Manual muscle test (MMT)

Manual muscle test (MMT)

1. MANUAL MUSCLE TEST (MMT)

INTRODUCTION:  Manual muscle testing is employed to work out the extent and degree of muscular weakness resulting from disease, injury or disuse. The records obtained from these tests provide a base for planning therapeutic procedures and periodic re-testing. Muscle testing is a crucial tool for all members of health team handling physical residuals of disability.

Muscular strength: The maximal amount of tension or force that a muscle or muscle group can voluntarily exert during a maximal effort; when sort of contraction , limb velocity and joint angle are specified.  Muscular endurance: the power of a muscle or a muscle group to perform repeated contractions against resistance or maintain an isometric contraction for a period of your time . 

Muscle power:  Power is defined because the generate the maximum amount force as fast as possible.  Power does require strength and speed to develop force quickly.  POWER = strength speed.

TYPES OF MUSCLE WORK: 1. Isometric contraction: Tension is developed within the muscle but no movement occurs; the origin and insertion of the muscle don't change their positions and hence, the muscle length doesn't change. 2. Isotonic contraction: The muscle develops constant tension against a load or resistance. There are two types: a) Concentric contraction: Tension is developed within the muscle and therefore the origin and insertion of the muscle move closer together; therefore the muscle shortens. b) Eccentric contraction: Tension is developed within the muscle and therefore the origin and insertion of the muscle move further a part; therefore the muscle lengthens.

RANGE OF MUSCLE WORK: the complete home in which a muscle work refers to the muscle, changing from an edge of full stretch and contracting to an edge of maximal shortening. the complete range is split into three parts: 1. Outer range: From an edge where the muscle is fully stretched to an edge halfway through the complete range of motion. 2. Inner range: From an edge halfway through the complete range of motion to an edge where the muscle is fully shortened. 3. Middle range: The portion of the complete range between the mid-point of the outer range and therefore the midpoint of the inner range.

GROUP OF MUSCLE ACTION: 1. first cause or agonist: A muscle or muscle group that creates the main contribution to movement at the joint. 2. Antagonist: A muscle or a muscle group that has an opposite action to the prime movers. The antagonist relaxes because the agonist moves the part through a variety of motion. 3. Synergist: A muscle that contracts and works along side the agonist to supply the specified movement.

There are three sorts of synergists: a) Neutralizing or counter-acting synergist b) Conjoint synergist c) Stabilizing or fixating synergist a) Neutralizing or counter-acting synergists: Muscles contract to stop any unwanted movement produced by the first cause . for instance , when the long finger flexors contract to supply finger flexion, the wrist extensors contract to stop wrist flexion from occurring.

b) Conjoint synergists: Two or more muscles work together to supply the specified movement. for instance , wrist extension is produced by contraction of extensor carpi radialis longus, carpi radialis brevis and extensor carpi ulnaris muscles. If the extensor carpi radialis longus or brevis contracts alone, the wrist extends and radially deviates, while if the extensor carpi ulnaris contracts alone, the wrist extends and ulnarly deviates. When the muscles contract as a gaggle , the deviation action is cancelled, and therefore the common action occurs.

c) Stabilizing or fixating synergists: These muscles prevent or control the movement at joints proximal to the moving joint to supply a hard and fast or stable base, from which the distal moving segment can effectively work. for instance , if the elbow flexors contract to lift an object off a table anterior to the body, the muscles of the scapula and gleno-humeral (shoulder) joint must contract to either allow slow controlled movement or no movement to occur at the scapula and gleno-humeral joint to supply the elbow flexors with a hard and fast origin from which to tug . If the scapular muscles don't contract, the thing can't be lifted because the elbow flexors will act to tug the pectoral arch downward.

