Week 4 - Manual Muscle Testing Flashcards
The assessment of strength by a physical therapist can be done though ___.
Manual Muscle Testing
Where is Muscle Performance listed in the guide to physical therapist practice?
Test & Measurements
What does muscle performance include the assessment of?
Strength, Endurance, & Speed (or Power)
What is Strength?
Measureable force exerted by a muscle or group of muscles to overcome resistance in one maximal effort.
What is Endurance?
Ability to contract a muscle repeatedly over a period of time.
What is Power?
Work produced by the muscle per unit of time
What is the product of both ____ and ____.
What is the product of both Speed and Strength
Manual Muscle Testing focuses on this component of performance.
Strength
What are the 3 definitions of Muscle Strength?
- Ability to develop tension or torque.
- Force generated over a single unlimited episode against an immovable object.
- The maximal force a muscle or muscle group can generate at a specified or determined velocity.
What are the 3 primary approaches to determining muscle strength?
- Isotonic
- Isokinetic
- Isometric
What is an isotonic contraction traditionally defined as?
testing of strength using a constant external resistance.
What does isotonic actually refer to?
“constant” muscle tension which rarely occurs in muscle
Because isotonic rarely occurs, what do we usually refer to the type of contraction as well as strength the muscle is generating during the activity?
Concentric vs. Eccentric
What is Concentric contraction?
Shortening contraction of the muscle
What is Eccentric contraction?
Lengthening contraction of the muscle
What do we usually use to assess the concentric and eccentric strength of the muscle?
Free Weights or Resistance Machines
Traditionally, how is strength assessed?
Using a 1 repetition max
What is use besides a 1 rep max and why?
Because 1 rep max could be detrimental to subject, usually MULTIPLE REPS are used to determine the MAX weight a subject can lift or move.
What is the most common number multiple repetition max used today?
3 repetition
In general, when using free weights or resistance machines to assess concentric or eccentric contraction, are we assessing the gross strength of muscle groups or the strength of individual muscles?
The gross strength of muscle groups (even though with certain patients we will be interested in the strength of specific muscles)
When did isokinetics become developed?
1960’s with introduction of isokinetic dynamometer
What does an isokinetic dynamometer allow measurement of?
Strength by having subject provide resistance through the ROM at a constant velocity
What does an isokinetic dynamometer provide?
“Peak Torque” values at specific points or throughout full ROM.
Are reliability of isokinetic dynamometer low or high?
High if test protocols are followed precisely.
What are the disadvantages of using isokinetic dynamomenter? (2)
- Cost of equipment is high (>= $40,000)
- Considered nonfunctional since strength of assessed in a non-weight bearing
(however still used to assess speed of contraction in atheletes)
How is muscle length during an isometric contraction?
remains “almost” the same throughout the contraction. (during the initial stages of contraction there will be movement in the muscle as the actin and myosin filaments interact to generate tension)
How is the testing of isometric muscle strength done?
by having muscle generate force against an immovable resistance.
T/F: Muscle length is unchanged during an isometric contraction.
True
What is the advantage of muscle length remaining unchanged during an isometric muscle strength test?
Issues associated with variability in muscle length and velocity of joint motion are eliminated.
What are the most common methods of Isometric Testing?
Manual Muscle Testing (MMT) Handheld dynamometry (HHD)
What is the disadvantage of isometric testing?
Provides muscle strength data at only one point in ROM (as a muscle undergoes contraction through the full range of motion different fibers will be recruited throughout that activity.
What must be considered when selecting a muscle test? (3)
- Which method is most appropriate based on patient’s muscle strength?
- Must consider patients age
- Best tools that fits our current practice environment
What are patient’s with significant muscle weakness best assessed using? Why?
MMT
HHD and other instrumented forms of muscle testing may not be sensitive enough to detect low levels of strength.
At which strength range should a patient not be tested with MMT? Why?
Good (4) to Normal (5)
MMT does not delineate between gradations of muscle strength in these ranges.
If a patient should not be tested with MMT due to their strength range, what should be used?
Consider using HHD, strength testing (10 rep max) or isokinetic dynamometry
Why must you consider a patients age when selecting a muscle test for young children?
Young children may not have concentration or ability to understand the necessary instructions for MMT.
Why must you consider a patients age when selecting a muscle test for elderly?
Elderly individuals may not be able to tolerate certain positions or have the balance/motor control to perform tasks required for testing
Why must you consider the best tools that fits our current practice environment?
Home visit or free clinic will not have the accessibility to expensive equipment.
If more than one method of muscle strength testing is available, which should the PT select?
PT should select the method that provides the most objective and quantifiable data.
MMT remains that method of choice for the assessment of muscle strength of which patient’s?
those whose muscle test grades fall below FAIR+ (3+)
Which is the most convenient and inexpensive method of muscle strength assessment?
MMT
Manual Muscle Testing (MMT) was designed to measure what?
muscle strength which is defined as ability of muscle to develop isometric tension against resistance.
