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Muscle Strength Testing. University of the Philippines Manila COLLEGE OF ALLIED MEDICAL PROFESSIONS PT 142 Assessment in Physical Therapy Mitch B. Encabo , MPA, PTRP Edited for instruction by: Aila Nica J. Bandong , PTRP. LEARNING OBJECTIVES .

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muscle strength testing

Muscle Strength Testing

University of the Philippines Manila

COLLEGE OF ALLIED MEDICAL PROFESSIONS

PT 142 Assessment in Physical Therapy

Mitch B. Encabo, MPA, PTRP

Edited for instruction by:

AilaNica J. Bandong, PTRP

learning objectives
LEARNING OBJECTIVES

At the end of the session the students should be able to:

  • Define muscle strength and their functional implications
  • Discuss basic considerations in performing muscle strength testing
  • Differentiate methods of doing muscle strength testing
    • Discuss Daniels and Worthingham’s manual muscle testing
    • Discuss modified tests used in assessing muscle strength
      • Instrumental muscle strength testing
      • Functional muscle strength testing
  • Discuss probable conditions that require modifications of the standard technique
muscle strength testing3
MUSCLE STRENGTH TESTING
  • Refers to the determination of the strength of a muscle or muscle group
  • Does not reflect muscle function
  • Test based on the
    • Effective performance of movement
    • Manual resistance
    • Gravity
muscle strength testing4
MUSCLE STRENGTH TESTING

Purpose

  • Diagnostic
  • Examine the improvement or deterioration of a patient’s status over time
  • Predictive or prognostic tool
  • Determine the extent of strength loss
  • Outcome measures in clinical research
  • Determine the need for compensatory measures or assistive devices
  • Helps in the formulation of the treatment plan
  • Evaluates the effectiveness of treatment
muscle strength vs endurance
MUSCLE STRENGTH vs ENDURANCE

Muscle Strength

  • Force production
  • Voluntary exertion in one maximal effect
  • Results in isotonic or isometric contractions
  • Gross indicator of functional ability

Muscle Endurance

  • Repeated contractions
  • Maintenance of isometric contraction
muscle weakness
MUSCLE WEAKNESS
  • Any reduction of the normal ability of the muscle to generate force
  • Causes:
    • Muscle strain
    • Pain, reflex inhibition
    • PNI, Nerve root lesion, UMNL
    • Tendon pathology, avulsion, rupture
    • Prolonged disuse/immobilization
    • Psychological overlay
test performance
Test Performance
  • Muscle origin, insertion and action
  • Function of participating muscles
  • Patterns of substitution
  • Ability to detect contractile activity
  • Ability to palpate muscle or tendon
  • Ability to detect atrophy
  • Recognize abnormal position or movement
test performance9
Test Performance
  • Awareness of deviation from normal ROM , laxity or deformities
  • Identify muscles with the same innervation
  • Relationship of diagnosis to sequence and extent of test
  • Ability to modify test procedures as necessary
  • Effect of fatigue
  • Effect of sensory loss and movement
evaluation of muscle strength
Evaluation of Muscle Strength
  • Detect substitution whenever weakness exist
  • Accurate grading of muscle strength
basic considerations
BASIC CONSIDERATIONS
  • Observation
  • Palpation
  • Positioning
  • Stabilization
  • Resistance
  • Validity and reliability
observation and palpation
Observation and Palpation
  • Observe the size and contour of muscles
  • Palpate contractile tissues
positioning
Positioning
  • Patient comfort
  • Depends partly on the effect of gravity
  • Use position that offers the best fixation of the body as a whole
  • Use antigravity positions as applicable
  • Two jointed muscles
stabilization
Stabilization
  • Proximal attachment of muscles
  • Used to isolate the desired action to a specific joint
  • Stabilize the part proximal to the part being tested
  • Stabilization of the proximal attachment of the muscle through:
    • Muscle tension
    • Gravitational pull
    • External pressure from

