ficient> 0.75 wasachieved for MMT. gesrate inthe ofdisease progression. nfirm andextend observations byothers (P < .01) strength. Predictive validityof strength. Predictive .01) (P< s .90;For the intraevaluatorphase, ly reliable for usein for ly reliable gn clinicaltrialsthathave ced and novice examiners. ced andnovice bjects with pathology had bjects withpathology compared. Perception compared. Perception of ng AK had reliability ng AK of individual muscle of individualmuscle multiinstitutional

Page 5 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table 1: Characteristics of 10 Characteristicsof Table 1: Jacobs Jacobs Florence et al Wadsworth et al Hsieh andPhillips 44 18)65 patientssuspected with (1981) 34 18)Patients with Duchenne (1984) 45 46 18)5 musclegroups on11 (1987) 19)1 smtmtcsbet 3chir asymptomatic subjects 15 (1990) studies of the intraexaminer and studies oftheintraexaminer Muscular Dystrophy thyroid dysfunction patients hsclteait Toevaluate the physicaltherapists hsclteait To therapists physical 2 chiropractors To compareAKdiagnostic To chiropractors 2 interexaminer reliabilit opractors To To determine the reliability opractors comparing doctor-initiated and patient-initiated MMT (interobserver) reliability reliability (interobserver) procedures to assessprocedures to the hand-held dynamometer of manualdynamometry findings with laboratory laboratory with findings using AK style of MMT, of style using AK efficacy oftreatment of reliability of MMT and reliability ofMMT Duchenne muscular compare the intrarater (intraobserver) and and (intraobserver) of MMTevaluation y of manual muscle testing (RCTsindica manualmuscletesting y of dystrophy. findings tests therapeutic proceduredoesornot have MMT anddynamometry are reliable testing methods, giventhe conditions describedin MMT method. The intertester re The intertester MMT method. 0.75, and0.76method; withdoctor-initiated0.99, 0.96,0.97 and when patient-initiated examiner's MMT scores when muscle groups tested dyname muscle groups test-retest reliabilitycoefficients for two muscle groups tested could manually not be calculated becausethe values between subjects wereidentical. Concludedthat both respectively fordoctor-initiated method;and 0.95 and0.96 for the patient-initiated The correlation coefficients we coefficients The correlation Showed there was significant improvement in Intratester reliability and corre Intratester reliabilityand in MMT. Author's concluded that MMT de Author's concludedthatMMT in MMT. Thisdouble-blind study demonstrated an 81.9% agreementbetween two testers, method that providedanobjective founda ted by**) indicating goodinte trically and fortwomuscle trically the examiner had more clinical had more the examiner (Continued) liability coefficients were0. liability coefficients re high and significantly different from zero for four four zero for from different significantly and high re lation coefficients for tester for lation coefficients dystrophy. this study. method. r-examiner reliability. r-examiner monstrated reliability for anevaluation reliabilityfor monstrated antreatingin effect Duchenne muscular tion on whichtion on toclaimifadrug or thedegreecons of groups tested manually. The testedgroups manually. 77 and0.59onday12 s 1, 2, and 3 were 0.55, 3 were0.55, s 1,2,and experience andtraining experience istency ofagiven istency

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This review of the literature shows the importance of clin- outcomes and showed that these changes were not attrib- ical experience and expertise, and this factor has been utable to decreased or increased testing force from the highlighted in many papers discussing the reliability of practitioner performing the tests [49]. the MMT [20-23,34-36]. The skills of the examiners con- ducting studies on MMT and their skills in interpreting the Table 1 provides a brief synopsis of several studies that derived information will affect the usefulness of MMT investigated the reliability of MMT in both healthy and data. The examiner is obliged to follow a standardized symptomatic subjects. The Table does not show the sub- protocol that specifies patient position, the precise align- stantial amount of normative data that exists regarding ment of the muscle being tested, the direction of the resist- muscle strength relating to patient age, position, tasks per- ing force applied to the patient, and the verbal instruction formed, and so on [51,52]. There also exists a large body or demonstration to the patient. All of these precautions of data demonstrating how electromyographic signals are have proven necessary to reliably study the validity of the used as an objective representation of neuromuscular MMT in the diagnosis of patients with symptomatology. activity in patients. The EMG is a valid index of motor unit recruitment and reflects the extent to which the muscle is There was significant improvement in the degree of con- active; however there are some difficulties with the sensi- sistency of a given examiner's scores (as noted by Florence tivity and specificity of electrodiagnosis [53]. All of these et al 1984) [34] when the examiner had more clinical studies using MMT and instrumentation have collectively experience and training in MMT. Mendell and Florence made a significant contribution to the study of neuromus- (1990) [35], Caruso and Leisman (2000), [36] and many cular function and represent different aspects of the mus- other researchers of MMT have discussed the importance cular activity going on in patients. of considering the examiner's training on the outcomes of studies that assess strength via MMT [20-23]. Research On the Validity of MMT The next section of Results looks at the relationship Interexaminer reliability of the MMT has been reported by between muscle strength as measured by MMT findings Lilienfeld et al (1954) [37], Blair (1955)[38], Iddings et al and the functional status of patients with a variety of (1961) [39], Silver et al (1970) [40], Florence et al (1984) symptoms. [34], Frese et al (1987) [41], Barr et al (1991) [42] and Perry et al (2004) [43]. Test-retest reliability has been Validity is defined as the degree to which a meaningful examined by Iddings et al (1961), [39] Jacobs (1981) interpretation can be inferred from a measurement or test. [44], Florence et al (1984) [34], Wadsworth et al (1987) Payton (1994) [58] states that validity refers to the appro- [45], Mendell and Florence (1990) [35], Hsieh and Phil- priateness, truthfulness, authenticity, or effectiveness of lips (1990) [46], Barr et al (1991) [42], Florence et al an observation or measurement. In examining research (1992) [47], Lawson and Calderon (1997) [48], Caruso studies and examination techniques using MMT and spi- and Leisman (2000) [36], and Perry et al (2004) [43]. The nal manipulative therapy (SMT), clinicians need to levels of agreement attained, based upon +/- one grade become familiar with several different types of validity. were high, ranging from 82% to 97% agreement for interexaminer reliability and from 96% to 98% for test- Construct and content validity of MMT retest reliability. The results of these studies indicate that Construct and content validity are two types of theoretical in order to be confident that a true change in strength has or conceptual validity. Generally, construct and content occurred; MMT scores must change more than one full validity are proven through logical argument rather than grade. In clinical research studies on chiropractic treat- experimental study. Construct validity is the theoretical ment, the change from an "inhibited" or "weak" muscle to foundation on which all other types of validity depend. a "facilitated" or "strong" muscle is a change in at least Construct validity attempts to answer the questions, "Can one full grade, and is a common result of successful treat- I use this measurement to make a specific inference?" and ment. "What does the result of this test mean?"

