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 Author's personal copy

Journal of Bodywork & Movement Therapies (2011) 15, 192e200

available at www.sciencedirect.com

journal homepage: www.elsevier.com/jbmt

CLINICAL ASSESSMENT: PILOT STUDY

Association of manual muscle tests and mechanical

neck pain: Results from a prospective pilot study
Scott C. Cuthbert, D.C.*, Anthony L. Rosner, Ph.D., LL.D.[Hon.], LLC,
Donald McDowall, D.C., DIBAK, FACC

Chiropractic Health Center, P.C., 255 West Abriendo Avenue, Pueblo, CO 81004, United States

Received 6 July 2010; received in revised form 9 November 2010; accepted 19 November 2010

KEYWORDS Summary Objective: To determine whether there was a statistical difference for manual
Neck pain; muscle test (MMT) findings for cervical muscles in subjects with and without mechanical neck
Neck muscles; pain (MNP), and to use confidence intervals to evaluate the sensitivity and specificity of the
Muscle weakness; MMT in this group of subjects.
Cross-sectional studies; Clinical features: Manual muscle strength tests were conducted on two groups of patients who
Diagnostic techniques reported to two outpatient chiropractic clinics. In group 1, 148 patients were evaluated for
and procedures; MMT data (50 males and 98 females, average age 37), 127 with “whiplash”-type injuries
Chiropractic; (average duration 16 weeks) and 21 with non-traumatic chronic neck pain (average duration
Kinesiology, applied 36 weeks). In group 2, 100 patients were evaluated for comparative MMT data (39 males and
61 females, average age 38) with no current MNP or remarkable history of MNP.
Methods: Standardized MMT assessments of the strength of the sternocleidomastoid, anterior
scalene, upper trapezius, and cervical extensor muscles bilaterally were performed on all
subjects in groups 1 and 2.
Results: In group 1, 139 of 148 patients reporting neck pain also showed positive results in at least
one of four MMT tests (sternocleidomastoid, anterior scalene, upper trapezius, and cervical
extensors). In group 2, 30 of the 100 patients without MNP showed positive results in one or more
of the four MMT tests. Confidence intervals were calculated and showed that, in terms of MMT
findings, there was a significant difference between the two groups of patients.
Conclusions: A symptomatic group of patients with MNP demonstrated significantly increased
MMT findings in the form of reduced strength levels compared to a control group. This evidence
suggests that the MMT is potentially a sensitive and specific test for evaluating cervical spine
muscular impairments in patients with MNP.
ª 2010 Elsevier Ltd. All rights reserved.

* Corresponding author. Tel.: þ1 719 544 1468.

E-mail addresses: cranialdc@hotmail.com (S.C. Cuthbert), arosner66@aol.com (A.L. Rosner), cosmos2k@bigpond.net.au (D. McDowall).

