This is an offshoot from theChiropractor test thread.
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I laid down the challenge of a £50 bet that AK could not be shown to be more than ideomotor effect under test conditions. To my considerable delight, Ted Jed (is that your full name BTW?) took up this challenge.
Game on:drinks
By way of introduction.
There is a lot of interesting information around the science behind AK. To me this is all moot unless the test is reproducable. If I constructed a theory that in a house with spinach in the fridge the mice will be green, you would not need to know my reasons to test my theory. You would need, initially, to show me a green mouse in such a house.
You can tell I've been reading a lot of Dr Zeus recently can't you.
So then. This needs to be a quick and simple test to see if AK is reproducable in the absence of the ideomotor principle.
Hypothesis.
AK Has a mechanism which is outside of the Ideomotor effect.
Null hypothesis
AK has no mechanism which cannot be explained by the ideomotor effect.
So this is not a study to investigate the efficacy, the validity or anything like this. It is simply to investigate if the effect is reproducable.
The ideomotor effect is based on the principle that somebodies muscular activity (in this case perceived strength) can be affected by SUBconcious controll on behalf of the subject. Emphasis on the Sub, people exhibiting this are rarely aware that they are doing so.
Well documented examples include pendulum dowsing.
So there are two possible effects of this on AK.
1. The tester pushes harder.
2. The subject perceives a drop in strength.
Therefore to blind this study we must attempt to eliminate both the tester, and the subjects knowledge of the test conditions. It is not enough to blind either the tester OR the subject. Either can produce the effect, or indeed by non verbal communication, communicate the test state.
The simplest way to do this would be by testing heel raises. In the volumes we tend to use in orthoses raises it can be tricky to detect the level of a raise (though not impossible). The effect of the aforementioned non verbal communication could further be reduced by blinding (literally) the tester.
Further effort at blinding could be made by using a subject who is unaware of the nature of the test. If the muscle weakness is truly a physiological mechanism this will have no impact. If its psychological, it will.
So we could have 3 situations. Heel raise in left foot, heel raise in left and heel raise in right. This gives a total 6 mm difference between the two test conditions. Test, say, 20 times in random order with each time the subject leaving the room to have their shoes modified. If we place the raises under a thin poly strip which stays in both shoes it should reduce the patients ability to conciously detect the change (and be closer to the situation of adding raises under insoles)
So.
Ted.
Would a 6mm differential be enough to produce a discernable AK change under normal circumstances?
Anyone else
Can anyone else think of any modifications / enhancements to the test protocol (without hydraulic raisable platforms etc or anything else which would make the test excessively complex )
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Hi Rob
Sounds very interesting. When will this happen ?
Deborah -
14 or 17 of April is when the main main is in london. Don't know if he is around in the meantime...
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Thanks. Let me know if you're able
Deborah -
Hi Rob
The protocol sounds largely fine. However, the subject could be blinded by removing the footwear in the test room (or elsewhere), so they are not aware of what - if any - alteration has been made. I do feel that the subject will be aware of the heel raise which could affect the result.
I am always dubious about any test where p =1. How about lining up 20 to 30 subjects? Still not ideal but statistically more significant.
All the best
Bill -
Hey bill.
That was exactly what I had in mind with the shoes. I don't know how detectable a 3mm raise would be. Remember the subject won't know what I'm doing to their shoe.
I'm looking at it this way. Let's say for the 3 states there are 2 conditions, weak and strong. When a pattern has been set (weak / strong) the tester has a 1/2 chance of getting one right, 1/4 chance of two right 1/8 chance of 3, etc etc.
More subjects would be fab but I don't know how much time ted is willing to devote!
Cheers
Robert -
How's about this one, it should be possible to have 3 kinds of insole: one that strengthens the voodoo, one that weakens the mojo, and one that does nothing at all.
So, you have 20-30 subjects and you randomly allocate each of them to receive one of the above types of insoles, they don't know which one they get. Ya' man then tests each subject and "guesses" which subject is wearing which insole.
Trouble is it becomes a circular argument, how do we know the insole had the prescribed weakening effect, strengthening effect etc.... -
Hi Rob
You say that the tester may subconciously push harder.
What if, instead of pushing, the tester were to pull down on the arm?
The subject could have a spring scale attached to his/her arm which the tester pulls thus measuring the the amount of force used.