In the latter 11 studies, correlation coefficients are From the original work of Lovett (1915) [25,26] who reported. These coefficients ranged from 0.63 to 0.98 for developed MMT as a method to determine muscle weak- individual muscle groups, and from 0.57 to 1.0 for a total ness in polio patients with damage to anterior horn cells MMT score (comprised of the sum of individual muscle in the spinal cord, to the measurement of physical weak- grades). ness from faulty and painful postural conditions, injuries, and congenital deformities [20-23,59,60], to neurologists Using force measurements from both practitioner and who adopted MMT as part of their physical diagnostic patient, Leisman and Zenhausern demonstrated a signifi- skills, [24] to the use of MMT by some chiropractors cant difference in "strong" versus "weak" muscle testing beginning with AK technique to diagnose structural,

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chemical, and mental dysfunctions, the concept of manu- rupted transducer signals (that research suggests may be ally examining the nervous system's status through MMT detected by EMG, dynamometers, and MMT), which lead continues to evolve and gain adherents to this method to corrupted muscle response patterns produced by the [61]. The validity of Lovett's original MMT methods was neuromuscular control unit. based on the theoretical construct that properly inner- vated muscles could generate greater tension than the par- This article may be important for those in the manipula- tially innervated muscles present in patients with anterior tive professions who are evaluating the existence and con- horn cell damage. sequences of spinal dysfunction. The key technical factor in this hypothesis would be the MMT that makes the AK extends Lovett's construct and theorizes that physical, detection of the muscular imbalances and spinal dysfunc- chemical, and mental/emotional disturbances are associ- tion cited by Panjabi identifiable. Another paper by ated with secondary muscle dysfunction affecting the Hodges et al (2003) suggests this hypothesis also [68]. anterior horn of the spinal cord – specifically producing a Pickar has also shown there is a substantial experimental muscle inhibition (often followed by overfacilitation of body of evidence indicating that an opposing muscle and producing postural distortions in impacts primary afferent neurons from paraspinal tissues, patients). Goodheart suggested, contrary to the physio- immediately effecting the motor control system and pain therapeutic understanding of the time, that muscle spasm processing [69]. was not the major initiator of structural imbalance [3,6]. According to Goodheart, the primary cause of structural Lund et al (1991) [70] reviewed articles describing motor imbalance is muscle weakness. Goodheart theorized that function in five chronic musculoskeletal pain conditions the primary weakness of the antagonist to the spastic mus- (temporomandibular disorders, muscle tension head- cle to be the problem. Muscle weakness (as observed by ache, fibromyalgia, chronic lower back pain, and post- MMT) is understood as an inhibition of motor neurons exercise muscle soreness). Their review concluded that the located in the spinal cord's anterior horn motor neuron data did not support the commonly held view that some pool [62]. form of tonic muscular hyperactivity maintains the pain of these conditions. Instead, they maintain that in these Chiropractic AK research has also suggested that there are conditions the activity of agonist muscles is often reduced five factors or systems to consider in the evaluation of by pain, even if this does not arise from the muscle itself. muscle function: the nervous system, the lymphatic sys- On the other hand, pain causes small increases in the level tem, the blood vascular system, cerebrospinal fluid flow, of activity of the antagonist. As a consequence of these and the system [3,6]. changes, force production and the range and velocity of movement of the affected body part are thought to be Lamb states (1985) that MMT has content validity reduced. because the test construction is based on known physio- logic, anatomic and kinesiologic principles [63]. A This paper describes with fascinating similarity one of the number of research papers have dealt with this specific major hypotheses in MMT and chiropractic, namely that aspect of MMT in the diagnosis of patients [64,65]. physical imbalances produce secondary muscle dysfunc- tion, specifically a muscle inhibition (usually followed by There have been a number of papers that have specifically overfacilitation of an opposing muscle). A paper by Falla described the validity of MMT in relationship to patients et al (2004) described a similar model but involving with low back pain. The correlation between "inhibited" patients with chronic neck pain [71]. A paper by Mellor et or "weak" MMT findings and low back pain has been well al (2005) presented this model in relationship to anterior established in the research literature. Several papers have knee pain [72], and Cowan et al (2004) in relationship to shown that MMT is relevant and can be employed in a chronic groin pain with another paper demonstrating this reliable way for patients with low back pain [63,66]. In a mechanism in patellofemoral pain syndrome [73,74]. paper by Panjabi, it is proposed that the function of mus- cles, as both a cause and a consequence of mechanorecep- According to several studies, patients with low-back pain tor dysfunction in chronic back pain patients, should be have lower mean trunk strength than asymptomatic sub- placed at the center of a sequence of events that ultimately jects (Nummi et al 1978, Addison & Schultz 1980, Karvo- results in back pain [67]. This paper argues that as a result nen et al 1980, MacNeill et al 1980, Nordgren et al 1980, of spinal dysfunctions (articular dysfunction, spinal Mayer et al 1985, Triano 1987, Rantanen et al 1993, Hides lesions, and somatic dysfunction are terms also et al 1996, Hodges et al 1996) [75-83]. Lifting strength is employed), muscle coordination and individual muscle also decreased in persons disabled with chronic low-back force characteristics are disrupted, i.e. inhibited muscles pain (Chaffin & Park, 1973, Biering-Sorensen 1984, on MMT. The injured mechanoreceptors generate cor- Mayer et al 1988) [84-86]. Pain itself is possibly a

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strength-reducing factor, as is the duration of back pain low back pain in patients with and without low back pain (Nachemson & Lindh 1969) [87]. [54]. The study also aimed to determine the sensitivity and specificity of the procedure. Of 67 subjects who These studies do not always clarify whether a muscle reported low back pain, 58 (86.6%) reported a positive weakness or imbalance is primary or secondary to low- test of both low back pain and ICV point test. Of 33 sub- back pain. In spite of this, muscle weakness has frequently jects, 32 (97%) with no back pain positively reported no been cited as a primary factor in the etiology of low-back response to the ICV point test. Nine (9) subjects (13.4%) pain. (See Table 2) This is one of the bases on which Lamb reported false negative ICV tests and low back pain, and 1 argues that MMT has content validity [63]. subject (3%) reported a false positive response for ICV test and no low back pain. Their results demonstrated that the A number of general MMTs have been employed by all low back pain group had significantly greater positive primary contact practitioners for the examination of results (inhibited MMT) than those of the pain free group. patients with sciatic neuralgia. Dorsiflexion of the foot Assuming this study is sound it may demonstrate the con- and the great toe, plantar flexion of the foot and great toe, vergent validity of the method of MMT in relationship to quadriceps weakness, and peroneal muscle tests are each patients with low back pain. The discriminant validity of indicative of the status of the sciatic nerve and its branches MMT was shown in this study by its ability to find a low [88,89]. number of positive test results in the pain free groups. However, before accepting these results it would be To test the construct validity of these original hypotheses, important for them to be reproduced in another study. researchers have attempted to quantify the muscle weak- ness that occurs with specific clinical conditions such as Studies like the ones described above and later in this low back pain and soft tissue injuries. (See Table 2) review (that examine whether MMT can discriminate between abnormal and normal spinal function and pain The Convergent and Discriminant Validity of MMT states) contribute to the evidence available to clinicians Convergent validity exists when a test, as predicted, dem- supporting the validity of MMT. onstrates a strong correlation between two variables. Dis- criminant validity exists when the test, as predicted, Concurrent Validity of MMT demonstrates a low correlation between two variables. The concurrent validity of MMT has also been examined These tests, when found to have the proper correlations, in several studies comparing strength scores obtained by lend support to the construct validity of the method of MMT with strength readings obtained using quantitative testing. instruments. The concurrent validity of a test refers to a test's ability to produce similar results when compared to The convergent and discriminant validity of MMT was a similar test that has established validity. The concurrent examined in a study by Jepsen et al (2006) [93]. They validity of the MMT would be examined when the MMT is examined the relationship between MMT findings in compared to a "gold standard" confirmation diagnosis patients with and without upper limb complaints. The using EMG and/or dynamometer testing, for instance. examiners were blinded as to patient-related information, Many studies have compared the findings of MMT with and examined 14 muscles in terms of normal or reduced dynamometer tests favorably. (See Table 3) strength. With a median odds ratio of 4.0 (95%CI, 2.5– 7.7), reduced strength was significantly associated with Marino et al (1982) [50] and Wadsworth et al (1987) [45] the presence of symptoms. showed significant reliability between handheld dynamometers and MMT. Scores measured with the Perry et al (2004) showed excellent convergent and discri- dynamometers were consistent with the examiner's per- minant validity of MMT in 16 patients with and 18 ception of muscle weakness (P less than 0.001) in both patients without post-polio syndrome pathology. Subjects studies. with pathology showed significant differences in mean muscle strength (P < 0.01). The predictive validity of MMT Leisman et al (1995) showed that chiropractic muscle in patients with symptomatic post-polio syndrome affect- testing procedures could be objectively evaluated through ing the hip extensor muscles was found to be excellent quantification of the electrical characteristics of muscles, [43]. and that the course of chiropractic treatments can be objectively plotted over time [49]. Pollard et al (2006) also studied the convergent and dis- criminant validity of MMT in order to determine if a pos- The use of EMG or dynamometers as a gold standard is itive correlation of therapy localization to the "ileocecal arguable however because false positive or negative find- valve point" producing weakness on MMT could predict ings may exist, and these instruments measure different

