Manual Muscle Testing Book
Twyla Plack
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Physical therapists require an accurate, reliable method for measuring muscle strength. They often use manual muscle testing or hand-held dynametric muscle testing (DMT), but few studies document the reliability of MMT or compare the reliability of the two types of testing. We designed this study to determine the intrarater reliability of MMT and DMT. A physical therapist performed manual and dynametric strength tests of the same five muscle groups on 11 patients and then repeated the tests two days later. The correlation coefficients were high and significantly different from zero for four muscle groups tested dynametrically and for two muscle groups tested manually. The test-retest reliability coefficients for two muscle groups tested manually could not be calculated because the values between subjects were identical. We concluded that both MMT and DMT are reliable testing methods, given the conditions described in this study. Both testing methods have specific applications and limitations, which we discuss.
Muscle strength testing is an important component of the physical exam that can reveal information about neurologic deficits. It is used to evaluate weakness and can be effective in differentiating true weakness from imbalance or poor endurance. It may be referred to as motor testing, muscle strength grading, manual muscle testing, or many other synonyms. The muscle strength evaluation may be performed by nurses, physicians, physical therapists, occupational therapists, chiropractors, and other practitioners.
The function of muscle strength testing is to evaluate the complaint of weakness, often when there is a suspected neurologic disease. It is an integral part of the neurologic exam, especially for patients with stroke, brain injury, spinal cord injury, neuropathy, amyotrophic lateral sclerosis, and a host of other neurologic problems.
Commonly tested muscles include the shoulder abductors, elbow flexors, elbow extensors, wrist extensors, finger flexors, hand intrinsics, hip flexors, knee extensors, dorsiflexors, great toe extensor, and plantar flexors. These muscle groups are commonly chosen, so that important spinal nerve roots are assessed systematically; however, further muscles can be tested to evaluate individual peripheral nerves. For example, testing the strength of the elbow flexors, elbow extensors, wrist extensors, finger flexors, and hand intrinsics allow for a methodical evaluation of the C5 to T1 nerve roots. However, one could more specifically test the thumb abductors to evaluate the median nerve and the abductor digiti minimi to evaluate the ulnar nerve. [1][2][3]
Proper technique must be employed during testing to ensure valid results. Tight or restrictive clothing should be removed so that the examiner can visualize the muscles being tested and observe for muscle twitch. The examiner should also stabilize the joint and ensure that other muscles do not provide assistance. Muscles should first be tested with gravity eliminated by positioning the patient, so that muscle contraction is perpendicular to gravity, such as along an examining table or bed. If the patient is unable to engage the muscle with gravity eliminated, the examiner should place a hand on the muscle and ask the patient to contract his or her muscles again. This allows the examiner to feel for a muscle twitch, even if a twitch is not visible. This observation would differentiate a score of 0 from a score of 1. When the patient demonstrates the full range of motion with gravity eliminated, the test should be repeated against gravity for the full range of motion. If this is successful, the patient should be challenged by the addition of a small degree of resistance, then maximal resistance by the examiner. The unaffected or less affected side should be tested first to gauge contralateral strength for comparison; all four limbs should be tested for completeness and to help guide the differential diagnosis based on patterns of weakness, such as upper extremity only, lower extremity only, or proximal muscles rather than distal. [2]
The Alternatives to the Medical Research Council Manual Muscle Testing system aims to quantify strength directly in terms of pounds, Newtons, or other units. This requires specialized equipment, most commonly dynamometers. Dynamometry provides a more precise measurement of the force that a muscle can exert and can allow for differences in strength to be tracked over time that an examiner may not subjectively notice when using the MRC scale. Hand-grip dynamometry is a popular example, in which the patient squeezes a handle that records the force being applied. Limitations of dynamometry include the need for costly or specialized equipment, limited muscle groups that can be tested, and limited availability of testing equipment to clinicians across specialties or settings. [5]
Another approach to muscle strength testing involves testing functional movements instead of quantifiable strength. Examples of functional tests include squatting or rising from a chair. Functional strength tests provide information about whether the patient is strong enough to perform essential daily activities, a limitation of both the Medical Research Council Manual Muscle Testing method and dynamometry. However, functional strength tests do not provide a grade or numeric quantity that can be tracked over time to gauge improvement. [5]
Muscle strength testing can help a practitioner diagnose neurologic problems in which weakness is a prominent deficit. The muscles targeted for testing should be methodically chosen based on suspected diagnoses and for complete characterization of the strength deficit in various limbs. Careful technique is important for ensuring valid and reproducible results. The Medical Research Council Manual Muscle Testing method is commonly accepted, performed across several disciplines, does not require special equipment, and demonstrates reasonable interrater reliability. More precise methods of measurement, such as hand-grip dynamometry, are less subjective and provide a quantifiable measurement that can be tracked over time. Functional assessment of strength focuses on how independently patients are able to perform their activities of daily living and whether strength is a limiting factor.
In patients with fictitious or hysterical weakness, the initial resistance to movement may appear normal, followed by a sudden giving away. Or the individual may not be using the adjacent or other supportive muscles in an appropriate fashion.
In this study, we investigated the feasibility of applying manual muscle testing (MMT) for bedding selection and examined the bedding effect on sleep. Four lay testers with limited training in MMT performed muscle tests for the selection of the bedding systems from five different mattresses and eight different pillows for 14 participants with mild sleep-related respiratory disturbances. For each participant individually, two bedding systems-one inducing stronger muscle forces and the other inducing weaker forces-were selected. The tester-participant pairs showed 85% and 100% agreement, respectively, for the selection of mattresses and pillows that induced the strongest muscle forces. The firmness of the mattress and the height of the pillow were significantly correlated with the body weight and body mass index of the participants for the selected strong bedding system but not for the weak bedding system. Finally, differences were observed between the strong and the weak bedding systems with regard to sleep-related respiratory disturbances and the percentage of slow-wave sleep. It was concluded that MMT can be performed by inexperienced testers for the selection of bedding systems.
The wireless microFET2 Digital Handheld Dynamometer muscle tester is an accurate, portable Force Evaluation and Testing (FET) device. It is designed specifically for taking objective, reliable, and quantifiable muscle testing measurements. It is a modern adaptation of the time-tested art of hands-on manual muscle testing. The microFET2 aids in diagnosis, prognosis, and treatment of neuromuscular disorders. Now with wireless capability, you can enjoy freedom from inconvenient cord tangling and being wired to the data-collecting computer. No more cables, cords, or wires.
This unique, handheld dynamometer muscle tester is battery operated, weighs less than a pound, and is ergonomically designed to fit comfortably in the palm of your hand. The microFET2 muscle tester is microprocessor controlled, to provide accurate, repeatable muscle strength readings.
The microFET software package automatically performs calculations and validity checks, generates tables and graphs from muscle tester data, creates high-impact session and comparison reports, walks the clinician through selected tests or entire protocols, and provides built-in pictures to demonstrate proper gauge and patient positioning. (At this time, the software is compatible with Windows operating systems XP or newer.)
Your Purchase Includes: Wireless microFET2 Digital Handheld Muscle Tester, Flat Transducer Pad, Curved Transducer Pad, Digit Transducer Pad, User Manual, Calibration Certificate, Wall Pack Power Supply, and Carrying Case. 1 year standard warranty included, with extended warranties available.
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