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Manual Muscle Testing for Post-Stroke Upper Extremity Assessment | Encyclopedia MDPI
Federal government websites often end in. Before sharing sensitive information, make sure you're on a federal government site. The site is secure. NCBI Bookshelf. Usker Naqvi ; Andrew l. Authors Usker Naqvi 1 ; Andrew l. Sherman 2. 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. The most commonly accepted method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing scale.
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. 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.
The Medical Research Council Manual Muscle Testing method is very common, easy to perform, and does not require any specialized equipment. Despite these advantages, it also has its limitations. There is variability between examiners for the maximal resistance they are able to apply, as some examiners are stronger than others. The test does not account for musculoskeletal conditions that may make testing painful or difficult to tolerate, such as tendinopathy or arthritis.
The test is dependent on patient effort, which may be poor in some patients, owing to pain, proper comprehension of instructions, psychological causes, or secondary gain. Finally, the grading system classifies strength level but does not directly quantify strength.
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. 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. 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.
You are not required to obtain permission to distribute this article, provided that you credit the author and journal. Turn recording back on. Help Accessibility Careers. StatPearls [Internet]. Search term. Affiliations 1 Univ. Introduction Muscle strength testing is an important component of the physical exam that can reveal information about neurologic deficits.
Function The function of muscle strength testing is to evaluate the complaint of weakness, often when there is a suspected neurologic disease. Issues of Concern Proper technique must be employed during testing to ensure valid results. Clinical Significance Muscle strength testing can help a practitioner diagnose neurologic problems in which weakness is a prominent deficit.
Enhancing Healthcare Team Outcomes Muscle strength testing is an important component of the physical exam that can reveal information about neurologic deficits.
Review Questions Access free multiple choice questions on this topic. Comment on this article. References 1. Manual muscle testing, development and current use. Phys Ther Rev Variations in current manual muscle testing. Compston A. Aids to the investigation of peripheral nerve injuries. His Majesty's Stationery Office: ; pp. Saunders Elsevier: ; pp. Manual muscle testing: a method of measuring extremity muscle strength applied to critically ill patients.
J Vis Exp. Manual muscle strength testing: intraobserver and interobserver reliabilities for the intrinsic muscles of the hand. J Hand Ther. Muscle Strength Grading. In: StatPearls [Internet]. In this Page. Bulk Download. Related information. Similar articles in PubMed.
J Orthop Sports Phys Ther. Variance in manual treatment of nonspecific low back pain between orthomanual physicians, manual therapists, and chiropractors. J Manipulative Physiol Ther. Larson ST, Wilbur J. Am Fam Physician. Muscle endurance deficits in myositis patients despite normal manual muscle testing scores.
Muscle Nerve. Epub Dec Review Neuromuscular electrical stimulation for muscle weakness in adults with advanced disease. Cochrane Database Syst Rev. Epub Oct Recent Activity. Clear Turn Off Turn On. Muscle Strength Grading - StatPearls. Follow NCBI.
- Spinal Injuries
Gabriela Sechel. View Times: Revisions: 2 times View History. Update Date: 16 Jun Table of Contents. Evaluation helps medical practitioners to set the rehabilitation goals and to outline the physical therapy programs. The use of standard methods or scientifically validated evaluation scales can be invaluable in maximizing the details of data collection and in reducing the time for diagnosis and goal setting. In addition to establishing the elements related to disability, the evaluation in medical rehabilitation and physiotherapy includes objective and subjective evaluation modalities that allow the clinical and functional diagnoses to be achieved.
Functional assessment and diagnosis are related to daily activities ADLs , instrumental daily activities I-ADLs , or professional activities [ 1 ] [ 2 ] [ 3 ]. The most common impairments in the acute and chronic stages of post-stroke are cognitive states and motor deficits contralateral to the affected cerebral hemisphere. After stroke, there is profound neuromuscular reorganization. Depending on the brain injury site and dimensions, the affected limb either loses muscle strength or is characterized by spasticity, abnormal synergic motions with stereotyped movement patterns, caused mainly by abnormal co-activation of muscles and increased activity of antagonistic muscles [ 4 ] [ 5 ].
Currently, patients are assessed mainly by clinical scales, with the Fugl—Meyer test being one of the most commonly used measures of motor impairment after stroke [ 6 ].
However, the accuracy of these clinical tests is limited by inter-rater and intra-rater reliability, and floor and ceiling effects. In addition, some of them require a considerable amount of time to perform. In stroke, spontaneous neuromotor recovery is known to occur approximately three months after the incident, so the ability to recover from severe neuromotor impairment differs from patient to patient, depending on the type of stroke, the capacity of spontaneous neurorehabilitation, early treatment, and early application of the rehabilitation protocol.
There is a big difference in terms of evolution and prognosis between a patient who had a recent episode of stroke and is referred to rehabilitation in the sub-acute phase, and a patient who had a stroke two years ago, who is already in the chronic phase and has not benefited from early rehabilitation [ 8 ] [ 9 ] [ 10 ].
