THE ACCURACY AND PRECISION OF KINESIOLOGY-STYLE MANUAL MUSCLE TESTING: DESIGNING AND IMPLEMENTING A SERIES OF DIAGNOSTIC TEST ACCURACY STUDIES Anne Marie Jensen Wolfson College University of Oxford A thesis submitted for the degree of Doctor of Philosophy Initial Submission 19 June 2014 Revision Submitted 24 October 2014 ii ABSTRACT Introduction: Kinesiology-style manual muscle testing (kMMT) is a non-invasive assessment method used by various types of practitioners to detect a wide range of target conditions. It is distinctly different from the muscle testing performed in orthopaedic/neurological settings and from Applied Kinesiology. Despite being estimated to be used by over 1 million people worldwide, the usefulness of kMMT has not yet been established. The aim of this thesis was to assess the validity of kMMT by examining its accuracy and precision. Methods: A series of 5 diagnostic test accuracy studies were undertaken. In the first study, the index test was kMMT, and the target condition was deceit in verbal statements spoken by Test Patients (TPs). The comparator reference standard was a true gold standard: the actual verity of the spoken statement. The outcomes of the muscle tests were interpreted consistently: a weak result indicated a Lie and a strong result indicated a Truth. A secondary index test was included as a comparator: Intuition, where Practitioners used intuition (without using kMMT) to ascertain if a Lie or Truth was spoken. Forty-eight Practitioners were recruited and paired with 48 unique kMMT-naïve TPs. Each Pair performed 60 kMMTs broken up into 6 blocks of 10, which alternated with blocks of 10 Intuitions. For each Pair, an overall percent correct was calculated for both kMMT and Intuition, and their means were compared. Also calculated for both tests were sensitivity, specificity, positive predictive value and negative predictive value. The second study was a replication of the first, using a sample size of 20 Pairs and a less complex procedure. In the third study, grip strength dynamometry replaced kMMT as the primary index test. In the fourth study, the reproducibility and repeatability of kMMT iii were examined. In the final study, TPs were presented with emotionally-arousing stimuli in addition to the affect-neutral stimuli used in previous studies, to assess if stimuli valence impacted kMMT accuracy. Results: Throughout this series of studies, mean kMMT accuracies (95% Confidence Intervals; CIs) ranged from 0.594 (0.541 – 0.647) to 0.659 (0.623 - 0.695) and mean Intuition accuracies, from 0.481 (0.456 - 0.506) to 0.526 (0.488 - 0.564). In all studies, mean kMMT accuracies were found to be significantly different from mean Intuition accuracies (p ≤ 0.01), and from Chance (p < 0.01). On the other hand, no difference was found between grip strength following False statements compared to grip strength following True statements (p = 0.61). In addition, the Practitioner-TP complex accounted for 57% of the variation in kMMT accuracy, with 43% unaccounted for. Also, there was no difference in the mean kMMT accuracy when using emotionally-arousing stimuli compared to when using affect-neutral stimuli (p = 0.35). Mean sensitivities (95% CI) ranged from 0.503 (0.421 - 0.584) to 0.659 (0.612 - 0.706) while mean specificities (95% CI) ranged from 0.638 (0.430 - 0.486) to 0.685 (0.616 - 0.754). Finally, while a number of participant characteristic seemed to influence kMMT accuracy during one study or another, no one specific characteristic was found to influence kMMT accuracy consistently (i.e. across the series of studies). Discussion: This series of studies has shown that kMMT can be investigated using rigorous evidence-based health care methods. Furthermore, for distinguishing lies from truths, kMMT has repeatedly been found to be significantly more accurate than both Intuition and Chance. Practitioners appear to be an integral part of the kMMT dynamic because when replaced by a mechanical device (i.e. a grip strength dynamometer), distinguishing Lies from Truth was not possible. In addition, since specificities seemed to iv be greater than sensitivities, Truths may have been easier to detect than Lies. A limitation of this series of studies is that I have a potential conflict of interest, in that I am a practitioner of kMMT who gets paid to perform kMMT. Another limitation is these results are not generalisable to other applications of kMMT, such as its use in other paradigms or using muscles other than the deltoid. Also, these results suggest that kMMT may be about 60% accurate, which is statistically different from Intuition and Chance; however it has not been established if 60% correct is “good enough” in a clinical context. As such, further research is needed to assess