Page 9 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table 2:Characteristics of 8Studies showingtheprevalence of mu Authors, date Subjects Design Findings and statistics Findings Biering-Sorensen Triano et al Design Hodges etal Falla etal Subjects Hossain etal Authors, date 71 20)* 10 patients wi ** (2004) 91 83 90 (1987) ** 41 low-back low-back 41 ** (1987) 19)* 15 patients with lowback pain and ** (1996) (2005) Literature review Gait analysis Gait stud Literature review (2005) 85 18)49mnad49wmnThe examination consisted ofanthropometric measurements, 449and men 479 women (1984) 15 matched control subjects pain-free controlsubjects 10 controls th chronic neckpain; chronic th pain patients; and 7 scle dysfunctioninpatientswi maximus fibres –lyingalmostperp maximus fibres tran weight the jointandeffective flexibility/elasticity measurements flexibility/elasticity muscle activation – this contribut muscle activation–this extension inresponsea to visual stimulus. Electromyographic important muscle that can also important musclethatcan To examine relations among s Subjectsperformed rapidshoulder flexion, abduction, and To compare activityofdeep To are oriented forpurpose. this activity of the abdominal, and activity oftheabdominal, well astests for trunk musclestrength and endurance. proximal attachment tosacrotuberous ligament. muscles during a test of craniocervical flexion. atest craniocervical during muscles of measures of low-back of measures recorded bysurface electrodes. ies reviewed show an orderly sequence of ies reviewedshowanorderly th back pain (RCTs indicated b indicated (RCTs pain back th and superficial cervical flexor cervical and superficial ome objective and subjective ome objectiveandsubjective sfer to the lower limb. Gluteus Gluteus limb. lower the to sfer influence joint stabilitybyits joint influence Biceps femoris is another of thebackand endicular toth endicular lumbar multifidus muscles es to efficient stabilization of stabilization es toefficient -related disability -related e jointsurfaces hamstrings, as y **) onset of onset of contraction of transver Oswestry disability score related si Oswestry disabilityscorerelated Showed a strong linear relation between the electromyographic can resultcan frommalrecruitment of gluteus maximus motor units performance of the craniocervical of the craniocervical performance during weight bearing, resulting disability score (P less than .05). .05). lessthan (P score disability trouble (LBT) in men and that men with hypermobile backs are in patients with low back pain with all movements. The delayed incremental stages ofthe craniocervical flexion test forcontrol more liable tocontractmore muscles LBT.Weaktrunk andreduced Contraction of transversus abd oftransversus Contraction may be used as objective indica beusedasmay weight bearing. It is proposed Itisproposed weight bearing. signal levels,trunk strength ratios, andranges oftrunkmotion The mainfindings werethatendurance isometric good of the lower, poor joint st lower, poorjoint linkage intransmissionof weight from theupperthe limbsto flexion. Mean trunk st flexibility/elasticity of flexibility/elasticity back musclesfirst-ti mayprevent Altered patternof muscle recruitment has been observed in residual signs, in particular, among those with recurrence or recurrence with those among particular, in signs, residual to presence or absence of rela patientsback withlow pain. Becauseof itsposition as akey of motor control andishypothes control of motor over activation. Theresulting over amplitudethe deep of cerv and individualswithneck This thesis wasalso proposed byJanda (1964). dysfunctiondeep ofthe flexor cervical muscles. instability may manifest it instability maymanifest persistence of LBT in thefollow-upyear. LBTin persistence of muscularstabilization of thespine. ability could havemajo ability could the backandhamstringswerefound as rength ratios were inversely related to to related inversely were ratios rength pain (P = 0.002). Areduced 0.002). (P = pain that sacro-iliac that sacro-iliac joint dysfunction sus abdominis indicated adeficit in compensatory biceps femoris ominis was significantly delayed was significantly ominis tors of low-back pain disability. low-backpain of tors ical flexormusclesandthe Findings Findings imply thatmyoelectric xation in back muscles during xation inbackmusclesduring soft tissuestrainandjoint self in low back pain. self inlowback flexion testisassociatedflexion with me occurrence oflow back gnificantly (P less than 0.001) (P gnificantly ized to result in inefficient in inefficient ized toresult r consequenceson 18

Page 10 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table Characteristics 2: 8 Studies showing the of prevalence mu of Addison et al et Addison Karvonenal et et al McNeill T 76 76 77 92 (1980) 16 male 16 and 17 female patients (1980) (1980) 183 male conscripts. A history of Ahistory 183maleconscripts. (1980) 18)* 27healthy males30 and healthy (1980)** females; and 25male and15 female patients withlow-backpain and/or 13% and low back insufficiency by low backinsufficiency 13% and lumbago by 13%, back injury by by injury back lumbago by13%, sciatica was reported by 8%, reported by8%, sciatica was with chronic LBP with chronic sciatica. 63%. scle dysfunction in patients with back pain (RCTs indicated b were measured during attemptedflexion,extension, lateral and To correlate muscleweaknesses Maximum voluntarystrengths isometric were measuredduring Maximum voluntary trunk streng Maximum voluntarytrunk compared with those of health patients withlow-back disorderswho sought treatment as attemptedflexion, extension,and lateral bending froman bending. The trunkstrengthsthesepatients of werethen outpatients of ageneral orthopaedic office practice. upright standing position. of LBP y subjects and withthose of in young menwith complaints ths inthestanding position y **) poorly during 12 minof running. for patients with sciatica. Both male and female with LBPand/or sciatica had extensionstrengths measurements proved suitable fo sciatica; weak trunk flexors sciatica; flexors with weak trunk sciatica had approximately 60%ofthe absolute trunk strengths associations with a history of lo history of associations witha The ratiosshowed that the patients withlowback pain and/or history oflumbago and ofhip andknee complaints performed strengthattempted ratios for extension wereparticularly low their strengthstheir inthe other types ofmovements tested. The leave due toleave dueback the with and current hip pain.Menwith a When comparedwith healthy subjects, the patients seeking Weak trunkWeak extensors were associatedwith ahistoryof backache atwork/exercise. hospitalization had (Continued) attempted extension relative totheir strengths during of thecorresponding healthy subjects. attemptedor flexion lateral bending. in its early stages. in itsearly significantly smaller significantly Weak leg extensors showed showed extensors leg Weak The questionnaire and strength w back insufficiency andofsick back insufficiency w that lessthan were significantly r studying low back syndrome r studying back injuries andwithcurrent strengths during

