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Correlation of manual muscle tests and salivary hormone tests in adrenal stress disorder: a retrospective case series report.


Introduction: The correlations between salivary hormone testing and the manual muscle test have not to our knowledge been reported before. Methods: Correlations between manual muscle tests and salivary hormone tests for 110 participants (83 female, 17 male) experiencing adrenal stress disorder (ASD) are described. Saliva samples were collected and screened for cortisol and dehydroepiandrosterone (DHEA). Results: We observed that patients with signs and symptoms of ASD and abnormal hormone levels on salivary hormone testing demonstrate distinct neuromuscular impairments that could be detected using the MMT. Discussion: Evidence for the linkages between neurohormonal imbalances and muscular imbalances are presented. Conclusion: This physical examination procedure, used within a number of health professions, may warrant further investigation given its utility, noninvasiveness, rapidity, and cost-effectiveness as a day-to-day clinical evaluation and management tool in cases of ASD.

Keywords: adrenal insufficiency; stress disorders; salivary hormone test; diagnostic techniques, endocrine; kinesiology, applied

Introduction: Adrenal Stress Disorder and the Manual Muscle Test

Adrenal gland imbalances are one of the most common conditions in the world, and stress-related illnesses are one of the most common conditions faced by functional medical physicians. (1) Serum blood samples and salivary hormone testing are standard diagnostic procedures for patients with "stress-related illnesses"; however, these diagnostic procedures cannot be performed on every patient who may be experiencing adrenal stress disorder (ASD), nor can it affordably be performed repeatedly on established patients or in patients who are undergoing recovery from this condition, due to their cost. (2), (3) In these patients with chronic stress, new stressors often arise, and repeating the salivary hormone test during the course of a lifetime of care becomes more and more unwieldy. Additionally, a single serum blood sample or salivary hormone test for ASD is insufficient for treatment; a second and even a third must be performed to determine whether the treatment protocol being used is working. (4)

However, previous research has shown the advantage of salivary cortisol measurements over serum measurements in the management of patients with ASD. (5) The advantages (simplicity, decreased stress during the procedure, convenience, sample mail-in and temperature stability) have been described, and for these reasons this method was chosen in order to compare the physical applied kinesiology manual muscle test (AK MMT) examination with this laboratory test! (6)

Salivary (or serum blood) testing may help guide physicians to the hormonal imbalances present in a patient with ASD, but it will not tell them how to best treat the problem. As an alternative, the manual muscle test identifies a functional disorder (inhibition) of the locomotor system. In the applied kinesiology (AK) evaluation of cases of adrenal stress disorder (ASD), this muscle inhibition occurs in specific muscles that immediately respond to specific adrenal gland nutritional support and/or adrenal gland viscerosomatic reflex stimulation (therapy localization). (7)

For example, a patient with a low DHEA value may need the actual hormone DHEA, or may show a need for a vitamin or mineral supplement that acts as a substrate to synthesize DHEA in order to strengthen the inhibited adrenal-related muscle. The physical examination procedure presented here provides information about the patient with "stress-related illness" that we did not previously know. This functional disorder associated with the adrenal-stress patient (the attendant viscerosomatic muscle inhibition) removes circularity from the AK method of diagnosis; the treatment required to remove this diagnostic finding in the adrenal-stress patient is what immediately strengthens the muscular inhibition. The corrective approach is thereby contained within the diagnostic procedure.

AK practice and experience has shown that when a substance comes into contact with the tongue, there is immediate change of muscle function as determined by the manual muscle test. (8), (9) That is, there is an increased response from the oral chemoreceptors if the papillae are moved in conjunction with the substance tested. (10) The testing of nutrition as advocated by the International College of Applied Kinesiology is a discipline limited to the tested substance stimulating the gustatory or olfactory nerve receptors, combined with accurate and specific muscle testing. (11)

It seems evident that the effect is due to stimulation of the gustatory and olfactory receptors. (10) Certain substances enter the bloodstream almost immediately by oral absorption, such as sodium and sugar. For instance, patients with untreated Addison's disease have increased taste sensitivity, roughly 100 times more acute than that of normal subjects. (12)