its clinical utility, such as randomised controlled trials investigating the effectiveness of whole kMMT technique systems. Also, future investigators may want to explore what factors, such as specific Practitioner and TP characteristics, influence kMMT accuracy, and to investigate the validity of using kMMT to detect other target conditions, using other reference standards and muscles other than the deltoid. Summary: This series of diagnostic test accuracy studies has found that kMMT can be investigated using rigorous methods, and that kMMT used to distinguish Lies from Truths is significantly more accurate that both Intuition and Chance. Further research is needed to assess kMMT’s clinical utility. v DEDICATION This thesis is dedicated to my father.... Thank you for teaching me perseverance. “I am thankful to all those who said, ‘No.’ Because of them I did it myself.” - Albert Einstein vi GRATITUDE (ACKNOWLEDGEMENTS) “At times our own light goes out and is rekindled by a spark from another person. Each of us has cause to think with deep gratitude of those who have lighted the flame within us.” — Albert Schweitzer There were innumerable times over the last 7 years that my flame sputtered and waned, and were it not for its rekindling at just the right times and places, I would have never reached this point. There are many of you out there who acted in this capacity – by giving advice or instruction, by giving moral or financial support, by giving a kind word or warm hearth, or by kicking me out the nest so I could experience flying myself. To each and every one of these rekindlers, I am humbly grateful...  Amanda Burls, DPhil Supervisor – thank you for taking me on when no one else dared  Richard Stevens, DPhil Supervisor – thank you for your interminable patience  To anyone who acted as an Advisor / Consultant:  Bruce Arroll  Mike Clark  Beth Shinkins  Tim Kenealy  Rafael Perera  Tom Fanshaw  Joanna Stewart  Susan Mallett  Adai Ramasamy  Paul Glasziou  Sharon Mickan  Jay Triano  Carl Heneghan  Jeremy Howick  Charlotte LeBoeuf-Yde  Dan Lasserson  Alison Ward  Adrian Stokes  Clare Bankhead  Jason Oke  Ben Feakins Thank you for your kind guidance and great ideas  Oxford’s Department of Primary Care Health Sciences and the Department of Continuing Education – thanks to everyone in these department for their help and support – especially Jane McCaffrey. vii  Joseph LeDoux – thank you for not “believing” in muscle testing... and starting this whole ball rolling.  To other sources of academic inspiration or support:  Rolf Peters  Bruce Lipton  Patrick Bossuyt  George Lewith  Geoff Miller – thank you for voluntarily reading this from cover to cover.  My practitioner-colleague-friends:  Howard Cohen  Leslie Oldershaw  Katherine Moyer  Erika Barrantes  John Campise  Trish Anton  Khelly Webb  Victoria Moore  Mary Lowther  Wil Bos  Linda Christian  Linda Li  Kit Macy  Kim Makoi  Scott Cuthbert Thank you for your help and for trusting me  Thank you very much for the financial support:  Virginia Hernly  Wolfson College  Santander  Ellen Blasi  Chris Guile – for his computer wizardry and his just being there... much of the time  A HUGE THANK YOU to all the study participants – Practitioners and Test Patients alike – from all over the world! Thank you SO much for generously sharing with me your time, space and thoughts  My friends and fellow cohort in the EBHC DPhil programme (especially Antoine) – thank you for your inspiration and support, and all the best completing!  Eleanor and Erland Jensen, my parents – thank you for your giving me in death what you could not in life  Ellen Jensen, my sister – thank you for sticking by me  Tom Jensen, my brother – thanks for teaching me about “wiggle room” – it has come in handy many times!  Aunt Christiane Stolte – thank you for making sense viii  Matthew, Connie and Diana Patane, my Australian family – thank you for always being there  My friends all over the world:  Kerri Elston Doherty  Michelle Hogan  Mike Hall  Maryellen Stephens  Suzy Dormer  Judith & Mike Hotek  Finn Jenk  Lorna Corgat  Francis Murphy  Konstans Foskolos  Lindsay Collins  Louis D'Amico  Greg Hayman  Curtis Rigney  Caroline Omo  Roz Gibbs  Steph Essex  Marty Hall  Naretha & Japie Nel  Darryl Cole  Martin Enderlin  Merlijn Wolsink  Nick Kovacs (& Derrick)  Jackie Fairbourn  Wanyo Jennings  Mark Postles  Catherine & Eric Four  Jeff Schelling & family  Marcella MacArthur Thank you for your help, love and support, for encouragement and smiles, for BBQs and cuppas, for normality and sanity, for insanity and giggles, for fresh air and fresh views. Each one of you mean so much.  (The late) Bill Harris – for your unwavering faith and enduring legacy of wisdom: “Oh and one more thing... remember...”  