Page 11 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table 3:Characteristics of8studies ex Hsieh andPhillips alPerot et al et Schwartz (1997) ** Lawson andCalderon Examiner (2000) Caruso andLeisman Subjects Bohannon Authors, date 95 57 20)128 acute kneerehabilitation (2001) 19)1 ujcsChiropract 10subjects (1991) 96 (1992) 122 patients 122 with spinalcord (1992) 46 36 19)1 smtmtcsbet 3 15 asymptomatic subjects (1990) 48 30 asymptomatic volunteers Medical do Medical 30 asymptomaticvolunteers knowledge about MMTor 27 volunteers with no injuries at C4–C6 injuries at patients amining the concurrent validity of MMT concurrent validityof amining the AK hsclteait Relationship betweenMMT therapists physical physical therapist To compare MMTwith compare To physical therapist xmnr To show the difference 2 examiners chiropractors To determine the To determine chiropractors ctor 10 upper extremity muscles 10upperextremity ctor r To measure compare and ors s Design Findings andstatistics Findings Design s between "weak" and "strong" concurrent validityofmanual concurrent proprioceptive techniquesto dynamometry using AK style initiated andpatient-initiated both strengthen andweaken bothand electromyographic of MMT, comparing doctor- MMT, comparing of and hand-head myometry hand-held dynamometer muscles, using MMT and muscles, usingMMT methods indouble-blind measurements ofknee were tested using AK dynamometer testing extension strength MMT resultsMMT after conditions. compared muscles MMT reproducibility when their outcomeswerecompar their when reproducibility 0.76 with doctor-initiated method; 0.96, 0.99 showedthat22 of 24correlations between MMT Intratester reliability and Intratester reliability weeks post-spinal1,injury cord2, 3, andat Response oftibialisanterior prop muscleto Sequential examinations withmyometry MMTand were madeat 72hours,1 week,and 2 difference that corresponded tothe differe outcomes. AKproprioceptive pr MMT and dynamometer scores highly correlated The intertester reliability coeff reliability The intertester Study showed that examiners with over 5ye over Study showedthatexaminerswith made byexaminerwas corroborated by test MMTs of "weak" or "strong"muscles showed significantlydifferent electromyographic measurements anddemonstrated ahigh doctor-initiated method;and 0.95 and0.96 for the patient-initiated method. construct validity of MMTanddyna of validity construct correlation coefficients for testers fortesters coefficients correlation icients were 0.77 and0.59on were icients ocedure toreducemusclefound tone tocorrelate with MMT outcomes. less than.001. mometry measurementsdemonstrated. 4, 6, 12, 18, and 24 months post-injury. Results nce found betweennce found "strong" and"weak" MMT rioceptive technique showed asignificant EMG , and 0.97when patien correlation between testing methods. ars experience using AK had reliability and and hadreliability experienceusingAK ars pressure analysis pressure andmyometry were sign ed. Perception of "inh Perceptionof ed. (r = 0.768; P < 0.001).(r =0.768; Convergent P and 1, 2,and3were0.55,0.75, day 1 and 2 respectively for respectively for day1and2 using the dynamometer. t-initiated MMT t-initiated method. ibition" or weakness ibition" or ificant atpvaluesificant

Page 12 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table 3:Characteristics of8studies ex Triano andDavis Marino etal Bohannon Wadsworth etal 97 50 18)5 ainspyia hrps Tothe determine physical therapist 50patients (1986) 18)18ptet physicalther 128 patients (1982) 45 98 18)5musclegroups11 on (1987) 17)10 patients with "reactive (1976) muscle" phenomena described inAK patients amining the concurrent validity of MMT concurrent validityof amining the physical therapist To To c physical therapist chiropractor In patien In chiropractor apists To compare MMT findings MMTfindings compare To apists reliability of MMT and hand- and reliability ofMMT dynamometer force scores relationship betweenMMT relationship musclepairs (between the muscles), EMG and MMT muscles), EMGandMMT findings were compared. held dynamometer tests (Continued) repetition ofthe MMT rhomboid anddeltoid dynamometer (HHD) findings, with precise findings, withprecise ompare the concurrent concurrent the ompare using Kendall tau. word scores and with hand-held ts withreactive Study demonstrated that the reactive muscle ph The MMTand HHD values were within 5%of each other. Theaverage hip abduction and hip mu two for coefficients reliability MMT scores anddynamometer test scoreswere si 0.001). These results suggest that thetwo pr The correlation coefficie the values between subjects were identical. groups tested dynametrically an groups testeddynametrically flexion scores measured bythe HHDwere co PercentageMMT anddynamometer test scoreswe overpoweringthe tested of of musclemeasurableMMT andwas byEMGanda not suggestion psychologic or an rhomboid "reactive muscle" represents a real physiological phenomenon. physiological a real represents muscle" "reactive rhomboid are reliable testingare reliable methods, giventhe nts were high and significantly di nts werehighandsignificantly muscle weakness (Plessthan0.001). arm bybrute force.These datashowed that the deltoid- scle groups tested manually co manually scle groupstested d for two muscle groups test for twomusclegroups d Conclusion thatboth ocedures measuresame the variable-strength. enomenon is,in fact, nsistent withthe examiner's perception of conditions described in this study. inthis conditions described gnificantly correlated (p lessthan 0.001). re significantlythan(p less different fferent from fferent for zero muscle four ed manually. The test-retest Thetest-retest manually. ed uld not be calculated because uld notbecalculated MMTand dynamometry a physiologic imbalance imbalance a physiologic

