MANUAL MUSCLE TESTING
MMT
DR. SAIMA AZIZ (PT)
DPT (KU), MSPT (DUHS), FD-MRT (LASH)
Senior Lecturer
IPM&R, DUHS
LECTURE OUTLINE
Principles of manual muscle test
Functional classification of muscle
Types of manual muscle test
Grade of muscle test
Assessment, contraindications and precautions of manual muscle testing
Factors affecting muscle strength
Muscle testing terminology
LEARNING OBJECTIVES
At the end of the session the
participants 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
PRINCIPLES OF MANUAL MUSCLE
TESTING
DEFINITION
Muscle testing is a
procedure for evaluating
the function and strength
of individual muscles and
muscle groups, based on
effective performance of
a movement in relation
to the forces of gravity
and manual resistance
through available range
of motion
It is an evaluation system
for the diagnosis of
disease or dysfunction of
the musculo-skeletal and
nervous systems
PURPOSE
Diagnostic
Examine the improvement or deterioration of a patient’s status over time
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 AND Evaluates the
effectiveness of treatment
IMPORTANCE
Muscle origin,
insertion and
action
Function of
participating
muscles
Standardized
method
Proper
positioning and
stabilization
Patterns of
substitution
Ability to detect
contractile
activity
Ability to
palpate muscle
or tendon
Ability to detect
atrophy
IMPORTANCE
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
Limitations
It has limitations in the
neurological disorders, where
there is an alteration in muscle
tone, altered reflex activity or if
there is a loss of cortical control
due to lesions of the central
nervous system.
BASIC CONSIDERATIONS
Observation
Palpation
Positioning
Stabilization
Resistance
Validity and reliability
OBSERVATION AND PALPATION
• Observe the size and contour of muscles
• Palpate contractile tissues
POSITIONING
•
•
•
•
Patient comfort
Depends partly on the effect of gravity
Use antigravity positions as applicable
Two jointed muscles
STABILIZATION
• 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
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 uniformly
 Long lever arm vs. Short
lever arm
 Break test vs. Active
resistance test
Break Test
• Resistance applied
at the end range
• Patient is asked to
hold the part at a
point and examiner
“breaks it”
Active Resistance
Test
• Application of
manual resistance
against actively
contracting muscles
• Examiner gradually
increases resistance
until maximum
tolerance
VALIDITY AND RELIABILITY
• Coordinate the muscle testing findings with other
standard diagnostic procedures
• The amount of pressure used to test may vary
between persons performing the test.
• Comparison of both sides is a better indicator of
loss
• Affected by




Difference in testing methods
Magnitude of resistance
Force application, point of application, speed
Factors




Patient factors
Therapist factors
Environmental factors
Others
• Patient
Factors
– Age
– Gender
– Pain
– Fatigue
– Lower
motor
neuron
disease
 Therapist factors  Environmental
 Experience
factors
 Manner and content
 Temperature
of instructions
 Interaction
 Distractions
 Other factors
 Muscle factors
 Psychological factors
 Methodological
factors
Subjective
Factors
 Examiner’s
Objective Factors
impression of the  Ability of the patient
amount of
to move the body part
resistance to give
against gravity
before the actual  Ability of the patient
examination
to complete full range
 Amount of
of motion
resistance that
 Ability of the patient
the patient
to hold the position
tolerates during
once at the end of the
the actual test
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
MUSCLE
TESTING
ASSESSMENT
PROCEDURE:
1. Explanation
and
instruction:
• The therapist demonstrates
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
patient’s normal strength
and to demonstrate the
movement before assessing
the strength of the involved
side, considering the factors
that affect strength
3. Patient
position:
• The patient is positioned to isolate
the muscle or muscle group to be
tested in either gravity elimination
or against-gravity position. Ensure
that the patient is comfortable
and well supported. The muscle or
muscle group being tested should
be placed in full outer range, with
only slight tension.
4.
Stabilization:
• Stabilize the site of attachment of the
muscle origin, so the muscle has a
fixed point from which to pull.
Prevent substitutions and trick
movements by making use of the
following methods:
• a) The patient's normal muscles:
For example, the patient holds the
edge of the plinth when hip flexion
is tested and uses the scapular
muscles when gleno-humeral
flexion is performed.
b) The patient's
body weight:
• Used to help fix the shoulder or pelvic girdles.
• For example, when assessing hip abduction muscle
strength in side lying, the patient holds the non-tested
limb in hip and knee flexion in order to tilt the pelvis
c) The patient’s
posteriorly and fix the pelvis and lumbar spine.
position:
d) External
forces:
• May be applied directly by the therapist or by devices
such as belt and sandbags.
e) Substitution
and trick
movements:
• When muscles are weak or
paralyzed, other muscles
may take over or gravity may
be used to perform
movements, normally
carried out by the weak
muscles.