1360-8592/$ - see front matter ª 2010 Elsevier Ltd. All rights reserved.
doi:10.1016/j.jbmt.2010.11.001
 Author's personal copy
Association of manual muscle tests and mechanical neck pain
Introduction
The Bone and Joint Decade 2000e2010 Task Force on Neck
Pain and Its Associated Disorders recently published its
findings (Haldeman et al., 2008a,b). In the executive
summary of this review, a challenging judgment was made
for manipulative physicians and manual therapists:
“The clinical physical examination is more predictive at
excluding a structural lesion or neurologic compression
than at diagnosing any specific etiologic condition in
patients with neck pain. All other assessment tools such
as electrophysiology, imaging, injections, discography,
functional tests, and blood tests lack validity and utility”
(Haldeman et al., 2008a,b).
Notwithstanding the Task Force’s assessment, it may still
be reasonable to investigate whether there are specific tissue-
based impairments related in particular to mechanical neck
pain (MNP) revealed upon further examination. Abnormal
cervical postures and muscular activity are commonplace in
patients with MNP (Haldeman et al., 2008a,b). Because
muscular imbalances, articular disturbances, trigger points,
tender points, muscle injuries, referred pain and postural
distortions manifest themselves in individual muscles, these
offer themselves as individual criteria to determine whether
these muscle dysfunctions are evident in patients with MNP
compared to patients without MNP (Carroll et al., 2008).
The incidence of neck pain is high in the general pop-
ulation. Neck and shoulder problems occur in nearly as many
individuals as low back pain, with lifetime prevalence
between 50% and 71% of the population (Lidgren, 2008). Hill
estimates that 48% of these neck pain patients have their
pain persisting for at least one year (Hill et al., 2004). Like
low back pain, the natural history of neck pain is generally
persistent with only one-third of patients experiencing
a complete resolution of symptoms (Côté et al., 2000, 2004).
Many researchers have suggested that neck pain has
a local physio-pathologic cause, and that this cause can be
identified and treated (Travell and Simons, 1983). Others
consider neck pain as a primarily nonorganic problem with
psychological and social roots (biopsychosocial model) and
that psychosocial disturbances have the major influence on
MNP (Hogg-Johnson et al., 2008). The relationship between
psychosocialepsychological variables, physical impairment,
and neck pain and disability is complex and not yet fully
understood (Linton, 2000).
Where MNP derives from irritation of pain receptors and
where this results in measurable functional changes (such
as from inhibited muscles that fail to stabilize the joints
they are meant to move), Lewit offers the descriptive term
“functional pathology of the motor system” (Lewit, 1999).
If there is a modifiable risk factor for MNP then it would
be prudent to develop preventive strategies to help identify
and target important subgroups of the population at
greatest risk for MNP (Guzman et al., 2008), Guzman et al.
note that there is a profound need to translate the results
of clinical and epidemiologic studies into meaningful and
practical information for clinicians. One such result could
be muscle strength impairments as a modifiable risk factor
in patients with MNP. Chaitow’s recent discussion of Clinical
Prediction Rules e clinical examination findings that can
193
predict the presence of a condition e may link muscle
strength impairments in patients with MNP as a modifiable
risk factor (Chaitow, 2010).
Several studies have in fact related measurements of
impaired muscle strength to MNP. In 2008, a literature review
on neck muscle strength by Dvir confirms that, “overall
studies indicate that compared to normal subjects, patients
suffering from neck-related disorders present with signifi-
cant reduction in cervical strength” (Dvir and Prushansky,
2008). This is consistent with previous research offered by
Dvir in his review (Nederhand et al., 2002, 2003; Vorro and
Johnston, 1998; Vernon et al., 1992).
Barton et al. also measured strength deficits in patients
with neck pain (Barton and Hayes, 1996). They showed that
all force values were significantly lower in the neck pain
population. Specifically, for the deep neck flexor test and
the SCM muscles, the peak force in the control group
(mean Z 45.3  17.6N ) was reduced by 50% in the neck
pain subjects (mean Z 22.4  13.1N ) (p  0.004).
Falla has similarly reported that both the SCM and anterior
scalene muscles’ strength was significantly reduced in
patients with neck pain at 25% of maximum voluntary
contraction (p < 0.05) (Falla et al., 2003, 2004a,b). Falla
suggests that “reduced neuromuscular efficiency in the
superficial cervical flexor muscles in patients with neck pain
may be a measurable altered muscle strategy for dysfunction
in other muscles. This aberrant pattern of muscle activation
appears to be most evident under conditions of low load.
Neuromuscular efficiency, when measured at 25% maximum
voluntary contraction, may be a useful objective measure for
future investigation of muscle dysfunction in patients with
neck pain”.
In addition, Prushansky et al. have demonstrated cervical
muscle weakness in chronic whiplash patients (Prushansky
et al., 2005). Silverman et al. also found that individuals
with neck pain had reduced neck flexor strength compared
to asymptomatics (Silverman et al., 1991).
Further support linking MNP to reduced muscle strength
was offered by Edgerton et al. who found altered muscle
activation ratios of synergist spinal muscles during a variety
of motor tasks in whiplash patients (Edgerton et al., 1996).
Their study showed that underactivity of agonists and
overactivity of synergists was able to discriminate chronic
neck pain patients from those who had recovered from neck
pain with 88% accuracy.
Ylinen et al. pointed out that decreased isometric strength
in neck flexion, extension, and rotation distinguished female
chronic neck pain patients from those without pain (Ylinen
et al., 2004). Jull and colleagues have offered a substantial
body of evidence showing that patients with neck pain
demonstrate reduced electromyographic activity of the deep
cervical flexor and extensor muscles during performance of
the craniocervical flexion test (a form of MMT) (Jull et al.,
2008).
Following cervical trauma and with postural strain,
numerous myofascial trigger points (MTrPs) in the cervical
region are commonly identified (Travell and Simons, 1983). In
addition to pain, numerous remote symptoms can be caused
by trigger points. Travell, Simons and Mense state that
weakness is generally characteristic of a muscle with active
MTrPs (Mense and Simons, 2001; Travell and Simons, 1983).
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194 S.C. Cuthbert et al.