The medical history and physical examination of post-stroke patients, in addition to the continuous updating of the literature in the field of UE assessment and rehabilitation by physicians, represent added medical value. Medical rehabilitation and physical therapy aim to provide safe, efficient, and high-quality care and rehabilitation services to improve the health and function of individuals.
Therefore, the use of evidence-based treatments, performance scales, and globally defined standards in physical medicine is critical to the development of a valuable and robust healthcare system [ 11 ] that is patient centered. When used appropriately by clinicians who have the necessary skills, validated measurement tools, even in adapted forms, are part of the improvement process of assessment and diagnosis in the context of rehabilitation development.
In clinical research, the greatest advantage is that they provide clinicians and researchers with data and meaningful indicators for clinical practice and decision making [ 12 ] [ 13 ].
Manual Muscle Testing Scoring System and Its Patient-Customized Variations Manual testing of muscles is performed with the hands of the therapist or physician, isokinetic machines, and other portable devices. However, isokinetic machines and dynamometers used for more objective muscle tests are still too expensive or burdensome for clinical use, although these devices are valuable for research purposes [ 14 ] [ 15 ].
The most frequently used approach is the use of MMT to assess the grade of muscle weakness in different pathologies [ 16 ]. The authors propose a grading system from 0 to 5, with 0. Its development is attributed to Wright and Lovett [ 19 ]. It was first used to assess muscle strength impairments manifested during the polio outbreak in the early part of the 20th century, which are related to progressive muscle weakness followed by muscle atrophy, fibrosis and retraction, pain from joint degeneration, and fatigue [ 19 ].
Table 1. The classical Manual Muscle Testing scoring system. Grade 2, weak muscle contraction, differs from grade 3 by position, grading two without the involvement of gravity, while for grading three the motion is performed against gravity; both scoring points require complete movement.
Since , different adaptations or customizations of MMT scoring have been made, especially in the last two decades, responding to the needs of patients with different muscle impairments.
A notable modified MMT scoring scale was proposed by Noureau and Vachon in [ 18 ] in their research focused onspinal cord injuries. Depending on the amplitude of motion performed by the subject, their approach split the scoring intervals into two, resulting in four additional scores: 1.
The same scoring protocol was used in children with Spina Bifida, in , by Mahony et al. Both attempts showed good reliability and a robust assessment correlation with dynamometry as an objective evaluation method.
MMT has become an assessment tool in all rehabilitation fields. Therefore, a rigorous protocol must be used and respected in each MMT assessment setting [ 16 ] [ 20 ] [ 23 ] [ 24 ]. References Li, H. Sensors , 15, — Shih, M. Teasell, R. Hemiplegic Upper Extremity Rehabilitation. Pierella, C.
A multimodal approach to capture post-stroke temporal dynamics of recovery. Neural Eng. Tsuzuki, K. Do somatosensory deficits predict efficacy of neurorehabilitation using neuromuscular electrical stimulation for moderate to severe motor paralysis of the upper limb in chronic stroke? Woytowicz, E. Stinear, C. Prediction Tools for Stroke Rehabilitation. Stroke , 50, — The physiatric history and physical examination. Essers, B. Sensors , 21, Koroleva, E. Halmai, E.
Quality and outcome measures for medical rehabilitation. Gadotti, I. Importance and Clarification of Measurement Properties in Rehabilitation. Fawcett, A. Recent from the Newsroom. View All Services. View more projects. Featured Research. View all Webinars View all Courses. Learning through research. Federal Research Designations. Your Support Matters Body Your gift of Ability affects everything we do every day at Shirley Ryan AbilityLab — from the highest-quality clinical care and groundbreaking research to community programs that improve quality of life.
Give Now. Stories of support. Taking Authority Over Chronic Pain. For Patients Have any questions? Request Appointment. Find a Doctor Find a Location. Refer a Patient. Have a Question About Click for Content Navigation. AbilityLab menu. Last Updated May 09, Purpose MMT is a standardized set of assessments that measure muscle strength and function.
Link to Instrument Instrument Details. Acronym MMT. Assessment Type Performance Measure. Musculoskeletal Conditions. Spinal Injuries. Pediatric Disorders. Non-Specific Patient Population. Number of Items Determined by the number of muscles being tested.
Less than 1 minutes. Required Training No Training. Infant 0 - 2 years. Preschool Children 2 - 5 years. Child 6 - 12 years. Adolescent 13 - 17 years. Adult 18 - 64 years. Considerations MMT may not be sufficiently sensitive to measure strength in good and normal range. Schwartz et al, Herbison et al and Schwartz et al found significant differences in strength change over time using myometry that were not detected with manual muscle testing with strength grades greater than 3.
Normative Data Trapezius Muscle: Cibulka et al. Normative Data Myositis Pfister et al. Scores are expressed as a percentage of the maximum potential score. Construct Validity Myositis Pfister et al. See Table 2 for testing methodology. Bibliography Cibulka, M. Find it on PubMed Herbison, G.
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