FACTORS
AFFECTING
'STRENGTH
Age:
Strength apparently increases for
the first 20 years of life, remains at
this level for 5 or 10 years and then
gradually decreases throughout the
rest of life. The changes in muscular
strength by aging are different for
different groups of muscles.
Gender:
Males are generally stronger
than females. The strength of
males increases rapidly from 2
to 19 years of age at a rate
similar to weight and more
slowly and regularly up to 30
years.
The strength of females is
found to increase at a more
uniform rate from 9 to 19 years
and more slowly to 30 years It
has been found that women
are more 28 to 30% weaker
than men at 40 to 45 years of
age.
Type of muscle contraction:
Muscle size:
More tension can be developed
during an eccentric contraction
than during an isometric
contraction. The concentric
contraction has the smallest
tension capability.
The larger the cross-sectional area
of a muscle, the greater the
strength of this muscle. When
testing a muscle that is small, the
therapist would expect less
tension to be developed than if
testing a large, thick muscle.
Speed of muscle
contraction:
When a muscle contracts
concentricity, the force of
contraction decreases as the
speed of contraction increases.
The patient is instructed to
perform each movement during
muscle test at a moderate pace.
Previous training
effect:
Strength performance depends up on the ability of the
nervous system to activate the muscle mass. Strength may
increase as one becomes familiar with the test situation. The
therapist must instruct the patient well, giving him an
opportunity to move or be passively moved through the test
movement at least once before muscle strength is assessed.
Fatigue:
As the patient fatigues, muscle
strength decreases. The therapist
determines the strength of
muscle using as few repetitions
as possible to avoid fatigue.
The patient's level of motivation,
level of pain, body type,
occupation and dominance are
other factors that may affect
strength.
CONTRAINDICATIONS &
PRECAUTIONS
Do Not Harm (use gentleness)
Know ROM limits
Follow procedure
Record
• Promptly
• Accurately
Manual assessment of muscle strength is
contraindicated where there is:
1. Inflammation in the region.
2. Pain:
• as it will inhibit muscle contraction and will not give an
accurate indication of muscle strength. Testing muscle
strength in the presence of pain may cause further
injury.
3. Extra care must be taken where
resisted movements might
aggravate the condition, as in:
• a) Patients with history of or at risk of
having cardiovascular problems.
• b) Patients who have experienced
abdominal surgery or patients with
herniation of the abdominal wall to avoid
unsafe stress on the abdominal wall.
c) Situations where fatigue
•May be detrimental to or exacerbate
the patients condition. Patients with
extreme debility, for example malnutrition, malignancy or severe
chronic obstructive pulmonary
disease. These patients do not have
the energy to carry out strenuous
testing.
OTHER TEST RESULTS
Weakness – defined as a strength below fair in non
weight bearing muscles; below fair + in weight
bearing muscles
Contracture – degree of shortness in muscle, so it
cannot move through ROM
Substitution – weak muscles are supported by other
muscles to move
GRADING SYSTEM
Numerals
Letters
Against gravity test
5
Description
The patient is able to move through:
N (normal)
The full available ROM against gravity and against maximal resistance, with hold at the
end of the ROM (Hold for about 3 seconds).
4
G (good)
4-
G-
The full available ROM against gravity and against moderate leading resistance.
Greater than one half of the available ROM against gravity and against moderate
resistance.
3+
F+
Less than one half of the available ROM against gravity and against moderate
resistance.
3
F
The full available ROM against gravity.
3-
F-
Greater than one half of the available ROM against gravity.
2+
P+
Less than one half of the available ROM against gravity.
Gravity eliminated test:
The patient is able to actively move through:
2
P
The full available ROM gravity eliminated.
2-
P-
Greater than one half the available ROM; gravity eliminated.
1+
T+
Less than one half of the available ROM; gravity eliminated.
1
T (trace)
None of the available ROM; gravity eliminated and there is palpable or observable
flicker contraction.
0
0 (zero)
None of the available ROM; gravity eliminated and there is no palpable or observable
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
– 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
CLINICAL APPROACH FOR MMT
“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
Presence of all materials needed for the test
REFERENCES
• Hislop and Montgomery(2002): Daniels and Worthingham’s
Muscle Testing: Techniques of Manual Examination(7th ed)
Philadelphia:WB Saunders Company.
• Clarkson & Gilewich(1989), Musculoskeletal Assessment. Joint
Range of Motion and Manual Muscle Strength: Williams &
Wilkins.
• 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.
Recommended book for MMT
• Techniques of Manual Examination.
Helen J.Hislop and Jacqueline
Montgomery