Paul -
You'll need to agree on insole design, perhaps Ted can tell us how to design insoles which will weaken; strengthen; do nothing in terms of strength... The question still remains, "how do you know the insole has weakened the shoulder muscles?" "Well I push down on his arm...." You got to show the validity of the pushing down on the arm test first... You'll also need ethical approval to get this published, so I'd get on with that if you want to collect data in April. -
In my previous limited experience of using this test method (in a different discipline) there are issues of:
- the differing subjects individual shoulder strength (something that can have a bearing on the subject response)
- the need for the subject to be advised of (even experience) what the tester is going to do to the arm in order to let them comply with the testers push
- in relation to the latter it may also be necessary for a subject arm to be pushed a couple of times so they are familiar with what to expect (maybe this can be done by someone else in another room)
- the push should be fleeting and relatively light as prolonged push may well increase the pressure applied by the tester (which comes back to item 1 as well)
It was for these, amongst other reasons, that I ceased doing this kind of test in the other discipline. I remain open to it possibly having some physiological or neurophysiological bearing or value but the variables involved in subject response alone left me feeling it was not the best test.
It might be worth Stanley giving some comment on this. -
Needs to be a test-retest anyway, so this shouldn't be a problem as it's relative to the subject
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You also need to ensure the lever arm is the same throughout, pretty easy to create greater displacement with the same impulse if you push more distally on the arm.
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1. The heel lift may or may not cause a muscle to be inhibited. So testing for an inhibited muscle when there is none is fruitless.
2. The muscle test proposed is an invalid test. A valid one tests one muscle, not a group of them, as only one muscle of the group may be inhibited.
3. The tester should be qualified. No offense TedJed, as I know nothing about you, but are you certified in AK, and where have you taken your course work?
4. Muscle testing is a skill that takes a long time to perfect, and the person’s nervous system determines how this muscle contracts. For instance in a professional athlete, the difference between inhibited and normal contraction is very minimal and is extremely difficult to determine. Also, the patient may have dysponesis, and until this is corrected, there will not be a normal muscular response. Each muscle has a different feel and strength to it and this is where the skill lies. For instance, I am confident in my ability to test the posterior tibial, and the peroneal muscles. I am not confident in my ability to test the hamstrings because I don’t routinely test them.
The muscle test is not the strength of the muscle; it is the quality of contraction of the muscle. An EMG during muscle contraction would be a more accurate and less subjective test.
Here is a reference in which EMG was used to with AK muscle testing:
http://www.ncbi.nlm.nih.gov/pubmed/19480696
Regards,
Stanley -
Thank you Rob for your extensive considerations and articulation of the proposed 'study'.
I think we looking to test 2 different hypotheses.
Your Hypothesis:
My hypothesis is:
Changing proprioceptive afferent input from the foot causes changes in muscle response (strength, ability to respond to a changing physical challenge) in muscle groups involved in gait (lateral deltoids).
I have no interest in testing 'subconscious' influences. This is too airy-fairy for me.:pigs:
Clinical relevance:
To test whether this neurological muscle testing can be a useful test for clinical assessment of orthoses, joint mobilisation or any other form of intervention.
Proposed Testing Procedure:
Tester (me, Ted Jedynak) is blindfolded.
Tester & subject are positioned within close proximity.
Subject is standing barefoot on a firm, flat surface.
Subject is given instructions verbally by the tester.
Tester tests to establish a 'baseline' of the quality of muscle contraction/resistance to the applied force.
Results observed and recorded.
Subject then has 1 of the following circumstances applied without the knowledge of the tester:
a) nothing or
b) pencils applied under the 1st & 5th metheads of one foot (to artificially sublux the transverse metatarsal arch = aberrant afferent proprioceptive feedback to the brain).
Tester re-tests deltoid response.
Results observed and recorded.
Subject then has 1 of the following circumstances applied without the knowledge of the tester:
a) nothing or
b) pencils applied under the 1st & 5th metheads of one foot
Tester re-tests the deltoid response.
Results observed and recorded.
Repeat whole process with further subjects.
In this set up, the tester is blinded to all the variations once a baseline has been established.
I don't think a 6mm heel raise will always be a sufficient intervention to consistently cause aberrant proprioceptive feedback (especially for someone with a LLD). A 7-8mm displacement of the metatarsal arch will directly affect the mechanoreceptors.