The MMT diagnosis of inhibited muscles and their covariance with patients' biochemical dysfunctions tells us something about the status of their condition as well as the responsiveness of this biochemical disorder to nutritional treatment. (7), (14-16)

Our approach in this case-series has been to determine the concurrent validity of the AK MMT diagnostic method compared to an established, "gold-standard" biochemical testing method, the salivary hormone test. The usual form for evaluating the concurrent validity of a test is to check any newly developed method of diagnosis against a method which has long been identified as a useful measure or reliable method of diagnosis. Were the AK sensorimotor tests of the biochemical component of ASD consistent with the findings of this laboratory test?


One hundred and ten subjects were selected over a 2-year period from patients presenting at three participating clinics, in Pueblo, Colorado (US); Chapel Hill, North Carolina (US); and Melbourne (Australia). The clinicians each had over 10 years of experience using the AK MMT. Being able to employ the AK MMT in a manner whose inter-and intraexaminer reliability and construct, concurrent, and predictive validity have all been documented requires considerable training on the part of the examiner. (30) Caruso and Leisman showed that examiners using the MMT with 5 years' experience have virtually perfect correlation with objective measurements by instrumentation for over 700 muscle tests. (31)

Participants were 83 female and 17 male patients between ages 13 and 72 (average age 41.4 years), who met the following inclusion criteria: experiencing self-reported "stress" symptoms and willing and able to undergo both AK chiropractic physical examination and salivary hormone testing (for which the patient paid approximately $300 US). Participants were excluded if they had any contraindications for chiropractic treatment, or if they were currently on any steroid or hormone medication. Participants were then briefed on the AK method of diagnosis and treatment, and the possible benefits and risks of treatment. Both verbal and written informed consent was obtained before assessment and treatment began.

For each participant in this case-series report, the focus was upon the Adrenal Salivary Index (ASI). The ASI offers the clinician and the patient an evaluation of the cortisol levels at various times of the day and a reading of the DHEA levels. It also offers a rating of overall adrenal function from normal to failure. A number of research studies have validated saliva as a diagnostic medium to measure the unbound, biologically active fraction of steroid hormones in the bloodstream. Saliva is a natural ultrafiltrate of blood, and steroids not bound by carrier proteins in the blood freely diffuse into saliva.


The protocol in this study was as follows:

1. A complete patient history was taken.

2. In the initial examination, each patient's blood pressure was tested in three positions (supine, seated, then standing), in addition to pupillary reflexes, Rogoff's sign, heart sounds, and ligament stretch reaction. (These physical tests are additional physical signs in AK examination regimen of adrenal gland dysfunctions.) (17)

3. The patient was physically examined with the focus upon the symptom history, particularly upon the function of muscles and joints and reflexes related in applied kinesiology to the adrenal gland (Figure 1, p. 46).

4. These muscles are the sartorius, gracilis, or posterior tibialis (Figures 2-4, p. 46). (13)

5. If these muscles were initially strong, then the sensorimotor stimulation (therapy localization in AK) of the adrenal glands' viscerosomatic reflexes (i.e., Chapman's and Bennett's and acupuncture meridian points) was implemented during the MMT (Figures 1, 5-7). (7), (13) If change in strength of the muscle occurred, this was noted (Table 1, p. 48).

Table 1: Patient Findings (Physical and Biochemical Correlations
of ASD in 110 Patients Found During AK MMT Examination)