BJ Galvin, my star sista – thank you for reminding me time and again how spacious I actually am  Maryellen Stephens, Lisa Naera, Frank So & Marie McElhinney – thank you for your confidence and many referrals  My Dallas neighbours, Paulette, Brenda, Paul, Brad, Chris, and Karen – thank you for margaritas and midnight swims, and being there when the roof(s) caved in  Thanks also to all the body workers, mind workers, mindbody workers and other healers who looked after me over the years – you all ROCK!  Wolfson College – thank you for being my “home” for the better part of the last 9 years. Special thanks to my College advisor, Professor Andrew Neil; former Senior Tutor, Dr. Martin Francis; President, Professor Dame Hermione Lee, Librarian Fiona Wilkes, and also Rose Truby, John Kirby, Melvin Curtin, Di Wheeler, Cheery Johnson, and all the maintenance staff, cleaning staff and ground staff. ix  Parker University and Parker Research Institute – thank you for your support during the initial phase of this journey  Thank you to all organisations that support kMMT, especially the ICAK, NET, Inc; TBM, Inc; PSYCH-K; and Health Kinesiology  Empirisoft Corporation – thank you for your support and technical assistance with your DirectRT software  Oxford’s IT Services (formerly OUCS) – thanks for saving the day more than once  University of Oxford – thank you for an amazing trip!  Finally, thank you to Dr. George Goodheart, for founding Applied Kinesiology, to Major Dejarnette, who paved the way, and to John Thie, who followed, for contributing to the widespread use of kMMT TABLE OF CONTENTS Abstract .............................................................................................................................. ii Dedication .......................................................................................................................... v Gratitude (Acknowledgements) ...................................................................................... vi Table of Contents .............................................................................................................. x Abbreviations .................................................................................................................. xvi Glossary ........................................................................................................................... xix CHAPTER 1 : Introduction ............................................................................................. 1 1.1 The Evolution of MMT ........................................................................................ 2 1.2 The kinesiology-style Manual Muscle Test ......................................................... 5 1.3 Applications of kMMT ......................................................................................... 8 1.4 Interpreting the outcome of the kMMT ................................................................ 9 1.5 The Current Status of the Evidence .................................................................... 10 1.6 kMMT as a “Diagnostic Test?” .......................................................................... 12 1.7 Diagnostic Accuracy of kMMT .......................................................................... 14 1.8 Diagnostic Precision of kMMT .......................................................................... 15 1.9 Choice of Research Topic .................................................................................. 18 1.10 Research Question and Paradigm to Investigate ................................................ 18 1.11 Choice of Populations ......................................................................................... 21 1.12 Main Study Aims ................................................................................................ 22 1.13 Chapter 1 – List of Tables and Figures .............................................................. 23 CHAPTER 2 : Study 1 – Estimating the Accuracy of kMMT .................................... 46 2.1 Abstract ............................................................................................................... 47 2.2 Introduction ........................................................................................................ 49 2.3 Methods .............................................................................................................. 51 2.3.1 Participants and Setting ............................................................................. 52 2.3.2 Practice Phase ............................................................................................ 53 2.3.3 Test Methods .............................................................................................. 55