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aspects of muscular activity [20]. Even the MRI (another function involving one or more of the "5-factors of the diagnostic "gold standard") has been found to lack sensi- IVF" [3-9,62]. tivity and specificity. MRI can identify a lesion but cannot detail the relationship of the finding with the patient's A complication to the original construct of MMT from symptoms [94]. Lovett and others has emerged with the increasing aware- ness that the responses to the MMT are not solely due to There is increasing demand for objectivity in regard to the denervation effects on neural tissues in conditions like muscle testing measurements. Electromyograms are polio, but also co-existing inputs to the spinal cord's ante- expensive machines, and setting patients up on the rior horn and the processing state of the CNS [62]. Chiro- machines in the clinical setting is time-consuming. A practic research and anecdotal evidence from clinical review of the literature on dynamometers reveals some of practice have also suggested that there are five factors or the problems associated with their use. These include systems to consider in the evaluation of muscle function: problems with the actual forces measured by a hand-held the nervous system, the lymphatic system, the vascular dynamometer (HHD); providing the stabilization that is system, cerebrospinal fluid flow, and the acupuncture sys- essential for controlling variables and for standardization tem [3-9,62]. Chiropractic clinical experience and of the testing technique; as even a slight tipping of the research has also suggested that dysfunction in a muscle devise during testing can alter its results [20-22,93]. These may be caused by a failure of any of these systems and that are important factors when considering the cost-effective- the MMT response may provide important clues regarding ness and clinical usefulness of these other testing proce- the origin of that dysfunction. Applying the proper dures for muscle strength assessment. manipulative therapy may then result in improvement in the inhibited muscle, pain, movement and posture. (See Predictive Validity and Accuracy of the MMT Table 5) However RCTs and other substantive research A second form of validity is called predictive validity. studies are required before we can assert with confidence Comparing a test to supporting evidence that is obtained the relevance of each of these factors. at a later date assesses predictive validity. To be valid in this new model the MMT would have to The accuracy of a diagnostic test is usually determined by reliably sample components of both the central and examining the ability of the test to assist clinicians in mak- peripheral nervous systems and be performed in the con- ing a correct diagnosis. A good diagnostic test minimizes text of a new, more holistic conceptual model of func- the probability of the clinician finding a positive response tional neurology. The future of chiropractic MMT research in healthy people and negative test results in people with will depend upon demonstrating the validity and reliabil- dysfunction or pathology. A good diagnostic test therefore ity of the MMT for evaluating these types of dysfunctions minimizes the probability of either a false positive or a affecting the anterior horn motor neuron pool. false negative result. The accuracy of the test is defined as the probability that people who truly should have the pos- Understanding normal neuromuscular mechanisms is itive response receive a positive response when the test is essential to identifying abnormal and also being able to performed. The accuracy of the test is also defined as the physically test them. In this way the practitioner may be probability that people who should truly have a negative able to specifically determine areas of dysfunction and response correctly receive a negative response when the thereby individualize the treatment given. More impor- test is performed. tantly, MMT may allow the neuromuscular system to be used interactively (by examiner and patient) and as a key Table 4 provides a brief summary of several studies that element in the assessment and treatment of the functional examine the presence of positive MMT in suspected disor- disorders of the patient. This ability to "manipulate" the ders of neural origin. neuromuscular system, with an aim of changing the patient's muscular function, postural balance and The Emerging Construct in the Research on MMT strength, and to measure the outcome is conceptually an In order to evaluate the scientific merit of MMT we have important component of the chiropractic and AK discussed the importance of the operational definitions, approach to health care. If a patient's injury causes pain reliability and validity in MMT research. The original con- and dysfunction, an effective therapy may not only be in struct of the MMT was that it documented impairments in the elimination of pain but also an improvement in mus- muscle strength. Muscle inhibitions (detected by MMT) cle function as evidenced by the same method of assess- are understood in chiropractic and AK to be reflective of ment originally used to diagnose the problem. This may an inhibition of motor neurons located in the spinal add an important measure of objectivity to clinical prac- cord's anterior horn motor neuron pool as a result of dys- tice, and potentially increase a patient's awareness about

Page 14 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table 4:Characteristics of14 studies exam ** (2004) Moncayo et al (2005) al et Michener (2005) ** Niemuth etal Repea Subjects Pollard etal Diagnosis Jepsen etal Authors, date ** 93 54 (2006) (2006) 99 100 (2006) (2006) 64 orbitopathy (TAO) Thyroid associatedThyroid Single legoveruse Upper limb pain 41 patients, 19 with 41patients, Upper limbpain o akpi 67 of100 patients Low backpain hudrpi 40 patients with Shoulder pain injury ining theClinicalRelevance, ining standing disease, and 9 32 patientsTAO, with 30 noninjured runners female,13 male) and (16 female, 14 male) 14male) (16 female, injured runners (17 (17 runners injured have low backpain have served ascontrols. served shoulder pain and showing discrete upper limb pain limb upper 30 recreational 23 with along- functional loss functional initial changes procedures were performed 24to 72 hours dysfunctionweaken and Hand held dynamometer testingHand helddynamometerperformed MMT, with examiners blinded asto patient reactions were found inthe submandibular tonsillar structures,th and withthe functional ocularlocktest of after theinitial testing bythe sametester. MMT with therapy loca withtherapy MMT the San YinJiao point, the lacrimal gland, trapezius, middletrapezius, serratus and anterior muscles. Concurrently, surface surface anterior muscles.Concurrently, groupsthe ofwas hip recorded using a as MMT for the lower trapezius, upper upper as MMT for lowertrapezius, the Muscle strengthof Muscle collected for the 4 the collected for PredictiveValidit electromyographywere (sEMG)data PositiveTL (patient touches area of hand-held dynamometer. cecal valve reflex point cecal valvereflex e bevtosTetet Outcomes Treatments Observations ted pain status. AK. the 6 majormuscle muscles. The samemuscles. The e tonsilla pharyngea, e tonsillapharyngea, y and Accuracyy and ofMMT(RCTs indicate ing occurs on MMT) ing occurs onMMT) lization to anIleo- lization AK treatment and homeo-pathic remedies None Intraclass correlation coefficien correlation Intraclass None oeNosignificant side-to-side None oeOf 67subjects who reported lowback pain,58 (86.6%) None oeReduced strengthofupper None d by **) d by across the 4muscle tests, reveal amounts ofisometric muscleact and 1 subject1and (3%)reported afalse positiveresponse forICV (90% confidence interval [CI])ranged from 1.3 to 2.7 kg; the the upper trapezius and lower trapezius muscles was highest reported a positive testreportedpositiveICV pointandlow backpain ofboth a (13.4%) reported false negative false reported (13.4%) abductor0.0003) (P= flexor and0.026) musclegroups= (P minimal detectableminimal change (90% CI) rangedfrom 3.6 1.8to ranged from.89of to.96.The theerror standard measure criteria including tende including criteria Medicine associated withthesymptoms. presencemedian A of odds reported noresponsepointsubjects test. toICV Nine(9) significantly stronger (P=0.010)than thenoninjured side. test. Of 33 subjects,test. Of 32(97%) excellent measures of sensitivit of excellent measures strength were found inthe noninjured runners (P =0.62– kg. Constructkg. validityassessment, donebycomparing the measurements ofisometric force obtainedan using HHD and tongue diagnosis were im addition, theinjuredhiside Change of lid swelling, of ocular movement discomfort, movement discomfort, ocular of lidswelling, Change of diagnostic measureof lowba test and no low back pain. Th test andnolowbackpain. 0.93). Amongthe injured runners, theinjuredhip side were significantly weaker than weaker were significantly ocular lock,tonsil reactivity andTraditionalChineseocular months showed allrelevant parameters improved. during theirduring respective tests. ratio of4.0 (2.5–7.7). competency. differences inhip groupmuscle p adductor muscle group was limb muscles was significantly limb muscleswassignificantly ICV tests and low back pain, ts for intratester reliability of reliability intratester ts for proved. Clinical trial of 3–6 of trial proved. Clinical with nobackpainpositively ed that themuscleactivityof ed ck pain wasfoundto have ivity (sEMG) foreachmuscle ivity (sEMG) y, specificity and diagnostic y, specificityanddiagnostic e ileocecalvalvetest asa rness of San Yin Jiao (SP6) (SP6) Jiao Yin San of rness the noninjured side.In