Correlations Found in Adrenal Stress Disorder

# MMT Correlations (adrenal-related muscle found inhibited)  110

# of Patients with Ragland's Sign/Paradoxical Pupillary       58

# of Patients with Abnormal Cortisol                         101

# of Patients with Abnormal Cortisol: DHEA Ratio              65

# of Patients with Blood Sugar Handling Disturbance as        20
Primary Complaint

# of Patients with Psychosocial Primary Complaints            38

# of Patients with Reproductive System Abnormalities          31

# of Patients with Insomnia as Primary Complaint               7

# of Patients with Fatigue as Primary Complaint               33

# of Patients with Headache as Primary Complaint               3

6. After the assessment, the subject was given verbal and written instructions on how to perform the salivary hormone test correctly. The subject took the test kit home and collected samples of their saliva in collection tubes in the morning, at noon, in the afternoon, and at bedtime. These were placed in a plastic, resealable bag and immediately sent to the laboratory via the postal service. The hormones evaluated by the laboratories in this study were cortisol (diurnal, 4 times daily), and DHEA. These saliva tests used an enzyme-immunoassay, but to solve the problem of the matrix effect for hormones at very low concentrations in saliva, an extraction step was used. This removed the contaminants that may interfere with the assay and yielded results comparable with those seen in published studies where highly sensitive assays have been used. (18)

Therapy localization to these reflexes in patients with adrenal gland dysfunction (suggested by symptomatology, history, and AK physical assessments, and confirmed by the salivary hormone tests) produced changes in strength of the adrenal-related muscles during MMT (Table 1).


In each of these 110 cases with ASD, musculoskeletal pain was one of the reported symptoms.

In 38 of these cases, psychosocial disturbance was a reported symptom, encompassing anxiety, depression, decreased mental clarity, foggy thinking, nervousness, emotional irritability, and impaired memory.

In 33 of these cases, fatigue was a reported symptom.

In 31 of these cases, disturbances in the reproductive system were reported, including amenorrhea, premenstrual syndrome, night sweats, vaginal dryness, and a loss of libido.

In 7 of these cases, insomnia was a reported symptom.

In 3 of these cases, headache was present (two tension-type headaches and one case of migraine).


This cohort showed a 100% correlation of the AK MMT with the presence of ASD (as measured by the ASI), confirming the hypothesis that distinct neuromuscular impairments (associated with the adrenal glands in AK) could be detected using the MMT. Every subject of this study who had positive AK MMT findings showing ASD had abnormal cortisol values (91%) and/or abnormal cortisol/ DHEA ratios (59%). It must be remarked that because a relatively large number of viscerosomatic reflexes relating to the adrenal gland were tested, the detection of the physical manifestation of ASD using the MMT as described here was more likely. In the clinical setting, as distinguished from the research setting wherein a more limited number of variables are permitted, multiple manual muscle tests are performed in a series or parallel manner before any diagnosis is ever made.

The prevalence of psychosocial complaints (n = 38) in this cohort might be explained by the fact that low cortisol indicates adrenal fatigue, which is usually caused by chronic, unresolved stress (biochemical/emotional/ physical). To treat the various forms of the condition called anxiety on a symptomatic level, Western medicine uses a variety of drugs such as benzodiazepines, buspirone, antidepressants, beta-blocking agents, and antipsychotics. (19) However, recent data reveal that a large number of patients either fail to respond or remain with clinically significant residual symptoms after this treatment. Statistics show that 1 out of 3 patients does not sufficiently improve on these standardized Western treatments. (20)

Disturbances in the reproductive system were reported (n = 31). Applied kinesiology methods for detecting and normalizing adrenal function, as well as identifying food allergies, and decreasing mechanical stress to the reproductive organs, have shown promise in managing cases of menopause and perimenopause, dysmenorrhea, and infertility. (8,) (21-24) Reproductive steroid levels may also influence the stress response, such that future work in this area is warranted.

Insomnia was reported as well (n = 7). (25) Cortisol affects melatonin levels. In this report, we saw an inverse relationship between cortisol and insomnia. As cortisol levels became abnormal (as is common with those under chronic stress or with blood sugar handling problems) melatonin levels drop. (26) Recent studies have also shown that disrupted circadian rhythms (indicated in 101 of the patients in this cohort) may be an early indicator of increased risk for Alzheimer's disease. (27)

Fatigue was reported (n = 33), and lower cortisol values predicted fatigue in a large prospective cohort, suggesting that it may be of pathophysiological significance. (28)

Finally, headache was reported (n = 3). Elevated plasma cortisol has also been reported in migraine, and a trend towards higher cortisol has been reported in tension-type headaches. (29) Menstrual headaches have been successfully treated with applied kinesiology protocols that include craniosacral and chiropractic manipulative therapies that included support of adrenal function, clinical nutrition, avoidance of aspartame, and food-combining principles. (30), (31)