To our knowledge, there are sparse published data
pertaining to manual muscle test (MMT) findings in patients
with MNP (Garten, 2008; Waddell, 2005; Dobson, 1999;
Cyriax, 1920). Furthermore, these previous studies lacked
a control group for normative data comparisons. A reliable
direct measure of the cervical muscles could provide the
opportunity for further research into the role of impair-
ments of these muscles, which is believed to exist in people
with neck pain (Carroll et al., 2008).
This investigation asked whether MNP was associated with
measurable muscular inhibition in the head and neck and
whether this could be detected using the MMT as it is
used in applied kinesiology (AK). The muscles in this study
were tested according to the method outlined in the texts by
Walther, Kendall, and Daniels and Worthingham (Kendall
et al., 2005; Daniels and Worthingham, 2002; Walther,
2000). This method of MMT has been previously investigated
in numerous reliability studies (Jepsen et al., 2004; Bohannon,
2001; Caruso and Leisman, 2000; Lawson and Calderon, 1997;
Kelly et al., 1996; Hsieh and Phillips, 1990; Leisman et al.,
1989; Wadsworth et al., 1987; Iddings et al., 1961).
A recent review of the validity and inter-examiner reli-
ability of the MMT by Cuthbert and Goodheart (2007) included
the studies just mentioned. The correlation coefficients
ranged from 0.63 to 0.98 for individual muscle groups, and
from 0.57 to 1.0 for a total MMT score (comprised of the sum
of individual muscle grades). The results in the studies
reviewed demonstrated good inter- and intra-examiner reli-
ability for the MMT.
The operational definition of the AK MMT as used in this
study is identical to the so-called “break test” described in
the literature cited above; this operational definition has
been part of the International College of Applied Kinesiol-
ogy’s (ICAK) training program since its first mission statement
was written in the early 1970s (ICAK-International website,
2010). Two recent papers (Schmitt and Cuthbert, 2008;
Cuthbert and Goodheart, 2007) review the operational defi-
nitions of the AK MMT and show that they are identical to the
ones originally offered by Kendall and Kendall, Daniels and
Worthingham, and later Janda and others (Janda, 1983).
Within the chiropractic profession, the International
College of Applied Kinesiology (ICAK) has established
an operational definition for the use of the MMT (ICAK-
International website, 2010):
“Manual muscle tests evaluate the ability of the nervous
system to adapt the muscle to meet the changing pressure
of the examiner’s test. This requires that the examiner be
trained in the anatomy, physiology, and neurology of
muscle function. The action of the muscle being tested, as
well as the role of synergistic muscles, must be under-
stood. Manual muscle testing is both a science and an art.
To achieve accurate results, muscle tests must be per-
formed according to a precise testing protocol. The
following factors must be carefully considered when
testing muscles in clinical and research settings:
 Proper positioning so the test muscle is the prime
mover
 Adequate stabilization of regional anatomy
 Observation of the manner in which the patient or
subject assumes and maintains the test position
 Observation of the manner in which the patient or
subject performs the test
 Consistent timing, pressure, and position
 Avoidance of preconceived impressions regarding the
test outcome
 Nonpainful contacts e nonpainful execution of the test
 Contraindications due to age, debilitative disease,
acute pain, and local pathology or inflammation”
In physical therapy research, the “break test” is the
procedure most commonly used for MMT, and it has been
extensively studied (Kendall et al., 2005; Daniels and
Worthingham, 2002; Harms-Ringdahl, 1993). This method of
MMT is the one used in chiropractic, developed originally from
the work of Kendall and Kendall (Walther, 2000; Goodheart,
1998).
Methods/design
This study included 248 patients who consecutively reported
to two chiropractic outpatient clinics in Canberra, Australia,
and Pueblo, Colorado for treatment. Data was collected
between January and December 2009. All participants were
made aware of the experimental details prior to assuming
their involvement in the study, and they were required to fill
out a symptom questionnaire and a consent form before
the testing was administered. The examination for MMT
impairments was recorded on the patients’ first visit.
For group 1, 148 new patients were admitted to the
study that came for chiropractic treatment in Canberra,
Australia who met the inclusion criteria of a primary
complaint of MNP. The following symptom clusters were
required for inclusion in group 1 (Table 1).
1. Neck pain.
2. Arm pain originating from the neck.