Page 15 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table Characteristics 4: 14 studies exam of (1998) Schmitt etal Monti etal al et Nadler Group Study Great Lakes ALS (2003) Rainville etal Goodheart 103 105 66 104 104 65 101 19)Nn 89healthycollege None (1999) 20)13 college athletes (2001) (1990) Imbalanced weight Imbalanced (1990) (2003) bearing on right and and right on bearing amyotrophic lateral lateral amyotrophic with lowback pain sclerosis (ALS) lege 7sbet To determine whether subjective muscle 17 subjects Allergies left feet sciatica 33 patients with L3 or L3or 33patientswith sciatica ining the Clinical Relevance, Predictive Relevance,Predictive ining theClinical patients with L5 or S1 male, 63 female), 5of male, 63female), 3ptet ihASCompared patients withALS 63 Ofathletes 163 (100 L4 radiculopathy;10 63 females and 8of 100 males required 100 malesrequired treatment forLBP. radiculopathy 0ptet 40 patientswere evaluated for pre- and 40 patients students practitioners, betweenthe right andleft hipextensors and outcomes after exposure to congruent and (MVIC) scoresamong abductors.The maximum generated force used tocalculate apercentage difference maximal voluntary is maximal voluntary testing employed byApplied Kinesiology for the hipfor the abductors andextensorswas specially designed anchoring stationwas specially designedanchoring individuals with sp individuals with validity by comparing validity bycomparing ots udiessrnt ihMTNn Knee flexedMMTweakness ofthe quadriceps showed kappa None MMT with strength quadriceps test To used for testingtheextensors hip and To determine thein differences MMT A dynamometer into incorporated a post-treatment weight balance. incongruent sema betweenand MVIC. MMT prospectively determine those test reliability of MMTand reliability of test Validity andAccuracy responses. abductors. ecific hyperallergenic ecific ometric contraction institutions andtest change over time ntic stimuli ntic of MMT (RCTs indicate LBP unrelated to blunt AK examin-ation and AK examin-ation athletic trainers for trauma over the ensuing year treatment oeApproximately 17% moretota None None Reproducibility betweenMV Reproducibility None None Each subject showed muscle-w Eachsubject None d by**) to oralprovocativetestingof Patientswi (0.66). of coefficient Logistic regression analysisind allergosorbent(RAST) andimmune testIgE complex testfor detect this change, however, fa that hip muscle imbalanceis that hip extensors was predictive of waspredictive extensors trials, uniformly trainedphysica trials, uniformly coefficients, essentially equiva essentially coefficients, Of the 40patients, onlyone and IgG againstall 21ofthefoodsthat tested positive with significant differences werefo differences significant authorstheMMT tobe found accurately measure strength reactionserum ofthe wereperformedboth usinga radio- required over the ensuing year period of time could be endured when subjects repeated Sensitivity to detect progre Sensitivity todetect upon twoscales beneaththe feetwhen both flexing and confirmed 19confirmed ofthe21 food thepercentage difference between the right and lefthip based onthe applied kinesiology screening procedures. semantically congruent statemen or S1couldperform thequadriceps test. Weakness of in female athletes.Research supports the needforthe 21 positivefoodreactions. A.K. musclescreening procedures.These serumtests between congruent andinco assessmenttreatment and ofhipmuscleimbalance in (Continued) quadriceps correlated with L3 or L4 radiculopathy. with correlated quadriceps strength becauseof itsbetter Pearson correlation favorable coefficient of variation. individuals with LBP. with individuals extending thespine. associatedLBP occurrence with whether treatment for LBP was ssive weakness andpowerto one ortwo foods foratotal of had minimal changes inweight had minimal Testsforahypersensitivity by both MMT and MVIC. The and MVIC. by bothMMT lent reproducibility, and more lent reproducibility,and icated that for icated thatfor female athletes, IC and MMT wasequivalent.IC and eakening (inhibition)reactions und inmuscleresponses test allergies(90.5%) suspected vored MMT.Inmulticentered th radicular pain caused by L5 paincausedbyL5 th radicular l therapistsreproducibly and preferred measure of global ngruent semanticstimuli. (P = 0.05). Validity shown Validity = 0.05). (P l force over a59% longer ts (p < .001). Over all, all, .001). Over ts (p<

Page 16 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table 4:Characteristics of14 studies exam (1977) Carpenter etal Scoop Jacobs et al 106 17)Alry1 ujcsSubjects with unilateral weak muscles were subjects 10 Allergy (1979) 44 18)Tyoddsucin6 ainsPatients evaluated forthyroiddysfunction patients 65 Thyroid dysfunction (1984) 107 oe8 tdnsThe muscleshypothesizedAKin tobe students 80 None ining theClinicalRelevance, ining given either aplacebo or the nutrient that is the muscle.Muscletone bya was measured associatedcertain with organs weretested related organs. Then evaluated:the eye,ear, stomach,lung. and The stomach byplacing was irritated cold hypothesized inassociated AKtobe with water; thewater; ear withof sound acontrolled tested. 4organmuscle associations were Jaymar dynamometerandAK with MMT withinstrument an afterirritation ofthe frequency and decibel rate; and thelung and rate; decibel and frequency water intoit;theey water PredictiveValidit by MMT, andlabo by MMT, with cigarette smoke. methods. a control musclewas a control e with chlorinated y and Accuracyy and ofMMT(RCTs indicate ratory testing. ratory AK andlabor-atory examina-tion Nutrition The increase in muscle increase The Nutrition oeIn 80 subjects, a total of None d by **) d by .91,suggesting that muscletesting isreliable betweentesters. study, a 15% decrease in decrease muscle study, a15% statistically significant (p < 0.05 was of .81. Observation clinical irritation. The contro The irritation. cases,associated the musclewe enhanced but did not replace clinical/laboratory diagnosis of the placebo group. In the cerebral allergy testing part ofthe clavicular was used as the criterion for cerebral allergy. The allergy. cerebral criterion for the as wasused clavicular Pearson Product-Moment Correlationbetween was testers Correlation between clinicalan Correlation identified asprovocative bymuscle testingtheby and fast testing suggests themethodha testing MMT ratings correlated with clinical ratings (r ratings withclinical ratings correlated MMT correlation with the laborato withthe correlation 0.002) and withlaboratory ratings(r muscle testing methodthen wascompared toresults (Continued) reintroduction offoods. Correlation between foods .47,p <0.000. ThreeAK TLpoints had asignificant ingestion was 21% for the nutrient group andwas a obtainedPh a by thyroid dysfunction." thyroid l muscle also weakened, but to a much muscle alsoweakened,butto l ilpott-type fast with progressive withprogressive fast ilpott-type lesser degree. tone approximately 10seconds after 139 organs were irritated. In all ) increase in comparison with ) increase incomparisonwith results obtainedwithmuscle results ry diagnosis (p < .05). "AK .05). diagnosis(p< ry akened significantly afterthe akened significantly tone of the pectoralis major thepectoralis of tone s utility. substantial clinical d laboratory diagnosiswas laboratory d s = .32,p<0.005). s = .36,p<