Salivary Hormone Tests for Adrenal Stress Disorder

It is accepted that blood cortisol levels rise in response to physical, chemical, psychological, and thermal stressors, and that there is a reliable direct correlation between blood cortisol and salivary cortisol levels. (3), (32) It is worth noting that the World Health Organization uses saliva testing to study human hormone levels around the world. (4), (17)

We found that testing hormones in saliva was convenient, painless, and therefore less stressful and less expensive than blood tests. More importantly, saliva contains the free, "bioavailable" fraction of steroid hormones that have moved out of the bloodstream and into the tissues. Furthermore, the stress caused by a conventional blood draw can alter test results. For salivary hormone determinations, the home collection kit allows for optimal collection times.

Can Internal Medicine and Physical Medicine Interact In This Way?

Exposure to taste elicits a variety of immediate neurological, digestive, endocrine, circulatory, and renal responses throughout the body and has been called the cephalic, or preabsorptive, response. (33) Of key importance are the skeletal muscles, which are affected through the action of foods upon the taste receptors. (34) The large mass of skeletal muscle in the body (60% of the body's weight) plays an integral role in blood sugar and insulin metabolism, with the latter disposing of approximately 50% of the increased postprandial blood glucose into muscle cells for use as energy, and up to 10% for conversion to glycogen. (35)

The sensory receptors embedded in lingual epithelium are used to distinguish chemical compounds that are potentially nutritive (e.g., salts, sugars, proteins, carbohydrates, fats, and so forth) from those that are potentially harmful (e.g., bitter-tasting plant alkaloids, allergens, toxins, etc.). (10)

The taste buds also have an effect upon blood sugar levels and insulin, which also influences a variety of other body functions through neurological mechanisms. (33) Chambers et al. showed that sweet taste in the mouth affects muscle function as measured by both exercise performance and brain activity. (36) They used both a 1-hour cycling test, which showed improved performance just by tasting, and functional magnetic resonance imaging (fMRI) to demonstrate that there are specific areas in the cortex associated with oral receptor stimulation. The authors state that the underlying mechanisms for this performance-enhancing effect do not appear to be metabolic but rather neurological, with afferent signals modifying motor output. That changes in motor function occur as a consequence of gustatory stimulation is evident from common examples such as with the administration of syrup of ipecac, which induces immediate vomiting. Jeukendrup and Chambers believe that the immediate changes in muscle function due to sweet taste are associated with specialized receptors in the oral cavity that have not yet been identified. (37)

The search to better understand the receptors for taste that affect muscle function is growing. (10) Goodheart first made the clinical observation in 1968 that taste stimulation affected muscle function, observations that are discussed elsewhere. (7), (9), (14), (38) As a result of Goodheart's original finding, many health-care professionals in various disciplines worldwide have since used this clinical tool (gustatory receptor stimulation then manual muscle testing) as an adjunct for both assessment and treatment. (7), (39)


The AK MMT system of biochemical evaluation is controversial. One reason for this is that there have been many modifications of Goodheart's original description. The applied kinesiologist uses the MMT to evaluate nutrition as an adjunct to standard laboratory, nutritional, and physical diagnostic methods. All factors of the examination should correlate, or something is being missed. Research sponsored by the International College of Applied Kinesiology points out that the use of the AK MMT to evaluate nutrition is not a viable approach in and of itself. (40) Some researchers, rather than have the participants stimulate the gustatory receptors with the substance being tested, have the individual handhold the substance or lay it on the belly; some even have the patient hold a bottle containing the substance to be tested. These modified systems are frequently taught to laypeople, who often do not have the anatomical knowledge necessary for accurate muscle testing nor a sufficient background in nutrition or general diagnostic ability. (41-44)

