1. Manual muscle testing

2. Objectives of the lecture topic
Appraise the importance and clinical benefits of test and measurements
Demonstrate how to prepare environment, equipment and patient for evaluation procedures.
Have the ability to conduct gross and individual muscle testing.
Classify and identify different grades of muscle evaluation.
Apply different techniques of muscle testing with respect to both therapist and patient mechanical advantage.
Show professional behaviour and attitude

3. Definition
Manual Muscle Testing (MMT) is a procedure for the evaluation of the function and strength of individual muscles and muscles group based on effective performance of a movement in relation to the forces of gravity and manual resistance through the available ROM.
This procedure depends on the knowledge, skill. And experience of the examiner.
Muscle testing is an integral part of physical examination. It provides information, not obtained by other procedures, that is useful in differential diagnosis, prognosis and treatment of neuromuscular and musculoskeletal disorders

4. Purpose of MMT
The therapist must be a keen observer and be experienced in muscle testing to detect
- minimal muscle contraction,
- movement, and/or muscle wasting
- and substitutions or trick movements.
Is to provide information that may be of assistance to a number of health professionals in differential diagnosis, treatment planning and prognosis, but it has limitations in the treatment of neurological disorders where there is an alteration in muscle tone if reflex activity is altered or if there is a loss of cortical control due to lesions of the central nervous system

5. To asses muscle strength, the therapist must have a sound knowledge of anatomy (including joint motions, muscle origin and insertion, and muscle function) and surface anatomy (to know where a muscle or its tendon is best palpated).
A consistent method of manually testing muscle strength is essential to assess accurately a patient’s present status, progress, and the effectiveness, of the treatment program

6. Different measurement types
There are many ways for measurements:
Quick muscle testing. Ankle\shoulder\ hip..
Gross muscle testing.
Individual muscle testing.
Functional muscle testing( for pediatrics only).
Other equipment's:
Isokinetic Dynamometer.
Isometric Dynamometer.
Tensiometer.

7. Steps to do MMT There are many steps to do manual muscle testing:
Gravity. It is important to know the force of a muscle.
Resistance. Use it when a muscle can perform action against gravity, this include either:
Minimal resistance.
Moderate resistance.
Maximal resistance.
Range of motion - Is it complete\ full or incomplete\ partial ROM.
Position of patient - Supine, sideline, prone, sitting, standing……
Position of therapist\ examiner - Inner hand\outer hand, stabilization…
Substitutions\ trick movements.
Verbal command\instruction

8. Muscular strength:
The maximal amount of tension or force that a muscle or muscle group can voluntary exert in one maximal effort, when type of muscle contraction, limb velocity, and joint angle are specified.
Muscular endurance:
The ability of a muscle or muscle group to perform repeated contraction, against resistance, or maintain the an isometric contraction for a period of time.

9. Middle Inner range range Outer range Range of muscle work:
The full range in which a muscle work refers to the muscle changing from a position of full stretch and contracting to a position of maximal shortening. The full range is divided into part, outer, inner, and middle ranges.
Outer
range
Middle
range
Inner
range

10. Range of muscle work
Outer range: Is from a position where the muscle is on full stretch to a position half way though the full range of motion. Inner range: is from a position halfway through the full range to a position where the muscle is fully shortened. Middle range: is the portion of the full range between the mid-point of the outer range and the midpoint of the inner range.

12. Muscle testing assessment procedure
1- Explanation and instruction:
The therapist demonstrate and or explains briefly the movement to be performed and or passively moves the patient’s limb through the test movement.
2- Assessment of normal muscle strength:
Initially assess and record the strength of the uninvolved limb to determine the patients normal strength.
3- Patient position:
The patient is positioned to isolate the muscle or muscle group to be tested in either gravity eliminated or against gravity position.

13. 4- Stabilization:
Stabilize the site of attachment of the origin of the muscle
so that the muscle has a fixed point from which to pull.
Prevent substitution and trick movements by making use of
the following methods:
A- the patient’s normal muscles.
B- the patient’s body weight.
C- the patient position.
D- external forces.
5- Substitution and trick movements:
When muscles are weak or paralyzed, other muscles may
take over or gravity may be used to perform the movements
normally carried out by the weak muscles.

14. Conventional methods
Manual grading of muscle strength is based on three factors:
1- Evidence of contraction:
No palpable or observation muscle contraction (grade 0) or a palpable or
observable muscle contraction and no joint motion (grade 1).
2- Gravity as a resistance:
The ability to move the part through the full available range of motion
gravity eliminated (grade 2) or against gravity (grade 3) the most objective part of
test.
3- Amount of manual resistance:
The ability to move the part through the full available range of motion against gravity
and against manual resistance (grade 4) or maximal manual resistance (grade5).

15. Types of muscle testing
A- Break test
Manual resistance is applied to a limb or other body part after it has completed its range of movement or after it has been placed at end range by the examiner. Manual resistance should always be applied in the direction of the line of pull of the participating muscle or muscles. At the end of the available range, or a point in the range where the muscle is most challenged, the patient is asked to hold the part at that point and not allow the examiner to break the hold with manual resistance.