Table 1 Subgroups of MNP cohort.

Mechanical Whiplash- Non- Arm Cervico- MNP MNP
neck pain type traumatic/ pain cranial associated associated
occupational radiating headaches with shoulder with low
from neck pain back pain
# of patients 148 127 21 7 30 43 70
Duration of 16 week 36 weeks 9 weeks 42 weeks 15 weeks 7 weeks
complaint (1 week to (1 day to (3 weeks to (1 week to (1 week to (3 weeks to
25 years) 45 years) 2 years) 18 years) 5 years) 3 years)
 Author's personal copy
Association of manual muscle tests and mechanical neck pain
3. Thoracic pain associated with neck pain and originating
from the neck.
4. Headaches associated with neck pain and originating
from the neck.
5. Generalized symptoms originating from the neck.
For group 2, 100 otherwise healthy new patients were
admitted to the study that came for chiropractic treatment
in Pueblo, Colorado, who met the inclusion criteria of
a primary complaint other than MNP nor did they have
a previous history of MNP or injury.
Experimental procedure
Assessment of the participants involved standard MMT of
four predetermined muscle pairs of the anterior and
posterior neck bilaterally (the sternocleidomastoid or SCM,
anterior scalene, upper trapezius, and cervical extensor
muscles). From the basic texts on MMT (Walther, 2000;
Kendall et al., 2005; Daniels and Worthingham, 2002),
these are the individual neck muscles for particular neck
motions that are the prime movers whose strength can be
differentiated from their synergists. Each test was con-
ducted twice, with a 15 s rest period in between tests.
Description of manual muscle test procedures
All muscles were tested from a starting contracted position
as described by Kendall, Daniels and Worthingham,
Walther, and Goodheart (Kendall et al., 2005; Daniels and
Worthingham, 2002; Walther, 2000; Goodheart, 1998) among
others, with pressure applied toward lengthening. If the
subject maintained the starting position against gradually
increasing pressure for the duration of the test, it was graded
as “strong” corresponding roughly to grade 5 of 5 (American
Medical Association, 2007). If the muscle failed to hold the
starting position and broke away, the muscle was rated as
“weak” corresponding to a grade of less than 5. The MMT
began with a position designed to place the prime mover into
its greatest advantage for the testing activity, while the
synergist muscles were at the greatest possible disadvantage.
Janda has emphasized that prime movers and synergists
are tested with the MMT, not individual muscles (Janda,
1983). However, it should be pointed out that every muscle
functions as a prime mover in some specific action (Kendall
et al., 2005). The MMTs used were designed to replicate the
primary vector of motion of the muscles tested while mini-
mizing the contribution of secondary mover muscles. During
the individual MMT, the designated primary mover muscle
should have the highest level of activity compared with the
secondary mover or synergist muscles (Schmitt and Cuthbert,
2008; Walther, 2000).
During the MMT procedure, the examiner applied
a vector of force specifically designed to test the prime
mover. The examiner used this knowledge of what syner-
gists would attempt to take over if the prime mover was
weak e keeping in mind that many testing procedures rely
upon fixation of specific body parts by adequate action of
the patient’s fixator muscles. All these considerations were
applied with a specific speed and vector and at the correct
point of contact on the patient.
195
In order to optimize subject performance, the examiner
provided verbal instructions and demonstration of each test
procedure. To reduce recruitment of trunk, pectoral, and
lower limb muscle forces and to maximize isolation of the
neck musculature for all the flexor and extensor muscle
tests, the subject’s arms were lifted off the examination
table and the hands placed level with the head. This
eliminated the recruitment of the scapular and pectoral
muscles during the test (Chaffin, 1975).
Subjects were instructed to produce a level of resistance
that reached, but did not exceed, tolerable pain.
The SCM muscle was tested supine with the head lifted
from the table and rotated away from the muscle to be
tested. Pressure was applied against the temporal area in
a posteromedial direction (Altered muscular movement
patterns (what Janda called “trick patterns of substitution”)
have long been evaluated in proper MMT and are a common
finding in patients with muscle inhibitions as they attempt to
use synergist muscle substitution during the MMT.) (Walther,
2000; Daniels and Worthingham, 2002; Kendall et al., 2005;
Schmitt and Cuthbert, 2008; Cuthbert and Goodheart,
2007). Careful monitoring for slight changes of patient posi-