While our understandings of the neurological pathways that produce changes in muscle function remain incomplete, there is definite evidence in the literature of efferent response throughout the body resulting from stimulation of the gustatory and olfactory receptors. (33-36) Some of the observed reactions to lingual stimulation have included, for example: (1) exercise performance and brain activity, (2) canine pancreatic secretion, and (3) altered plasma levels of estrone, follicle stimulating hormone, and luteinizing hormone. (36), (45), (46) Despite the complexity of factors involved, this evaluation may become a useful adjunct to the standard methods used in determining a patient's nutritional and hormonal status and needs. (8), (9), (47)

This notion has some predictive implications. It might be possible, perhaps early in life, to identify individuals with reduced glucocorticoid metabolism who are at increased risk of stress-related illness and related disorders on exposure to trauma later in life. To test this, it will be helpful prospectively to follow cohorts such as the offspring of women with significant ASD during their pregnancy. It also implies that use of adrenal gland nutritional support during the early phase of development of symptoms may aid in the reversal of this condition in vulnerable individuals and their children. Recent clinical evidence suggests that this might be the case. (48)

Because muscle dysfunction frequently reflects biochemical dysfunction, the use of the AK MMT may expedite the broad-scope discovery of the causes of biochemical disorders. (49) Good heart originally observed, "The opportunity to use the body as an instrument of laboratory analysis is unparalleled in modern therapy; if one approaches the problem correctly, making the proper and adequate diagnosis and treatment, the response is satisfactory to both the doctor and the patient." (47) If it proves to be the case that the AK MMT is sensitive and selective to ASD, then the factors that correct the muscle inhibitions found related to the adrenal gland may become an important guide in the selection of treatment modalities and nutritional elements in these cases.


A primary limitation of this study was that it did not include patients without ASD; as a retrospective case-series report on patients with ASD, patients who undergo salivary assays usually have some form of ASD. Controls without this condition presenting to the clinician's practices were not common enough to create a control group.

The next steps of objectifying possible measurable muscle impairments associated with ASDs are to increase the sample size, to study patients in other situations involving physical, biochemical, and psychosocial imbalances resulting in stress-related symptoms, to develop an appropriate control intervention, to solve the problem of blinding and double-blinding, to find additional steroid hormone disturbances that may be assessed by the AK MMT, and to compare the treatment effects of AK with other methods that ameliorate the symptoms of adrenal stress disorder.

Finally, the effectiveness of the manual muscle test for diagnosis in this arena can only be established following a full-scale, randomized, controlled clinical trial with adequate follow-up and homogenized samples. A follow-up study showing the effect of AK treatment upon abnormal salivary cortisol values is currently under way.


This study supports a number of previous reports, showing that gustatory receptor-based sensorimotor challenges like the ones used here may permit the clinician to assess the impact of biochemical substances on patient neurophysiology and muscle function. This approach may afford clinicians the use of an interactive means by which to predict the clinical utility of a given substance for a given patient with ASD. If true, this would represent a significant conceptual expansion of the standard nutritional examination process.

We believe that the correlations obtained between AK MMT findings and salivary hormone tests in cases with ASD are a first step in suggesting that MMT is a potentially useful, inexpensive, noninvasive tool in the assessment of a primary endocrine dysfunction in the general population.

(See Table 1 in the online version of this article for the individual patient profiles documenting the correlations between manual muscle testing and laboratory diagnosis and primary complaints in 110 patients.)

AK MMT Examinations and Laboratory Tests: Concurrent Validity Review

(See the online version of this article for the literature review of the correlations found between manual muscle testing and laboratory diagnosis in previous reports, as well as an expanded discussion of the biological plausibility and physiological rationale for the MMT in the assessment of biochemical disturbances.)

Corresponding Author

Scott Cuthbert, DC

Chiropractic Health Center, PC

255 West Abriendo Avenue

Pueblo, Colorado 81004


Unabridged article is available at


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Table 2


Classic adrenal-related muscles in AK inhibited                   110

Rostand's Sign and/or paradoxical pupillary reaction present       58

Abnormal Cortisol                                                 101

Abnormal Cortisol: DHEA ratio                                      65

Correlation of AK MMT & Salivary Tests to expected ASD signs      110
and symptoms
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Author:Cuthbert, Scott; Rosner, Anthony; Chetcuti, Trevor; Gangemi, Steve
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Date:Jan 1, 2015
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