16. B- Active resistance test
An alternative to the break test is the application of manual resistance against an actively contracting muscle or muscle group (i.e., against the direction of the movement as if to prevent that movement). During the motion, the examiner gradually increases the amount of manual resistance until it reaches the maximal level the subject can tolerate and motion ceases.

17. Application of Resistance
Biceps brachii i.e. – when the elbow is straight, the biceps lever is short; leverage increases as the elbow flexes and becomes maximal (most efficient) at 90 degrees, but as flexion continues beyond that point, the lever arm again decreases in length and efficiency.
Two joint muscles – the point of maximum resistance is generally at or near midrange
Apply resistance near the distal end of the segment to which the muscle is attached.
Resistance should never be sudden or uneven.
Apply resistance slowly and gradually, allowing it to build to the maximum tolerable intensity

18. Grading system
Grades represent an examiner’s assessment of the strength or weakness of a muscle or a muscle group. In manual muscle testing, grading is based on a system in which the ability to hold the tested part in a given position against gravity.
With gravity.
Against gravity.
With gravity eliminated.
The grade of Fair (3) is the most objective grade because the pull of gravity is a constant factor

19. The grading system
Grades for a manual muscle test are recorded as numerical scores ranging from (0), which represents no activity, to five(5), which represents a normal or best possible response to the test or as great a response as can be evaluated by a manual muscle test. Each numerical grade can be paired with a word that describes the test performance in quantitative terms.

20. Grade 0-no muscle contraction
Grade 1-flicker of contraction
Grade 2-full range of motion in gravity eliminated plane
Grade 3- full range of motion against gravity
Grade 4- full range of motion against gravity with half maximal resistance
Grade 5- full range of motion against gravity with maximal resistance

21. The grade 5 (Normal) Muscle:
The patient has an ability to complete a full range of motion
or maintain end-point range against gravity and maximal
resistance.
The grade 4 (Good) Muscle:
against gravity and can tolerate strong resistance without
breaking the test position

22. The grade 3 (Fair) Muscle:
The grade 3 muscle test is based on an objective measure.
The patient has an ability to complete a full range of motion
against only the resistance of gravity.
The grade 2 (Poor) Muscle:
in a position that minimizes the force of gravity. This
position often is described as the horizontal plane of
motion.

23. The grade 1 (Trace) Muscle:
The examiner can detect visually or by palpation some
contractile activity in one or more of the muscles that
participate in the movement being tested.
The grade 0 (Zero) Muscle:
Muscle is completely quiescent on palpation or visual
inspection.

24. Plus (+) and Minus (-) Grades
Use of a plus or minus addition to a MMT grade is discouraged except in three instances- Fair +, poor + and poor –
Fair Plus 3+: The subject completes ROM against gravity with only minimal resistance
Poor Plus 2+: The subject is able to initiate movement against gravity
Poor Minus 2-: The subject does not complete ROM in a gravity eliminated position

25. Screening tests
Observation of the patient before the examination will provide valuable clues
to muscular weakness and performance deficits. For example, the examiner
can:
Watch the patient as he or she enters the treatment area to detect gross abnormalities of gait.
Watch the patient sit and rise from a chair, fill out admission or history forms, or remove street clothing.
Ask the seemingly normal patient to walk on the toes and then on the heels.
Ask the patient to grip the examiner’s hand.
Perform gross checks of bilateral muscle groups.

26. Preparing for the muscle test
The examiner and the patient must work in harmony if the test session is to be
successful, some basic principles should be present:
1- The patient should be as free as possible from discomfort or pain for the duration of each test.
2- The environment for testing should be quiet. The temperature should be comfortable for the partially disrobed subject.
3- The plinth or mat table for testing must be firm to help stabilize the part being tested.
4- Patient position should be carefully organized so that position changes in a test sequence are minimized.
5- All materials needed for the test must be at hand. This is particularly important when the patient is anxious for any reason or is too weak to be safely left untended.

27. Validity
Definition of validity: Means that a test actually measures what it is suppose to measure. Reliability Definition of reliability: Is the repeatability and the extent to each comparable results are achieved every time a test repeated. If a muscle test is repeated by one or more therapist who obtain the same grade every time, then the test is reliable. Types of reliability: 1- Inter rater reliability means that another person who performs the test should arrive at same results, to an acceptable extend. 2- Intra rater reliability means that one person should come up with the same results on every repetition of the test within acceptable level.

28. Influence of the patient on the test
There may be variation in the assessment of the true effort expended by a patient in a given test.
The patient’s willingness to endure discomfort or pain may vary.
The patient’s ability to understand the test requirements may be limited in some case because of comprehension and language barriers.
The motor skills for the test may be beyond some patient.
Lassitude and depression may cause the patient to be indifferent to the test and the examiner.
Cultural, social, and gender issues may be associated with palpation and exposure of a body part for testing.
Though not an individual variation but causing considering differences in grading are the size and non-comparability between big versus small muscles.