2. 2) DEFINITION OF MMT:  Manual muscle test (MMT) could even be a procedure for the evaluation of strength of individual muscle or muscles group, based upon the effective performance of a movement in regard to the forces of gravity or Manual Resistance through the available Range of motion (ROM).  MMT is that the foremost significant a neighborhood of motor assessment performed in checkup .
3. BASIC COMPONENTS OF MOTOR EXAMINATION: i. Nutrition or Bulk of muscle ii. Tone iii. Reflexes iv. Range of motion (ROM) v. Manual muscle test (MMT) vi. Functional Assessment *Important of the Sequence
4. Individual versus group muscle test:  Muscles with a typical action or actions could even be tested as a gaggle or each muscle could even be tested individually. for instance , flexor carpi ulnaris and flexor carpi radialis muscles could even be tested together as a gaggle in wrist flexion. Flexor carpi ulnaris could even be tested more specifically within the action of wrist flexion with ulnar deviation. On the other hand, Flexor carpi radialis longus and brevis could even be tested more specifically within the action of wrist flexion with radial deviation.
5. 3) Purposes and uses of MMT:  CLINICAL USES : i. The severity of problem are often understand. (It is diagnostic Tool) ii. we will planning our treatment goals. iii. Determine the extend & degree of muscular weakness resulting from disease, injury. iv. Correlating muscle picture with in level innervations (myotoms) . v. MMT may be a crucial tool for all the members of the Rehabilitation team. vi. Prevents deformities by locating problem areas. vii. Help and Evaluate effectiveness of treatment to the therapist.
6. WHY MMT IS PERFORMED? : to urge some answers such as:- i. may be a particular muscle is normal? ii. Is it weak? (How much weak) iii. Is it strong enough? (How much strong) iv. Is it weak on both the side (bilateral symmetrical)? v. Is it weak only on one side (Unilateral)? vi. Is proximal muscles are weaker than the proximal one? vii. Is there any particular pattern of muscle weakness?
7. GRADES OF MMT: i. MRC Scale ii. OXFORD Scale iii. KENDALL Scale iv. And Others .
8. MEDICAL RESEARCH COUNCIL (MRC) SCALE:
9. OXFORD SCALE :
10. KENDALL SCALE:
11. + or – GRADES :
12. 5) PRINCIPLES OF MMT: 1) Position 2) Stabilization 3) Demonstration 4) Application of Grades 5) Application of Resistance 6) Checking normal strength 7) Objectivity 8) Documentation 1) POSITION : PATIENT POSITION:  Patient is positioned Eliminated or Against gravity. (Patient depend on testing on muscle or muscles group).  Do not change patient position repeatedly.  The patient should be as free as possible from discomfort or pain for the duration of every test. It may be necessary to permit some patients to maneuver or be positioned differently between tests.  Patient position should be carefully organized so that position changes in a test sequence are minimized. The patient' s position must permit adequate stabilization of the part or parts being tested by virtue of weight or with help provided by the examiner.
13. JOINT POSITION:  The joint position is also changed depend upon their performance.  Distal part of the joint is moved.  Place the joint in Antigravity position- Grade 3  Place the joint in Horizontal position – Grade 4
14. 2) STABILIZATION :  Patient could stabilizes our self during performed Antigravity position.  The hand placement of the therapist is important. HAND PLACEMENT: I. PROXIMAL HAND – At Origin of muscle & proximal joint giving stabilization. II. DISTAL HAND – Distally offering resistance or Assistance depend on performance. 3) DEMONSTRATION:  Demonstrate the desired movement.  Therapist demonstrate the appliance of movement or performance to the patient. 4) APPLICATIONS OF GRADES:  Always start with GRADE 3 (If you start to examine the muscle power, first you should test the grade 3).  Isolation of muscle could be tested.
15. d) External forces: They may be applied manually by the therapist or mechanically by devices such as belts 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.
16. 5) APPLICATIONS OF RESISTANCE:  Resistance is applied slowly & gradually.  Increasing or decreasing manual resistance.  Increasing length of weight arm.  Apply presence opposite to the road of pull (Grade 4,5)  Apply force distally.  It varies between the persons.  Use long lever to applied resistance whenever it possible.
17. . 6) CHECKING NORMAL STRENGTH:  Therapist to check the strength of the muscle normal side first. 7) OBJECTIVITY:  Therapist ability to palpate and observe the tendon or muscle response in very weak muscles.
18. . 8) DOCUMENTATION:  Examiners complete testing documentation or Record first.  this may help for next step of treatment applications.  And help for checking improvement of treatment.
19. 7) INDICATIONS OF MMT: 1)Lower efferent neuron (LMN) Disease. 2) Some other Neurological (Neuromuscular )disease. Such as,  MS  Muscular distrophy  Amyotropic Lateral Sclerosis  myasthenia .  Guillian - barre syndrome (GBS), etc.... 3) Some Musculoskeletal disorders.
20. 8) CONTRAINDICATIONS OF MMT: 1) Cerebral Palsy 2) Cardio vascular disease / Brain injury 3) Dislocated/ unhealed fracture 4) Myositis ossifications 5) Parkinson’s disease 6) Pain 7) Inflammation /(inflammatory disease in muscles and or joints) 8) Severe cardiac & respiratory disease .
21. . Cont. 9) Subluxation joint 10) Hemophelia 11) Osteoporosis