During MMT, what is done to each muscle?
Each muscle is isolated as much as possible within the available ROM and according to function, then give a grade of strength.
Which is one of the oldest test and measurements performed by PTs?
MMT
What is the history of MMT?
Developed during poliomyelitis epidemics during the early 1900s
MMT provided means for PT to assess level of paralysis in the individual with polio.
As the threat of polio subsided, MMT used as a test and measure for other neuromusculoskeletal diseases and trauma including (5).
- Spinal cord injuries
- Guillain-Barre syndrome
- Muscular Dystrophy
- Multiple Sclerosis
- RA and OA
PTs recognized for the development of MMT (2)
- The Kendall’s
2. Daniels, Williams, and Worthingham
What are 4 ways in which MMT assists the PT?
- Diagnosis and prognosis by determining level of lesion
- Planning treatment program
- Evaluating progress or regression of patient
- Basic starting point for developing an exercise program for the patient/client
Do we want to use the term Gravity-Eliminated or Gravity-Lessened?
Gravity-Lessened as gravity can never be eliminated on earth.
How do we confirm the muscle being testing is active?
Palpation of the muscle is always being done.
How do we determine the grade we will give for a manual muscle test?
Application of Resistance
Who applies the resistance force and how is it applied?
Examiner always applies the resistance force and it is always applied perpendicular to the DISTAL END of the distal segment of bone being tested.
What is the disadvantage and advantage to applying force perpendicular to the distal end of the distal segment of the bone being tested?
Results in a shorter lever arm, however prevents potential problems when resistance applied over compromised distal joints
What are the two ways that application of resistance can be performed?
- Make Test
2. Break Test
What is a Make test?
The patient exerts maximal force against the resistance applied on the limb by the examiner throughout the ROM.
What is a Break test?
The patient holds the position of the limb and the examiner applied maximum resistance until the patient’s maximal muscular effort is overcome and the limb begins to move.
What are the patient instructions for a Make test?
Patient is instructed to “pull (or push) as hard as you can”
What are the patient instructions for a Break test?
Patient instructed to “do not let me move your arm”
Which test will we always use in the class when performing MMT?
Break Test
Why is stabilization or fixation required?
to ensure desired action occurs at the specific muscle we are testing.
In general, which segment should be stabilized?
the stationary segment (muscle origin)
What 3 methods are used to stabilize?
- Patients body weight
- Examiner
- Muscle action
T/F: We can never assume segment or part is stabilized.
True
Because we can never assume segment or part is stabilized, what do we do in a patient with marked muscle weakness?
reason for proximal to distal sequencing
What must never be allowed when doing a MMT?
Substitution
What is substitution?
Occurs when muscle or muscle groups attempt to compensate for the lack of function of a weak or paralyzed muscle.
What is classic example of substitution?
Hip hike using quadratus lumborum to “substitute” for a weak gluteus medius.
Development of tension by the muscle varies based on what 2 categories of issues?
- Muscle Physiology Issues
2. Patient Issues
Development of tension by the muscle varies based on what Muscle Physiology Issues? (4)
- Number and firing rate of motor units activated
- Length of muscle at time of contraction
- Muscle cross-sectional area
- Fiber type composition of muscle
Development of tension by the muscle varies based on what Patient Issues? (5)
- Variation in true effort
- Willingness to suffer pain or discomfort
- Cognition and language
- Fatigue and age
- Psychological issues
What can a PT control while performing a MMT? (4)
- Patient positioning
- Point of application of resistance
- Use of proper stabilization techniques
- MOTIVATION of patient
What is procedure for MMT? (8)
- Explain purpose of the test to the patient
- Place patient in a gravity-resisted position
- Stabilize proximal joint segment
- Instruct patient in specific movement to be performed
- From starting position, ask patient to perform required movment
- If a patient can complete FULL ROM against gravity, apply resistance with palpation hand at end of ROM
- Apply resistance for 4 to 5 seconds or until “patient breaks”
- Assign appropriate muscle test grade
What can be done if a patient does not understand or is extremely weak?
Can demonstrate patient in specific movement to be performed by passively moving distal segment through ROM.
What does the PT do while a patient is performing required movement?
- PT palpates muscles and maintains stabilization
2. Observes for substitutions
If a patient can complete FULL ROM against gravity, what is done next?
Apply resistance with palpation hand at end of ROM
In which direction is resistance applied?
EXACT opposite direction of movment
Where is it important to apply resistance?
Do not cross distal end of bone segment muscle attaches to!
If you are testing the hip abductors, where should you apply resistance?
Attach to proximal femur so resistance hand is placed at the distal end of femur.
In what manner should resistance be applied?
In a smooth not jerky manner.
How long should resistance be applied and how should the patient be instructed?
Apply resistance for 4-5 seconds instructing the patient continually to hold the position.
When should you continue to apply resistance until?
until “patient breaks” OR until resistance was held for 4-5 seconds.
T/F: If necessary, the test can be repeated a 2nd time.