tion was necessary, as they could have indicated a subcon-
scious effort to recruit synergist activity. In the case of the
SCM, the examiner scrutinized the patient’s attempts to turn
his head medially, recruiting more synergistic action from the
scalene group and other neck flexors (Figure 1).
The anterior scalene muscles were tested supine with
the head lifted from the table by neck flexion and rotated
10 away from the side being tested. Pressure was applied
against the forehead in the direction of neck extension
directly toward the table and not in alignment with the 10
rotation of the patient’s head. Observation was made for
the patient’s attempt to rotate his head, thereby recruiting
more activity from synergist muscles in substitution during
the MMT (Figure 2).
The upper trapezius muscles were tested in a seated
position. The patient elevated his shoulder and laterally
flexed his neck and head, with rotation of the head slightly
away from the side being tested. The patient was not
allowed to bring the ear and shoulder into such close
proximity that the upper trapezius would be in compressed
and relatively immobilized position (Figure 3).
The cervical extensor muscles were tested bilaterally
together and then unilaterally with the patient in the prone
position. For the unilateral cervical extensor test, the face
was turned toward the side being tested, and the neck was
extended by lifting the head off the table. For the bilateral
test, the neck was extended off the table without any
rotation. Pressure was directed against the posterior or
posterolateral aspect of the head toward the table in the
direction of the muscle’s action (Figure 4A and B).
Results
For group 1 (MNP)
One-hundred and thirty-nine of 148 patients reporting MNP
showed inhibition on MMT in at least one or more of the four
tests (MMT of the sternocleidomastoid, anterior scalene,
upper trapezius, and cervical extensor muscles), yielding
 Author's personal copy
196
Figure 1 Sternocleidomastoid MMT and muscle.
a sensitivity of 93.9%. The total number of positive MMT
findings in the MNP group was 222, because many of the
members of this group had positive MMT results on more
than one test. Weaknesses were broadly and to a large
extent equally distributed (32.4e43.2%) across the four
muscle groups tested (Table 2).
If the 148 MNP patients in this cohort were truly repre-
sentative of the overall patient population, then it would be
possible to compute a confidence interval. In so doing, we
chose the ClopperePearson two-sided interval, the method-
ology being appropriate for binomial (yes/no) data and
making no assumptions about any data distributions being
normal or approximately normal (Newcombe, 1998). To arrive
at the confidence interval, we used the binom.test function
from the “R” statistical program (www.r-project.org).
Under these circumstances and using a 95% confidence
interval, we would estimate that between 88.8% and 97.2%
of all patients have positive MMT findings in one or more of
the four muscle pairs tested (Figure 5).
For group 2 (no MNP)
Thirty of the 100 patients without MNP showed positive
results in one or more of the four MMT tests, yielding
Figure 2 Anterior scalene MMT and muscle.
S.C. Cuthbert et al.
a specificity of 70%. The total number of positive MMT
findings in the control group was 37. However, there were
only 30 patients with positive MMT findings, because several
patients had positive results from more than one test. In
this instance, positive findings were generally confined to
the sternocleidomastoid and anterior scalene muscles
(Table 2). Using the assumptions discussed above, the 95%
confidence interval for this group would be between 21.2%
and 40.0% (Figure 5).
The apparently wide gap of confidence intervals between
those patient cohorts with or without MNP is noteworthy,
keeping in mind that (1) the specificity of the MMT in patients
without MNP was 70%, and (2) the sensitivity of the MMT
in patients with MNP was 93.7%.
The “sensitivity” of the MMT proved to be high for subjects
in group 1. Sensitivity indicates the likelihood of receiving
a positive MMT result in one or more of the cervical muscles
tested when MNP was truly present. The “specificity” of the
MMTwas not as high but still significant for group 2. Specificity
indicates the likelihood of receiving a negative MMT result
when MNP was not present. Under these circumstances, our
data as shown in Figure 5 suggest that MMT was a sensitive and
moderately specific test for differentiating the two groups of
patients with and without MNP.
 Author's personal copy

Association of manual muscle tests and mechanical neck pain 197

Figure 3 Upper trapezius MMT and muscle.