manual stabilization

resistance
Resistance
  • Force that acts in opposition to a contracting muscle
  • Applied in the direction opposite the line of pull
  • Must never be sudden or jerky
  • Applied gradually, but not to slowly, to allow the patient to “get set and hold”
  • Applied uniformly
  • Long lever arm vs Short lever arm
  • Break test vs Active resistance test
validity and reliability
Validity and Reliability
  • Inherent limitation
    • Types of muscle contractions
    • Rate of tension development
  • Affected by
    • Difference in testing methods
    • Magnitude of resistance
    • Force application, point of application, speed
    • Factors
      • Patient factors
      • Therapist factors
      • Environmental factors
      • Others
validity and reliability18
Validity and Reliability
  • Patient Factors
    • Age
    • Gender
    • Pain
    • Fatigue
    • Lower motor

neuron disease

    • Spasticity
  • Therapist factors
    • Experience
    • Manner and content

of instructions

    • Interaction
  • Environmental factors
    • Temperature
    • Distractions
  • Other factors
    • Muscle factors
    • Psychological factors
    • Methodological factors
methods of mmt
METHODSOFMMT

What is being tested?

Resistance

Type of Contraction

Method of Grading

daniels and worthingham mmt
Daniels and Worthingham MMT
  • Criteria used in assigning a muscle grade
  • Factors considered include the following:
  • Subjective Factors
  • Examiner’s impression of the amount of resistance to give before the actual examination
  • Amount of resistance that the patient tolerates during the actual test

Objective Factors

  • Ability of the patient to move the body part against gravity
  • Ability of the patient to complete full range of motion
  • Ability of the patient to hold the position once at the end of the range of motion

Other Factors

  • Amount of manual resistance applied
  • Ability of the muscle to move the part through the full ROM
  • Effect of gravity
  • Evidence of contraction
daniels and worthingham mmt grading
Daniels and Worthingham MMT: GRADING
  • Normal ( N or 5 )
    • Full range against maximum resistance and gravity
  • Good ( G or 4 )
    • Full range against moderate resistance and gravity
    • “Gives” or “yields” at the end of the range given maximum resistance
    • Functional threshold for the lower extremity
  • Fair Plus ( F+ or 3 )
    • Full range against mild resistance and gravity
    • “Gives” or “yields” to some extent at the end of its range given moderate or maximum resistance
    • For users of orthosis
  • Fair ( F or 3 )
    • Full range against gravity
    • “Gives” at the end of the range against mild resistance
    • Functional threshold for the upper extremities
daniels and worthingham mmt grading23
Daniels and Worthingham MMT: GRADING
  • Poor ( P or 2 )
    • Full range, gravity eliminated
  • Poor Minus ( P- OR 2 - )
    • Partial range gravity eliminated
  • Trace ( T or 1 )
    • Visible or palpable contraction
    • No movement of the body part
  • Zero (0)
    • No visible or palpable contraction
how to document
How to Document???

All muscles of the trunk and extremities are grossly graded 5/5 EXCEPT:

® Shoulder abductors – 3/5

® Knee flexors – 3/5

Significance: Muscle weakness 2 to deconditioning

how to document25
How to Document???
  • BREAK TEST

All the muscles of the wrist and hand are grossly

graded 5/5 EXCEPT:

® wrist flexors – 4/5

® radial deviators – 4/5 ( 10 deg )

Significance: Muscle weakness 2 to pain brought about by reflex inhibition

how to document26
How to Document???
  • RANGE TEST

All of the muscles of the lower limb are grossly graded as 5/5 EXCEPT for

® hip extensors = 4/5 (0-90 degrees)

® hip adductors = 4/5 (0-20 degrees)

Significance: Muscle weakness due to prolonged immobilization, range test was used 2 to contractures of the hip flexors and adductors

daniels and worthingham mmt limitations
Daniels and WorthinghamMMT:LIMITATIONS
  • Presence of UMNL/ Spasticity
  • Presence of joint instability due to chronic flaccidity
  • Presence of severe contractures
slide28

Daniels and Worthingham MMT:AREAS/CONDITIONS THAT REQUIRE MODIFICATIONS

  • Hands and toes
  • Face
  • Neck
  • Weight bearing muscles
  • Children
hands and toes
Hands and Toes
  • Weight is minimal so effect of gravity is unimportant and need not be considered
  • Tested in either gravity eliminated or gravity-assisted position
  • Grading:
    • 5 Full range with max resistance
    • 4 Full range with mod resistance
    • 3 Full ROM (whether gravity eliminated or assisted)
    • 2 Partial ROM (whether gravity eliminated or assisted)
    • 1 Palpable or observable flicker of muscle contraction
slide30
Face
  • Not always practical or possible to palpate muscle, apply resistance, or position the patient
  • Grading:
    • N/F (N)or light impairment