True
After the “patient breaks” or resistance was held for 4-5 seconds, what is done.
Assign appropriate muscle test grade.
What is done if the patient cannot complete full ROM against gravity?
Reposition patient in gravity-lessened position and repeated the procedure we previously used without applying resistance.
What are the three types of grades for MMT?
- Number
- Letter
- Word
T/F: The same definition applied to a Number, Letter, and Word grade.
True
If a patient can move through the full ROM against gravity and able to hold against NO resistance, what is their Number, Letter, and Word Grade?
Number Grade: 3
Letter Grade: F
Word Grade: Fair
If a patient can move through the full ROM against gravity and able to hold against MINIMUM resistance, what is their Number, Letter, and Word Grade?
Number Grade: 3+
Letter Grade: F+
Word Grade: Fair plus
If a patient can move through the full ROM against gravity and able to hold against MODERATE resistance, what is their Number, Letter, and Word Grade?
Number Grade: 4
Letter Grade: G
Word Grade: Good
If a patient can move through the full ROM against gravity and able to hold against MAXIMAL resistance, what is their Number, Letter, and Word Grade?
Number Grade: 5
Letter Grade: N
Word Grade: Normal
What is the definition for
Number Grade: 3
Letter Grade: F
Word Grade: Fair
patient can move through the full ROM against gravity and able to hold against NO resistance
What is the definition for
Number Grade: 3+
Letter Grade: F+
Word Grade: Fair plus
patient can move through the full ROM against gravity and able to hold against MINIMUM resistance
What is the definition for
Number Grade: 4
Letter Grade: G
Word Grade: Good
patient can move through the full ROM against gravity and able to hold against MODERATE resistance
What is the definition for
Number Grade: 5
Letter Grade: N
Word Grade: Normal
patient can move through the full ROM against gravity and able to hold against MAXIMAL resistance
If the patient cannot complete the full range of motion against gravity, what grades are used?
Gravity-Lessened Grades
If a patient has No evidence of contraction by vision or palpation, what is their Number, Letter, and Word Grade?
Number Grade: 0
Letter Grade: O
Word Grade: Zero
If a patient has Slight contraction; NO movement, what is their Number, Letter, and Word Grade?
Number Grade: 1
Letter Grade: Tr
Word Grade: Trace
If a patient has Movement through partial ROM in gravity-lessened position, what is their Number, Letter, and Word Grade?
Number Grade: 2-
Letter Grade: P-
Word Grade: Poor minus
If a patient has Movement through full ROM in gravity-lessened position, what is their Number, Letter, and Word Grade?
Number Grade: 2
Letter Grade: P
Word Grade: Poor
If a patient has Movement though full ROM in gravity-lessened position and up to 1/2 ROM against gravity, what is their Number, Letter, and Word Grade?
Number Grade: 2+
Letter Grade: P+
Word Grade: Poor plus
If a patient has Movement through full ROM in gravity-lessened position and more than 1/2 ROM against gravity, what is their Number, Letter, and Word Grade.
Number Grade: 3-
Letter Grade: F-
Word Grade: Fair minus
What is the definition for
Number Grade: 0
Letter Grade: O
Word Grade: Zero
No evidence of contraction by vision or palpation
What is the definition for
Number Grade: 1
Letter Grade: Tr
Word Grade: Trace
Slight contraction; NO movement
What is the definition for
Number Grade: 2-
Letter Grade: P-
Word Grade: Poor minus
Movement through partial ROM in gravity-lessened position
What is the definition for
Number Grade: 2
Letter Grade: P
Word Grade: Poor
Movement though full ROM in gravity-lessened position and up to 1/2 ROM against gravity
What is the definition for
Number Grade: 2+
Letter Grade: P+
Word Grade: Poor plus
Movement though full ROM in gravity-lessened position and up to 1/2 ROM against gravity
What is the definition for
Number Grade: 3-
Letter Grade: F-
Word Grade: Fair minus
Movement through full ROM in gravity-lessened position and more than 1/2 ROM against gravity
What do most studies find in terms of intra-tester reliability?
good levels
When lower levels of reliability are reported, what was the problem?
PTs did not used standardized testing protocols and positions.
Is inter-tester reliability the same, lower, or higher?
Lower
How are higher levels of inter-rater reliability attained?
When uniform method of MMT is used by all testers.
T/F: MMT more valid for grades of 3 or lower.
True
Standardized testing procedure improves
both reliability and validity.
To prevent fatigue of proximal muscles, order the muscles we are testing from
proximal to distal
In order to prevent frequent change of position, what should be done?
MMT progression should be planned.
How should MMT be planned?
Perform MMT on all muscles possible in sitting, supine prone, and sidelying proximal to distal.
Order of testing for LE and UE
don’t need to know for quiz but need to know for test?
Caution should be considered when using MMT to
- Assess muscle strength in the presence of spasticity or increased muscle tone as a result of neurological impairment.
- When significant pain or muscle guarding is present.
