February 2009

Commentary: Point/Counterpoint ...

>> POINT

Evidence-based chiropractic: objective proof by Dr. Todd Turnbull

Evidence-Based care is the buzz word in modern chiropractic. But does it really exist and what does it look like? Can you walk into a courtroom with your treatment notes and prove your exam findings and treatment results objectively? What exactly does a chiropractor find during an exam that is objective and upholds inter-examiner reliability standards?

Dr. John Markham's commentary ("Rethinking the subluxation…part 2", Nov. 2008, The Chiropractic Journal) discusses the paradox between achieving clinical results and the lack of reliability for detecting subluxations for various methods. He recommends that we as a profession need to make it a priority to "develop a method of determining optimal response indicators…" to determine which treatment methods work best for each patient. The definition of subluxation needs to be expanded to include a neuro-mechanical model. I agree!

We know the nervous system controls every function in the body including muscle function and co-ordination. Most chiropractors would agree that the goal of an adjustment is to reduce stress and irritation to the nervous system. What we need to do is be able to prove it with outcome-based objective tests. These tests require validity, reliability, sensitivity and specificity.

I contend that we already have 'optimal response indicators' and the ability to objectively prove the results of care to ourselves, our patients and the rest of the world. The objective testing I am referring to is muscle testing; more specifically, utilizing eccentric break testing protocols to evaluate pre- and post- test muscle power output and endurance.

Many Chiropractors use orthopedic tests as the core of their new patient exams. Why? This is what they were taught to do in school. I was never taught effective muscle testing procedures in school other than Applied Kinesiology protocols, which were quite confusing, and the standard AMA Guides impairment ratings. Neither procedure utilizes eccentric break testing protocols fully.

Know that you can prove when an adjustment is done correctly because the attached muscles will respond by improving both power output and endurance. The opposite is also true; an incorrect adjustment will not increase power output or endurance. Chiropractic can be proven with solid, objective, scientific proof every time!

Chiropractic Works!

(Dr. Todd Turnbull, DC is a 1991 graduate of Life University and teaches objective soft tissue technique seminars across the country. You can contact Dr. Turnbull at 503-805-3865. Seminar information - www.MyotonicFacilitation.com)

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>> COUNTERPOINT

We need scientific footing to advance by Dr. John Markham

Dr. Turnbull is a chiropractor I have great regard for. I appreciate his response to my article and welcome his critique. I recognize that in the hands of a skilled practitioner such methods as muscle testing can help the clinician produce excellent patient outcomes.

In my own research and reading the published research of many others the inter-examiner reliability of interactive muscle testing renders it a poor tool for scientific validation of our profession. The reported Kappa statistic for muscle testing is lower than leg checks and just barely above chance.

Basic muscle strength assessment as taught in physical diagnosis classes or as described by Kendall & Kendall is a different test altogether and is a well accepted clinical protocol. Use of strength dynamometers has not replicated nor has it validated the observations of clinicians using interactive muscle testing.

I believe the use of the kind of muscle testing promoted by Dr. Turnbull and others has a richer context in which it can be considered appropriate. It is not an objective reliable reproducible test. It may however provide a bridge to mapping the right brain sub-threshold sensory perceptions of the doctor and allow for a left brain awareness of the patients condition.

I realize this is very speculative, but the lack of reliability of the procedure is paradoxical when compared to the clinical benefits observed when the procedure is applied. In other words, I suspect we may be doing a procedure whose actual mode of operation may be quite different from the assumptions we have made concerning it and we are perhaps arguing out of context.

I look forward to your further comments and observations as we seek to validate this wonderful profession. We have made progress since 1895 because we produced great patient outcomes even though our scientific theories about how we accomplished this have been tenuous at best. The best for our profession is yet to come and I believe we are closer than ever to finding the right scientific footing for advancement.

(Dr. John Markham is the director of Level III Clinics at Life University and director of the Life University Clinic P.E.A.K. Program. He practices in Kennesaw, Georgia.)