Manual muscle testing

Fundamentals of MANUAL
MUSCLE TESTING
(MMT)
By
Dr. Muhammad Ejaz PT
DPT (AIMC), MS in Neurology * (UOL)
Lecturer Lahore institute of science and technology
9/15/2015
1

INTRODUCTION TO THE TOPIC
 MMT is the most vital part of motor assessment Performa in
medical examination.
 MMT is a procedure for the evaluation of strength of individual
muscle or muscles group, based upon the effective performance of
a movement in relation to the forces of gravity or manual
resistance through the available ROM.
 i.e. how efficiently a muscle is working or muscles strength /
power assessment using manual (hand) techniques.

BASIC COMPONENTS OF MOTOR
EXAMINATION
1. Nutrition or bulk of muscle
2. Tone
3. Reflexes
4. Range of Motion or TCD’s assessment
5. Manual muscle testing (MMT)
6. Functional assessment
** Importance of the sequence

WHY MMT IS PERFORMED?
To get some answers such as :-
 Is a particular muscle is normal?
 Is it weak ? (how much weak)
 Is it strong enough? (how much strong)
 Is it weak on both the sides (bilateral symmetrical) ?
 Is it weak only on one side (unilateral) ?
 Is proximal muscles are weaker than distal one ?
 Is distal muscles are weaker than the proximal one ?
 Is there any particular pattern of muscle weakness ?

CLINICAL REASONING OF
PERFORMING MMT
 To get an over view of muscle performance status so that the
cause of the problem can be understood.
 So that we can plan our treatmentgoals i.e. to strengthen
certain weak muscles by means of strengthening exercises.
 Monitoring of certain conditions i.e. whether it is getting better
or getting worst with time (Documentation and follow-up)
 Correlating muscle picture with its level of
innervations (Myotomes)

EXAMPLE - LBA WITH
NEUROLOGICAL DEFICIT
MYOTOME MUSCLES
L1 NONE
L2 HIP FLEXOR
L3 KNEE EXTENSOR
L4 DORSIFLEXOR
L5 GREAT TOE EXTENSION
S1 PLANTER FLEXORS

GRADES OF MMT
 Numerical Objectivity for documentation
 Existing grading systems are :-
1. MRC SCALE (medical research council )
2. OXFORD SCALE
3. KENDALL SCALE
4. AND SEVERAL OTHER

MRC SCALE EXPLANATION
0 No visible or palpable contraction.
1 Visible or palpable contraction.
2 Full ROM gravity eliminated.
3 Full ROM against gravity.
4
Full ROM against gravity, moderate
resistance.
5
Full ROM against gravity, maximum
resistance.
Ref. muscle testing and function by kendall

OXFORD
SCALE
EXPLANATION
0 No contraction is present.
1 There is flicker contraction
2
Full ROM with gravity counter balance.
*(Eliminated)
3 Full ROM against gravity.
4
Full ROM against gravity + added
resistance.
5 Muscle function normally.
ref: practical exercise Margaret Holleis(1)

KENDALL
SCALE
EXPLANATION
NONE No visible or palpable contraction.
TRACE Visible or palpable contraction.
POOR Full ROM gravity eliminated.
FAIR Full ROM against gravity.
GOOD
Full ROM against gravity, moderate
resistance.
NORMAL
Full ROM against gravity, maximum
resistance.
Ref. muscle testing and function by kendall

PLUS (+) AND MINUS (-) GRADES
(3) - Full range of motion against
gravity
(3+) - Full range of motion against
gravity slight resistance
(3-) - Movement >half but less than
full range of motion against
gravity

BASIC RULES
 Patient position
 Joint position
 Check the available passive range of the joint. (P.ROM)
 Give accurate, audible commands and instruction
regarding movement.
 Demonstrate the desired movement.
 Check the strength of normal side first (in c/o unilateral).
 Do not change patient position repeatedly.
 Always start with Grade 3 i.e. against gravity movement.

CONT..
 Isolation of muscle to be tested.
 Joint position.
1. Place the part in anti-gravity position. (Grade 3)
2. Horizontal (gravity eliminated) for weak muscle. (Grade 2)
 Apply gradual pressure opposite to the muscle segment being
tested. (Grade 4 and 5)
 Use long Lever to apply resistance whenever possible. **

HAND PLACEMENT
 Proximal Hand:- At origin of muscle & proximal
joint
giving stabilization.
 Distal Hand:- distally offering resistance or assistance
depending upon performance.

APPLICATION OF RESISTANCE
 Resistance is applied slowly and gradually.
 Increasing or decreasing manual resistance .
 Increasing or decreasing the length of weight arm.
 Example - with the patient in prone position a known
resistance given at the level of knee joint is more
easily overcome by the hip extensors than if it is applied
at the foot.

APPLICATION OF LEVERAGE IN
MMT

PRECAUTIONS
 Consider contraindications
 Do not Harm (Be gentle)
 Respect pain
 Know the available ROM
 Follow the principals of procedure
 Take care of patients comfort
 Record accurately (Documentation)

7) INDICATIONS OF MMT:
1)Lower Motor Neuron (LMN) Disease.
2) Some other Neurological (Neuromuscular
)disease. Such as,
Multiple Sclerosis
Muscular distrophy
Guillian - barre syndrome (GBS), etc....
3)Some Musculoskeletal disorders.