Completes test movement with ease and control

    • WF Moderate impairment that affects the degree of active motion

Performs test with difficulty

    • NF Severe impairment

Minimal muscle contraction

    • 0 Absent
slide31
Neck
  • Using gravity eliminated position when testing for neck flexion and extension is impractical
  • A muscle grade of 2 is assigned when the patient can complete partial ROM while in a gravity resisted position

Weight Bearing Muscles

  • To be resisted maximally, some muscles require the assistance of body weight
  • For gastrocnemius and soleus only
children
Children
  • May not cooperate with standard MMT procedures
  • 2-5 y/o can initiate test position, but they cannot sustain it because they don’t understand the concept of exerting counterforce vs examiners resistance
  • Needs to be modified for 4-6 y/o
daniels and worthingham modified tests
Daniels and Worthingham:MODIFIED TESTS
  • Combined tests for the extremities
  • Quickie tests
    • Squatting
    • Walking on heels and toes
  • Break test
    • Movement cannot be totally prevented but can be minimized by telling the patient “don’t let me move you”
  • Evaluation of functional activities
    • Donning and doffing
    • Gripping the examiners hand
slide34

Daniels and Worthingham:CONSIDERATIONS

  • Always start the test at grade 3
  • In case a movement needs to be tested in the non-standard position , indicate the position used
  • When in doubt about the grade assigned to a muscle group place a (?) beside the grade
  • Note special cases ( MMT of fingers or toes, UMNL )
  • Freedom from discomfort or pain
  • Quiet non-distracting well ventilated environment
  • Adequately firm and wide plinth with adjustable height
  • Minimal position changes
  • Presence of all materials needed for the test
instrumented muscle testing
Instrumented Muscle Testing
  • Advantage: increases the level of accuracy and reliability of strength testing
  • Instruments/ devices
    • Cable tensiometer
    • Strain gauge
    • Hand-held dynamometer
    • Modified sphygmomanometer
    • Grip strength dynamometer
    • Pinch meter
instrumented muscle testing limitations
Instrumented Muscle Testing: LIMITATIONS
  • Measures isometric strength only
  • Not useful for testing trunk strength

Instrumented Muscle Testing: CONSIDERATIONS

  • Reliability is reasonable
  • Important to standardize strength
  • Instruments are not interchangeable
dynamic muscle testing
Dynamic Muscle Testing
  • Makes more sense since muscles function dynamically
  • Machine use: Isokinetic machines
isokinetic testing machine limitations
Isokinetic Testing Machine: LIMITATIONS
  • Validity has not yet been established
  • Movement occurring at constant speed is artificial
  • Positions and movement constraints are not realistic
functional muscle testing
Functional Muscle Testing
  • Utilized in cases when muscle strength cannot be tested by MMT:
    • Presence of spasticity and flaccidity
    • Patients with poor comprehension
    • Patients who are unable to follow instructions
  • Observations and description of certain movements or activities of the patient
references
REFERENCES

Clarkson & Gilewich(1989), Musculoskeletal Assessment. Joint Range of Motion and Manual Muscle Strength: Williams & Wilkins.

Erickson and McPhee(1993) Clinical Evaluation. In Delisa: Rehabilitation Principles and Practice (2nd ed). Philadelphia: JB Lippincott Company.

Harms - Ringdahl(1993)International Perspectives in Physical Therapy.Muscle Strength. New York: Churchill Livingstone.

Hislop and Montgomery(2002): Daniels and Worthingham’s Muscle Testing: Techniques of Manual Examination(7th ed) Philadelphia:WB Saunders Company.

Kendall,McCreary, Provance: Muscle Testing and Function (4th ed)Baltimore: Williams and Wilkins, 1993.

Magee(1997) Orthopedic Physical Assessment(3rd ed) Philadelphia: WB Saunders Company.

Tobis and Hong (1990) Muscle Testing in Kottke and Lehmann: Krusen’s Handbook of Physical Medicine and Rehabilitation (4th Ed) Philadelphia:WB Saunders Company