Discussion While the incidence of muscle weakness appeared to be

The apparent ability of MMT applied across the four muscle
groups in this investigation to discriminate MNP from non-
MNP patients supports both our hypotheses that (1) MNP is
associated with a measurable muscular inhibition, and (2)
the MMT, in identifying these muscular inhibitions, may
lead to the discovery of a modifiable risk factor for MNP.
roughly distributed across all four of the muscle groups
tested in MNP patients, this was not the case in the non-
MNP patients (see Limitations section below).
The MMT expands the scope of traditional EMG-type
biofeedback (Maffetone, 2009; Kendall et al., 2005; Daniels
and Worthingham, 2002; Walther, 2000; Basmajian, 1985).
Although a large number of instruments have been developed

Figure 4 A. Cervical extensor (unilateral) MMT and muscle; B. Cervical extensor (bilateral) MMT and muscle.
 Author's personal copy
198
Table 2 Number and percentages of patients with posi-
tive MMT findings, by muscle group.
Control group Mechanical neck pain
(100 patients) group (148 Patients)
Sternocleidomastoid 18 (18%) 61 (41.2%)
Anterior scalene 13 (13%) 49 (33.1%)
Upper trapezius 4 (4%) 64 (43.2%)
Cervical extensors 2 (2%) 48 (32.4%)
that can measure resistance, the majority are not suitable
for practical use because they are difficult to handle, and not
all muscles can be tested with them. In place of electrodes
and mechanical sensors used in computerized devices, the
MMT integrates the practitioner’s sensory system as the
sensor. The process is similar and in many cases identical to
traditional EMG testing of active muscles.
The concurrent validity of the MMT (its comparison to
various mechanical instruments of muscle strength testing)
has been found to be good and frequently comparable to
dynamometer and EMG findings in 8 studies (Cuthbert and
Goodheart, 2007). In one study, for practitioners with five
or more years of experience, there was a virtual perfect
correlation of the results of MMT and those obtained with
a force transducer and electrogoniometer for over 700
muscle tests (Caruso and Leisman, 2001).
Kendall et al. (2005) state, “As tools, our hands are the
most sensitive, fine tuned instruments available. One hand of
the examiner positions and stabilizes the part adjacent to the
tested part. The other hand determines the pain-free range
of motion and guides the tested part into precise test posi-
tion, giving the appropriate amount of pressure to determine
the strength. All the while this instrument we call the hand is
hooked up to the most marvelous computer ever created. It is
the examiner’s very own personal computer and it can store
valuable and useful information of the basis of which judg-
ments about evaluation and treatment can be made. Such
information contains objective data that is obtained without
sacrificing the art and science of MMT to the demand for
objectivity”. According to Walther (2000), “Presently the
best ‘instrument’ to perform MMT is a well-trained examiner,
Figure 5 Comparison of positive MMT findings between MNP
and non-MNP groups.
S.C. Cuthbert et al.
using his perception of time and force with knowledge of
anatomy and physiology of muscle testing” (Walther, 2000).
When properly performed (Schmitt and Cuthbert, 2008),
the MMT is also thought to better isolate a muscle compared
to a dynamometer, strain-gauge, and other instrumental
testing, because the examiner can observe the MMT by visual
and tactile senses combined, guiding and thereby elimi-
nating the recruitment of synergistic muscles (Kendall et al.,
2005; Daniels and Worthingham, 2002; Walther, 2000). A
general evaluation of neck strength with a dynamometer
may not reveal the same information that MMT does if, for
instance, the injury is to a single nerve, an individual muscle,
or even a portion of a muscle. Several human muscles,
including the upper trapezius and anterior scalenes, have
broad fan-like attachments dividing the muscle into serial
segments, and each section of a dysfunctional muscle may
be assessed for strength using the MMT with precise patient
positioning.
Even in a severe MNP syndrome, only a portion of the
fibers may be involved, allowing some muscles to function
very well. These may be the muscles primarily tested by
instruments evaluating the gross muscle strength in group
muscle tests; yet significant changes in individual muscles
may be present when manually tested.
The muscle strength impairments in MNP patients in this
pilot study, shown to be commonplace in clinical practice and
the research literature, were supported by our data in this
report. If these findings are confirmed in more controlled
clinical trials, then an easy-to-use, inexpensive, and in-office