Page 17 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table 5: Characteristics19 case of report Cuthbert (2004) Moncayo etal Caso Chung etal Meldener (2005) Cuthbert etal Cuthbert Sprieser Weiss Maykel uhr,dt igoi ujcsRepeat Subjects Diagnosis Authors, date 113 116 115 117 congenital bowel (2004) 114 109 20)Menstrual difficulty and (2003) 111 (2003) Blocked naso-lacrimal naso-lacrimal Blocked (2003) 20)Episodic paroxysmal (2002) 112 20)Dw ydoe1 hlrnInformal report by the parents of child's 15 children Down syndrome (2003) (2006) Motion sickness sickness Motion (2006) (2005) Post-surgical hip hip Post-surgical (2005) 100 110 20)Dental occlusion (2005) abnormality related to relatedto abnormality malformation (Type I) optic nerveneuritis orbitopathy (TAO) Thyroid associated associated Thyroid exacerbated byan of the cerebellum low back pain. back low Arnold-Chiari Arnold-Chiari exhaustion dislocation problems disorder vertigo canal s of positive experiences for patients (n patients (n s positiveexperiencesfor of 23 with a long-standing23 with disease, and9showing 32 patients with TAO, TAO, with patients 32 discrete initialchanges discrete :1-ot aeAK MMTand 1: 14-month male :2 o eaeAK MMTto diagnose vertebral subluxations 1: 20 yoa female :3 o eaeA M n ain eoto odto Nutritional counseling and AKMMT andpatient report of condition 1: 39 yoa female 2: 45 yoa female 1: 66 yoa female :1 o eaeAK MMT andpatient report 1: 17 yoa female 3: 9yoa female 1: 75 yoa male AK MMT to diagnoseto muscular AKMMT weakness 1: 75 yoamale 1: 29 yoa male AK MMT to diagnose large AK MMT large diagnose to male yoa 29 1: 3: female 7: male 7: and cranial lesions; ocul and craniallesions; theJiao SanYin point, AK MMTduring application ofan oraldental dysfunction andweakening occurs onMMT) Proprioceptive testing (Freeman-Wyke and reactions were foundin the submandibular tonsillar structures, the tonsilla pharyngea, pharyngea, thetonsilla structures, tonsillar function andhealth status by the parents. Hautant's tests), AK MMT and palpation MMTand AK tests), Hautant's around hip and throughout the body the throughout and hip around Positive TL (patienttouches areaof with the ocular lock test ofAK. locktest with theocular function andhealth status. = 1–88)treatedwith informal report of child's child's of report informal dOsrain ramnsOutcomes Treatments ed Observations appliance testing the lacrimalgland, and ar muscle testing, TMJ TMJ testing, ar muscle oe yfnto CMT andstimulation of bowel dysfunction of her condition CMT to the spine and and spine the to CMT condition her of chiropractic AKtech meridian therapy techniques of the TMJ and occlusion to Chapman's reflex points by focusing on the connection connection the on focusing the doctor and the patient patient the and doctor the chiropractic manipulative manipulative chiropractic cranium, with nutritional withnutritional cranium, rna n pnlCTPatient had losther vision intheright eye3weeks Cranial and spinal CMT homeopathic remedies cranium as well asAK/ AK andCMTtherapy, CMT to the spine and and spine the to CMT CMT to the spine and and spine the to CMT CMT to the spine and and spine the to CMT instability of the hip the of instability support asneeded. AK treatment and treatment AK Spinal andcranial therapy (CMT) therapy at home cranium cranium oeAKMMT reliableand repeatable ondifferent days. MMT None nique Medicine criteria including tenderness of San Yin Jiao (SP6) previous to treatment. After 1 visit, patient could see 20– see could patient visit, After1 treatment. to previous No hip dislocation since verticaldimension was increased After 4 treatments and 3 other treatments by a -Gong aQi-Gong by and3 treatments other 4treatments After and tongue diagnosis were impr master the patient remained free of any vertigo at 3 year year at3 vertigo any of free remained patient the master 30 onSnellen eye chart. Visual acuity 20-13 after 3 useful to locate the kinesiologic occlusalposition for the correction and nutrit Improved fine motor skills; use of the hands and fingers; andfingers; hands of the use skills; motor fine Improved with new upper dentures on doctor's recommendation. Changeswelling, oflid of stand and walk;decrease in fabrication ofanoralappl ability to crawl bilaterally with arms and legs; ability to to armsandlegs;ability with bilaterally crawl to ability with ears and sinuses werea sinuses earsand with ocular lock, tonsil reactivi tonsil lock, ocular Resolution of the patient's low back pain as well as well as pain lowback patient's the of Resolution 1: Abletodrive carandride in aboat and airplane months showed allrelevantparametersimproved. showed months Treatment to the sacrococcy the to Treatment 3: Able to drive in car symptom free after 4visits after free symptom in car drive 3: Ableto Child treated5timesovera6-week period with 2: Able to drivecar symptom free after 6visits. noted by parents, teachers, and doctor. and asymptomatic 3yearslater. level and cycling performance. cycling and level resolution of his eyeproblem. his of resolution symptom free after 4 visits. 4 after free symptom improved bowel function. ional support improved her energy her improved support ional follow up. follow ocular movement discomfort, discomfort, movement ocular iance to treat TMJ disorders. ty and Traditional Chinese Chinese ty andTraditional tongue thrusting; problems ll improved ll improved in function as oved. Clinical trial of 3–6 of trial Clinical oved. geal areawithcranial rd visit visit