My thesis is that I should be able to 'tell' whether an intervention has been applied that causes aberrant proprioceptive feedback resulting in a significant weakness in the deltoids' strength through neurological muscle testing. This is a physiological response, not a subconscious voodoo ideometer response. My understanding of neurophysiology and neuroanatomy is what I am putting my $$$$ on.
Stanley, I have no training or certification in AK. I simply use rational scientific understanding of neurophysiology and muscles' responses to gauge the effectiveness of interventions.
Ted. -
This is great stuff.
I don't have time to do this justice this minute but Know I am mulling hard. Will get to it as soon as I can! -
Thanks for pitching in stanley.
In other words, if the muscle is weak one minute and strong the next, with the raise in the same side, then one (or both) of those readings does not pertain to the raise and is thus "bad".
Unless you are useing an EMG in everyday clinical practice, it is not needed for this test. An xray can measure SLLD. Demonstrating that would not prove that a clinical LLD measurement is accurate / useful / usable.
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Now this one
Now we CAN test the ideomotor hypothesis, because blinding the study will remove that effect, but not the proprioceptive afferent input from the foot. So if blinding the participants stops the test from working, we can safely say that its the ideomotor effect at work. If blinding the test has no effect, then we can say that its definitly NOT the ideomotor, and I am wrong.
In the same way, we agree that the ideomotor effect can cause the AK phenomina. So to find out how much validity there is to this test we need to remove that element. Whatever is left is the "true" AK effect.
I have a problem with this. The tester will be blinded but the subject will not! There are two possibilities for a psychological effect rather than a physiological one. First, the tester pushes harder, second the subject releases easier. A subject will know if they have a pencil under their 1st met head!!
Another source of error here. When you push down on someones arms, you pull their centre of gravity forwards on their feet. Onto their forefoot. Where two pencils are. I just tried this on my receptionist. First i pushed down with nothing under the foot and she went on tiptoes. Next I did it with the pencils and she said "ow". How do you know the muscles are not releasing because it hurts to keep the arms straight?
Thats not ALL it will do. It will also make the person aware that this is the "test condition". Which means by proxy they will know that the other is the "baseline" (especially as it was just established and we told them it was the baseline. Thus we no longer have a blinded test. Half blinded is not enough.
I know little about AK and a fair bit about psychology and suggestability. I could reproduce an AK test and make it go whichever way I wanted, simply by suggestion. I've done so before just for fun.
What could we change that would be hard for the subject to conciously detect, but which would still cause a discernable AK effect?
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There are two basic means of treating a patient with a tight muscle. The more common way is to stretch the muscle. The less common way is to “strengthen” the weak antagonist. AK strengthens the weak antagonist. So an inhibited muscle is found by history, postural examination, and some additional tests, and then different things are tested to see what tonifies the inhibited muscle.
A “subluxed” joint in the foot may or may not cause the posterior tibial muscle to become inhibited. If the “subluxed” joint is loaded by weight bearing the inhibition will then be noticed. We duplicate this by forcing a bone to go into a more subluxed position (challenge) and then testing the muscle. If the muscle weakens, we correct the joint (I correct the soft tissues to accomplish this), and when corrected, the challenge does not weaken the muscle. Challenging a normal joint will not cause muscle inhibition.
That is not to say that a heel lift won’t cause inhibition. For instance if there is a problem with a spinal vertebra and raising the heels increases the lordosis and thereby challenges the spinal vertebra, then a muscle can become inhibited.
Regards,
Stanley -
Strikes me if we tested your version then Ted could say "ah but that was just Stanley. Mine is REAL AK!"
would the real kinesiology please stand up... ;) -
Will reply to Stanley in due course...
Ted. -
maybe the orange beaning will come in handing !! -
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The tester pushing harder is not the correct way to apply this form of muscle testing. The test is about 'quality of contraction', not pure strength.
I like to think I have a reasonable skill and experience level in manual therapies and I see neurological muscle testing being one manual method (amongst many) that helps me make clinical decisions for my patients.
Cheers,
Ted. -
Just to interrupt this discussion re the metatarsal arch it´s a myth, but need to be specific re distal or proximal . So Ted if your talking about a metatarsal arch at the heads ie distal transverse metatarsal arch it does not exist.
So maybe you should say something like ...
the heads of the metatarsal are specific site of proprioceptive nerve endings, by changing the GRF acting on the 1st and 5th MTPJ we will test the effect proprioceptive disruption has on muscle strength.
or not but Ted Metatarsal arch at the met heads or distal transverse metatarsal arch, no.
sorry to interrupt but thought it might help discussions so you 2 can move forward and not get stuck on this point. Hope it helps with that.