clinical tool for the measurement of an important component
in MNP would be available and buttressed with greater
rationale than previously.
Limitations
All individuals were recruited and treated at separate
clinics by different practitioners, raising the possibility of
confounding of such factors as (1) patient demographics,
(2) the environment, and (3) the practitioner involved. Of
similar concern is the fact that patients who did not have
MNP were still under treatment for complaints in other
locations rather than being pain-free altogether. This could
have produced muscle weaknesses in the neck in some
instances, a possibility corroborated by our finding that the
rather unexpectedly high number of 30 patients without
MNP tested positive for muscle weakness as well as by the
apparently different distribution of muscle weaknesses
shown in Table 2. Further research should address a fully
asymptomatic patient population to strengthen the
hypothesis that weakness of the 4 muscle pairs taken
together may be a specific indicator of MNP.
An additional limitation of this study was the duration.
Because this was an in-office pilot cohort study, treatment
for the muscle weaknesses found was immediately given. In
cases of MNP, the natural history of muscle weakness and
MMT findings must be studied over longer periods.
It is possible that the practitioners performing the MMT
were doing so with differing criteria for the determination
of “weak” and “strong” MMT findings, and this may have
altered the results. The operational definition of the stan-
dard MMT as taught in the International College of Applied
Kinesiology (ICAK) and in the chiropractic colleges that
 Author's personal copy
Association of manual muscle tests and mechanical neck pain
teach MMT were followed (Schmitt and Cuthbert, 2008),
and the examiners for study 1 and 2 had 35 and 10 years of
experience, respectively, using this type of MMT.
The most intriguing question raised in our study pertains
to whether muscle weakness as a proposed risk factor for
MNP is reversible. This would be answered by the treatment
of a cohort of patients with MNP using a variety of inter-
ventions to treat MNP (spinal manipulative therapy, cranial
manipulative therapy, mobilization, myofascial release and
others). This treatment would be immediately accompanied
by examination of the four muscle groups to see if muscle
strength is regained using the MMT. Every patient with MNP
who visits an applied kinesiology practitioner faces this
clinical examination and treatment sequence. This question
will be answered in a forthcoming paper (using the MNP
cohort from the present study) from the authors.
Resolution of MNP accompanied by the return of muscle
strength after such treatment would further establish the
role of these four muscle groups as a specific indicator of
MNP. An additional refinement could include a control
group of MNP patients subjected to a sham treatment in
which pain resolution and the regaining of muscle strength
would not be expected.
Conclusion
The standardized MMT test protocols used were applied
to a symptomatic and non-symptomatic population and
revealed significantly more weakness in the MNP sufferers.
The wide gap of confidence intervals between these
cohorts with and without MNP is noteworthy. The specificity
of the MMT in patients without MNP was 70%, and the
sensitivity of the MMT in patients with MNP was 93.7%. The
MMT proved to demonstrate high sensitivity for patients
with MNP. The specificity of the MMT was not as high but
still significant for group 2. Our data suggest that MMT was
a sensitive and moderately specific test for differentiating
the two groups of patients with and without MNP.
The present study suggested that the use of the MMT in
the clinical setting could be a useful tool for assessment of
one of the components that may underlie MNP. Muscle
weakness in the neck as one such component may prove to
be a modifiable risk factor for patients with MNP. Further
study in more controlled environments with less heteroge-
neous cohorts is recommended.
Competing interests
SCC is a Board Member for the ICAK-USA. DM is a diplomate
of the International College of Applied Kinesiology (ICAK).
AR is the Research Director of the ICAK-USA. SCC and DM
both employ MMT and AK methods in their evaluation and
treatment of patients.
Authors’ contributions
DM and SCC conceived the research idea. DM evaluated
group 1, and SCC evaluated group 2 in their respective
clinics. SCC, AR and DM drafted the manuscript and
approved the final version for publication. George Heine
was the statistician, and he holds an MA in applied
199
mathematics and a PhD in applied probability from the
University of Colorado.
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