8) CONTRAINDICATIONS OF MMT:
1) Cerebral Palsy
2) Cardio vascular disease / Brain injury
3) Dislocated/ unhealed fracture
4) Myositis ossifications
5) Parkinson’s disease
6) Pain
7) Inflammation /(inflammatory disease in muscles and or
joints)
8) Severe cardiac & respiratory disease .

Cont.
9)Subluxation joint
10)Hemophelia (ability of the blood to clot is
severely reduced, )
11)Osteoporosis

LIMITATIONS OF MMT
 UMN Lesions :- Spastic muscle have poor control from higher
centers thus its better to go for Voluntary control
assessment rather than MMT.
 Presence of pain and swelling:- Pain and swelling
increases the intra articular tension causing
irritation of joint and can affect the MMT
result, Thus in case always mention about presence
of Pain along with grade.

 Type of contraction - MMT gives idea about Quality of
concentric contraction only. (Not eccentric which is more
functional)
 Understanding of command (Pediatric Age group <5
years / IQ/ higher functions)
 Strength Vs Endurance??
 MMT gives knowledge about only the
strength and not the endurance.
 Subjectivity (Patient) Hoovers Sign

OBJECTIVITY AND
RELIABILITY OF MMT
 OBJECTIVITY:- Examiners ability to palpate and observe the
tendon or muscle response in very weak muscle.
 RELIABILITY :- reliability of MMT in clinical settings hasbeen
low, it is found that percentage of therapist obtaining the same
muscle grade, only ranged from 50-60%
 INTERRATER(rater mean observers ) AND INTRARATE R
( single individual, reusing the same rating instrument, consistently produces the same
results ) RELIABILITY
 Despite of the above said lacunas MMT is still the most effective
clinical method for assessing muscle function.

ALTERNATE TECHNIQUES OF ASSESSING
MUSCLE STRENGTH APART FROM
CONVENTIONAL MMT
1. Resisted isometric test
2. Break test
3. Make test
4. Functional assessment
5. Myometer
6. Dynamometer

RESISTED ISOMETRIC TESTING
 Useful way of assessing muscle function when the
movement is contraindicated or causes pain.
 i.e. Resistance to muscle while performing Isometric
contraction.
 The location of pain and painful movements suggests
whether a lesion is contractile tissue(muscle or tendon)
or inert/ non-contractile tissue (capsule) is involved.

TESTING
 Patient’s joint position should be in middle ROM as
this position is resting position of the joint.
 Proximal part is stabilize to minimize substitution.
 The patient is then asked to hold the position
against resistance.

RESULT INTERPRETATION
Findings Possible pathology
Strong and painless contraction No neurological deficit
Strong and painful contraction Minor lesion of tested muscle or
tendon
Weak and painless contraction Disorder of nervous system,
complete rupture of muscle or
tendon or disuse atrophy
Weak and painful contraction Fracture, neoplasm, partial rupture
of muscle or tendon, inflammation
inhibiting contaction.

BREAK TEST
Resistance applied at the end of tested range is termed as break
test.
Resistance applied throughout the test is called make test.
Patient is instructed to complete the test movement and then hold
the segment against resistance.
The isometric hold (break test) shows the muscle to have a higher
grade then the make test.
For one joint muscle resistance is applied at end of ROM and for
two joint muscle it is applied at mid range.

INDICATION OF BREAK TEST
 When movement is contraindicated
 When there is pain in movement
 When we have to assess the quality of strength and not
the quantity.??

FUNCTIONAL TEST
Correlating the muscle strength with its functions Such as
 Standing/ walking on toes
 Standing/ walking on heels
 Walking on medial or lateral border of foot
 One leg standing
 Squatting and up squatting
 Sit to stand
 Intrinsic plus hand
 Backward / forward/ lateral trunk bending / hand to knee..
 Gower’s Sign

MYOMETER
 Myometer is used to measure the
strength of a particular muscle contraction.

DYNAMOMETER
Dynamometers are spring loaded device.
The best tool for accurately evaluating muscle strength and
objective way to document muscle weakness.
 As force is applied to the dynamometer the spring is compressed
and moves a needle to indicate the force output from the muscles.

GRASP or HAND
DYNAMOMETER
Types of Dynamometer

LOW BACK AND LEG DYNAMOMETER
.

ADVANTAGES
1. Easy to use
2. More objective
3. Lesser chances of discrepancy in result
4. Visual Feed back

DISADVANTAGE
1. Availability
2. Cost
3. No Universal equipments available
4. Group of muscle can be assessed but not individual muscle.
(Example Grip strength)

MMT CLINICAL VARIATION
 Individual muscle MMT – ex. tendon transfer.
 Gross MMT – ex Major muscles only as in case ofAmputation.
 Myotomal MMT – ex Neck or back pain with neurological
deficit/ SCI.

Manual muscle testing

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