Page 18 of 23 (page number not for citation purposes) Chiropractic & Osteopathy 2007, 15:4 http://www.chiroandosteo.com/content/15/1/4 Table 5: Characteristics19 case of report Goodheart Goodheart (1991) etal Masarsky (1999) ** al et Mathews Calhoon Cuthbert (2001) Gregory etal Leaf Jacobs et al et Jacobs etal Masarsky 118 20)Severeequilibrium (2002) 121 120 105 44 (2001) Multiple sclerosis 1: 43 yoa female AK MMTandpati AK female 43yoa 1: sclerosis Multiple (2001) (2001) Bell's Palsy 1: female AK MMT to diagnose cranial, cervical, TMJ, TMJ, cervical, cranial, diagnose to AKMMT female 1: Palsy Bell's (2001) 119 18)Tyoddsucin6:mlsadfmlsPatientsevaluated for thyroid dysfunction by females and males 65: dysfunction Thyroid (1984) 122 124 123 19)Imbalanced weight (1990) women withmoderate to severebreastpain to Chronic obstructive obstructive Chronic bearing onrightand Learning disabilities 10 children compared compared children 10 disabilities Learning pulmonary disease oai ype :mlsadfmlsAK MMT 6: males and females Somatic dyspnea problems left feet left s of positive experiences for patients (n patients (n s positiveexperiencesfor of with a control group of for age,IQandsocial premenopausal, with premenopausal, with background that had 10 children matched cyclical breast pain breast cyclical treatment over a not received any cyclical and non- :4 o eaeAKMMT andpatient repo 1: 48 yoa female predominantly similar period. 88: females, 0ptet 40patients were evaluated for pre- andpost- 40 patients 1: male AK MMT examinatio MMT AK male 1: capacity (FVC) andforced expiratory volume capacity (FVC) andforced expiratory volume measurements taken 3 days later to 1 month AK MMTtodiagnose ne challenges; the children were testedbefore in one second (FEV-1) measurements pre- in one second (FEV-1) measurements pre- and post-treatment, covering an 8-month Psychologist using st intelligence to monitor changesintheir monitor to intelligence and after treatment byanEducational and post-treatment (post-treatment (post-treatment and post-treatment AK MMTexamination and sensory dysfunction of the large intestine large of the dysfunction AK and laboratory testing treatment weight balance. examination examination and muscular imbalances = 1–88)treatedwith learning skills. period. later). ent report of condition CMT to the spine, TMJ, and TMJ, thespine, to CMT condition of report ent n methods; forced vital vital forced n methods; andardized testsof methods; forced vital vital forced methods; urolymphatic reflex reflex urolymphatic rt of condition Cervical traction of 6 of traction Cervical condition of rt chiropractic AKtech employed for the diaphragm were reflexes neurovascular pounds while patient walked walked patient while pounds manipulation (AK methods); methods); (AK manipulation CMT to the spine, TMJ, and TMJ, spine, the to CMT and treatmentfor inhibited Chapman's reflex points by the doctor and the patient patient the and doctor the muscle; evaluation of the the of evaluation muscle; meridian system; cranial CMT andstimulation of CMT AK treatment including cranium and nutritional and cranium nutritional AK examination and AK examination and neurolymphatic and muscles involved in involved muscles forminutes 15 KtetetEducational AK treatment respiration. treatment treatment at home cranium support oeAK ratings(r with laboratory correlatedratings None nique (Continued) was a reduction in severity, duration and frequency of pain pain of frequency and duration severity, in areduction was Of the 40 patients, only one ha one only patients, 40 the Of 26 months after initial visit patient had regained her ability herability patienthadregained visit after initial 26 months to write and could shower without assistance for the first Correlation between clinical clinical between Correlation Improvements were noted in forced vital capacity, forced forced capacity, vital forced in werenoted Improvements reduction in breast painin60 inbreast reduction enhanced but didnot replace resolution in 18%. 2 months af 2months in18%. resolution .47, p < .000. 3 AK therapy lo therapy 3 AK .000. p< .47, difficulty.of 4 the 6patients also hadimproved FCV and upon two scales beneath the the beneath scales two upon abilities during the course of 9 to 12 treatment sessions sessions 12treatment 9to of during thecourse abilities expiratory volumeone in se correlation withlaboratory the diagnosis (p <.05).AK treated with AKhad animprovementtheir in learning of thyroid dysfunction. Evid Complete resolution of facial nerve palsy after 6 visits 6visits after nervepalsy facial of resolution Complete correlation between certain After cervical traction-distraction patient was able to ableto was patient traction-distraction cervical After All patients reported improvement in their breathing breathing their in improvement reported All patients .002) andwith laboratory ratings (r stand with her feet together her feet with stand Immediately after treatment there was considerable ease ofbreathing (sign si Improvement was also noted in laryngospasm. of 50% or more in 60% of cases (P<0.01). of 50%ormorein60%cases FEV-1 between 0.1and 0.8liters. during aperiod of 6–12 months. psychologist's testing demonstrated children displayed nosigns ofnystagmus. extending thespine. LDH in the serum. time in 2years. in time over 14 days. and laboratory diagnosis was cond, coughing, fatigue, and fatigue, coughing, cond, ence indicated a significant asignificant ence indicated gnificant at 0.005 level). 0.005 at gnificant % of patients with complete clinical/laboratory diagnosis d minimal changes changes in d minimal weight feet when bothflexing and calizations had a significant hadasignificant calizations AK testsand anelevated ter initial treatment, there there treatment, ter initial withnobodyswayand s = .32, p < .005). .005). p < .32, = s = .32, p <

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their body and their body's ability for improvement as a MMT methods have been investigated with RCTs, pro- result of the therapy given. spective (cohort) studies, retrospective studies, single-sub- ject case series and case reports, many questions about the To provide the strongest evidence for the use of chiroprac- MMT remain unanswered. tic MMT techniques, more randomized controlled clinical trials (RCTs) and systematic reviews will be essential. One shortcoming is the lack of RCTs to substantiate (or Although RCTs will be required to document a cause- refute) the clinical utility (efficacy, effectiveness) of chiro- effect relationship between treatment and outcome, they practic interventions based on MMT findings. Also, are frequently impractical projects for the practicing clini- because the etiology of a muscle weakness may be multi- cian. This is frustrating because it is the clinician who factorial, any RCT that employs only one mode of therapy depends on scientific proof that these techniques work. to only one area of the body may produce outcomes that are poor due to these limitations. One alternative is for groups such as ICAK and those who use AK and MMT methods to organize and fund these A limitation of this review may involve research published RCT's. Work so far in this area remains largely limited to outside the main databases searched, as well as research reliability and observational studies. Unfortunately, there articles involving some form of muscle testing but not have not been significant efficacy studies in this area, nor using the terms manual muscle test, manual muscle testing, have there been many significant efficacy studies con- or applied kinesiology as they may not have been accessed ducted in the chiropractic research arena in general [108]. and included here. In addition this paper has not critically rated each study for its internal and external validity. Such Nineteen examples of peer-reviewed published case a systematic review should be the subject of future reports using MMT and chiropractic AK protocols are pre- research. sented in Table 5. These 19 case studies demonstrate how the practicing clinician may help narrow the gap between Throughout this paper we have tried to answer the ques- practice and research. tion, "Are AK and MMT worthy of scientific merit?" In order to evaluate the effectiveness of MMT in the diagno- Although case reports cannot prove a treatment's effective- sis of patients with musculoskeletal and nervous system ness, they can describe the performance of techniques in a problems, it is necessary to survey the full range of way that can initiate an hypothesis for a future RCT. More research studies that have addressed the topic, giving due case reports may also add to the body of knowledge in the consideration to the strengths and weaknesses of the stud- field of chiropractic AK and MMT. ies in the literature.

Conclusion Hopefully this literature review has stimulated a desire for After 42 years of development and research, the chiroprac- others to review the current MMT literature and become tic profession's use of MMT and AK chiropractic technique an effective user of and contributor to chiropractic MMT has become one of the many diagnostic methods from research [125,126]. which some doctors of chiropractic draw their clinical procedures. Competing interests SCC is a Board Member for the International College of In the last forty years we have become more aware of the Applied Kinesiology (I.C.A.K.). GJG is the Research Direc- nervous system. This awareness has allowed us to evaluate tor and Founder of the I.C.A.K. SCC and GJG both employ patients more completely and from an integrated neu- MMT and AK methods in their evaluation and treatment romuscular perspective. This holistic system of approach of patients. for the evaluation of neuromuscular function continues to be updated on a regular basis with new and exciting Authors' contributions research. Much of the evaluation and treatment of SCC and GJG conceived the research idea. SCC acquired patients using MMT and manual methods remains and the papers and constructed the literature review. SCC and will always remain an art. However, we must provide GJG critically appraised the studies. SCC and GJG drafted these artistic endeavors with a solid scientific foundation. the manuscript and approved the final version for publi- cation. Although this narrative literature review offers considera- ble evidence about the reliability and validity of MMT as References an examination tool, most of the rigorous, systematic 1. Coulter ID: Chiropractic: a philosophy for alternative health care Oxford: Butterworth-Heinemann; 1999. research on this form of examination has emerged in just 2. Strang V: Essential principles of chiropractic Davenport, IA: Palmer Col- the past 30 years. Although evaluation of patients using lege of Chiropractic; 1984.

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