:drinksAttached Files:
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The specifics of which MtPJs are affecting the proprioceptive nerve endings is probably a moot point. I'm proposing the altered proprioceptive feedback from any of the receptors located by the MtHds would have an effect on muscle strength.
Cheers,
Ted. -
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You sound reasonable and bright. I look forward to the test results.
Regards,
Stanley -
I THINK that when we remove the ideomotor we will be left with nothing. But I'm willing to be proved wrong. I'm a skeptic, not a cynic.
Ok then, back to a protocol, how would you feel about replacing the pencils with 4 mm by 1cm strips of evalon and making the test conditions baseline (nothing) 1 st and 5th met, pushed together under the centre of the 3rd met and, just for fun, under the medial side of the heel. If subluxing the "transverse arch" weakens the arm then building it up should have a different effect no?
If AK, single blinded, can consistantly discern whether the strips are making the trans arch convex, concave or nowhere near It, I would conceed that there may be more here than psychology.
In other words, if you can report "strong" or "weak" for 20 tests, in random order, and the strength correlates to condition (so each condition is either always strong or always weak), you win.
That work for you? -
Ain't never used pencils under a patients foot yet, never, not once, ever. No condition I have ever come across requires the prescription of pencils beneath the first and fifth metatarsal heads. Can I suggest you come up with an active insole design and a "sham" insole design and then employ these. Since standing on pencils versus not standing on pencils might be a little too obvious to all involved. On the other hand, if you place some paper between the pencils and the floor, you might come up with the next Turner prize winner.:rolleyes:
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Stanley, your comment that the joints would 'sublux over time' would be most likely, however, the changes in the structure (plantarflexed 2-3-4 relative to the dorsiflexed 1st & 5th) immediately changes the neurological function. The physical change in the structure cannot not change its function.
I saw this done for a patient who came to me for a 2nd opinion. The neurological muscle testing showed a 'weakness' when standing on her orthoses. Removal of the Morton's extension resulted in a 'strong' muscle test (immediately). The change in the structure caused a change in function which, in this case, was more tolerable and comfortable (over time, ~3 wks).
I think we are getting closer...
Ted. -
Mental.
And as for the prescription variables you describe above, I can honestly say I can't recall ever using a forefoot valgus post which elevated the 5th metatarsal head in association with a Morton's extension. But if that's the design of insole you want to test then I'm sure Robert is more than capable of constructing these and then constructing some "sham" versions. -
Thats not what I suggested. What I suggested was,
Might need a few subjects... -
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You guys are the 'design divas' (sorry for being sexist, but couldn't come up with an alliterated title to follow 'design'), I'll work with whatever you deem as suitable. As long as
Ted. -
Design Demons? Better than diva's!
If the evalon is the same height as the pencil then should be the same. -
BTW, would you say Ideometer? AK meridiens? Physiological? Voodoo?
http://www.youtube.com/watch?v=d977d7NmOyQ&NR=1
Ted. -
On the last video posted, watch the hands closely. When "closing" the joint he uses thr subjects thumb = "weak". Then he "opens" the joint but does this on the index finger which = "strong". Why should this work when he has compressed the thumb IPJ and then opened index finger IPJ? I would suggest this is ideomotor effect at it's best. Can't wait to hear what happens in April
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Well spotted Timm, except we don't get to see the muscle test result after the 'finger' test. It was edited out at that point. Could that have been because the 'result' didn't fit the desired outcome?!? (Sir Cynicism at work!)
Ted -
If you stand with your hands at your side, your center of mass is in one position. If you now stick your arms out in front of you with your center of mass will be shifted a little bit forward. If you hold a weight in your out stretched hands, the center of mass of the combined "system" of you and the weights will be shifted even further forward. A subject with weights in their hands may choose to lean backwards a bit to keep their center of mass over their center of pressure. Another option, and in my opinion a more likely option, is that the subject will activate their ankle plantar flexors to shift their center of pressure forward when you push down on their arms.
It is possible that the cause of the "release" is that the patient will feel that they will fall forward with the downward force on the outstretched arms. Any test with a force downward on the outstretched arms has to control for sagittal plane position of the center of mass relative to the foot.
Eric
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