22. . 9) PRECAUTION: 1) Considered contraindications 2) don't harm (Be gentle) 3) Respect pain 4) Examiner know the available ROM. 5) Follow the principles of procedure 6) lookout of patient comfort 7) Record accurately. 8) Extra care taken to giving Resisted Exercise.
23. Cont. 9) Abdomen surgery or hernia 10) Newly united fracture 11) Bony ankylosis 12) Hematoma 13) If patients take muscle relaxers and or pain medications 14) Prolonged immobilization
24. Extra care must be taken where Resisted movements might aggravate the condition:  Patients with history in danger of getting cardiovascular problems.  Abdominal surgery or herniation of wall to avoid stress on the wall .  Fatigue exacerbate the patients condition.  Patient with extreme debility, for instance ,  Malnutrition  Malignancy  And Severe COPD.
25. 10) LIMITATION OF MMT: 1) UMN LESIONS : Spastic muscle have poor control from higher centers thus its better to go for voluntary control assessment rather than MMT. 2)RESTICTED ROM DUE TO TCD’S (Transcranial Doppler) : TCD’s can give faulty interpretation about MMT, thus in case always mention about the MMT within available range along with Grade. 3) PRESENCE OF PAIN & SWELLING: pain and swelling increases the intra articular tension causing irritation of joint and can affect the MMT result, thus in case always mention about presence of pain along with Grade.
26. 4) TYPES OF CONTRACTION : MMT gives idea about Quality of concentric contraction only. (Not Eccentric which is more functional). 5) UNDERSTANDING OF COMMANDS:  Paediatric Age group < 5 years  IQ  Higher functions. 6) STRENGTH Vs ENDURANCE: MMT give knowledge about only the strength and not endurance.
27. 7) Subjectivity (patient) HOOVERS sign 8)And following methods also Limit the MMT ;  Showing the Co-ordination  Showing pictures of gross / patient contraction  Showing the ability of client to use muscle power  Showing the how much joint ROM the individual is working through.
28. 11) PROCEDURE: 1) Explanation & Instruction 2) Assessment of normal muscle strength 3) Properly positioned the patient 4) Stabilization 5) Substitution movements & Trick movements 6) Conventional methods 7) Alternating techniques.
29. PREPARATIONS:
30. The plinth or mat table for testing must be firm to assist stabilize the part being tested. The ideal may be a pave , minimally padded or not padded in the least . The pave won't allow the trunk or limbs to "sink in. " Friction of the surface material should be kept to a minimum. When the patient is fairly mobile a plinth is ok , but its width shouldn't be so narrow that the patient is scared of falling or sliding off. When the patient is severely paretic, a mat table is that the more practical choice. The height of the table should be adjustable to allow the examiner to use proper leverage and body mechanics.
31. Materials needed include the following: • Muscle test documentation forms • Pen, pencil, or computer terminal • Pillows, towels, pads, and wedges for positioning • Sheets or other draping linen • Goniometer • Interpreter (if needed) • Assistance for turning, moving, or stabilizing the patient • Emergency call system (if no assistant is available) • Reference material
32. 1) EXPLANATION & 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 STRENGHT: Always assess and record the strength of the unaffected side limb to determined the patient’s normal strength.
33. 3) PROPERLY POSITINED THE PATIENT: The patient is positioned to isolate the muscle (or) muscles group to be tested in either gravity eliminated or Against gravity positioned.
34. 3) STABILIZATION: I. PROXIMAL HAND – At Origin of muscle & proximal joint giving stabilization. II. DISTAL HAND – Distally offering resistance or Assistance depend on performance.  The plinth or mat table for testing must be firm to assist stabilize the part being tested.
35. The site of attachment of the muscle origin should be stabilized, therefore the muscle features a fixed point from which to tug . Substitutions and trick movements are avoided by making use of the subsequent methods: a) The patient's normal muscles: for instance , the patient holds the sting 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: it's wont to help fix the proximal parts (shoulder or pelvic girdles) during movement of the distal ones. c) The patient’s position: for instance , when assessing hip abduction strength in side lying, the patient holds the non-tested limb in hip and knee flexion so as to tilt the pelvis posteriorly and to repair the pelvis and lumbar spine.
38. 4) CONVENTIONAL METHODS:  Manual grading of muscle strength is predicated on three factors: * Evidence of contraction: No palpable or observable contraction (grade 0) or a palpable or observable contraction with no joint motion (grade 1). * Gravity as a resistance: the power to maneuver the part through the complete available range of motion with gravity eliminated (grade 2) or against gravity (grade 3). * Amount of manual resistance: the power to maneuver the part through the complete available range of motion against gravity and against moderate manual resistance (grade 4) or maximal manual resistance (grade 5). * Adding (+) or (-) to the entire grades: this is often needed to denote variation within the range of motion. Movement through but half the available range of motion is denoted by a “+” (outer range), while movement through greater than half the available range of motion is denoted by “-“ (inner range).
39. CONVENTIONAL GRADING:
40. Numerals Letters Description Against gravity tests: The patient is in a position to maneuver through: 5 N (normal) the complete available ROM against gravity and against maximal manual resistance, with hold at the top of the ROM (for about 3 seconds). 4 G (good) the complete available ROM against gravity and against moderate manual resistance. 4- G - (good -) Greater than one half the available ROM against gravity and against moderate manual resistance. 3+ F + (fair +) but one half the available ROM against gravity and against minimal manual resistance. 3 F (fair) the complete available ROM against gravity. 3- F - (fair -) Greater than one half the available ROM against gravity. 2+ P + (poor +) but one half the available ROM against gravity. Gravity eliminated tests: The patient is in a position to actively move through: 2 P (poor) the complete available ROM with gravity eliminated. 2- P - (poor -) Greater than one half the available ROM with gravity eliminated. 1+ T + (trace +) but one half the available ROM with gravity eliminated. 1 T (trace) None of the available ROM with gravity eliminated and there's palpable or observable flicker contraction. 0 0 (zero) None of the available ROM with gravity eliminated and there's no palpable or observable muscle
41. SCREENING TEST:  A audition may be a method wont to control muscle strength assessment, avoid unnecessary testing and avoid fatiguing and / or discouraging the patient. The therapist may screen the patient through the knowledge gained from: 1. The previous assessment of the patient's active range of motion. 2. Reading the patient's chart or previous muscle test result. 3. Observing the patient while performing functional activities. for instance , shaking the patients hand may indicate the strength of grasp (finger flexors). 4. All muscle testing procedures must begin at a specific grade; this is often usually grade “fair”. The patient is instructed to actively move the part through full range of motion against gravity. Based upon the results of this first test, the muscle test is either stopped or proceeds.
42. FACTORS AFFECTING STRENGTH: 1). Age: A decrease in strength occurs with increasing age thanks to deterioration in muscle mass. Muscle fibers decrease in size and number; there's a rise in animal tissue and fat and therefore the respiratory capacity of the muscle decreases. Strength apparently increases for the primary 20 years of life, remains at this level for five or 10 years then gradually decreases throughout the remainder of life. The changes in muscular strength by aging are different for various groups of muscles. The progressive decrease in strength is clearer within the forearm flexors and muscles that raise the body (anti-gravity muscles).
43. 2). Sex: Males are generally stronger than females. The strength of males increases rapidly from 2 to 19 years aged at a rate almost like weight and more slowly and frequently up to 30 years. then , it declines at an increased rate to the age of 60 years. The strength of females is found to extend at a more uniform rate from 9 to 19 years and more slowly to 30 years, after which it falls off during a manner almost like males. it's been found that ladies are more 28 to 30% weaker than men at 40 to 45 years aged .
44. . 3). sort of muscle contraction: More tension are often developed during an eccentric contraction than during an isometric contraction. The concentric contraction has the littlest tension capability. 4). Muscle size: The larger the cross-sectional area of a muscle, the greater the strength of this muscle are going to be . When testing a muscle that's small, the therapist would expect less tension to be developed instead of if testing an outsized , thick muscle.
45. 5). Speed of muscle contraction: When a muscle contracts concentrically, the force of contraction decreases because the speed of contraction increases. The patient is instructed to perform each movement during muscle test at a moderate pace. 6). Previous training effect: Strength performance depends abreast of the power of the systema nervosum to activate the muscle mass. Strength may increase together becomes conversant in the test situation. The therapist must instruct the patient well, giving him a chance to maneuver or be passively moved through the test movement a minimum of once before muscle strength is assessed.
46. 7). Joint position: It depends on the angle of muscle pull and therefore the length-tension relationship. the strain developed within a muscle depends upon the initial length of the muscle. no matter the sort of contraction , a muscle contracts with more force when it's stretched than when it's shortened. the best amount of tension is developed when the muscle is stretched to the best length possible within the body (if the muscle is fully outer range). 8). Fatigue: because the patient fatigues, muscle strength decreases. The therapist determines the strength of muscle using as few repetitions as possible to avoid fatigue.
47. The patient's level of motivation, level of pain, body type, occupation and dominance are other factors which will affect strength.
48. BREAK TEST:  Resistance applied at the top of tested range is termed as BREAK TEST.  For one joint muscle resistance is applied at End of ROM.  for 2 joint muscle resistance is applied at Mid Range.  The isometric hold (break test) shows the muscle to possess a better grade than the make test.  MAKE TEST: Resistance is applied throughout the test is called MAKE TEST.
49. INDICATIONS OF BREAK TEST: 1. When movement is contraindicated 2. When there is pain in movement 3. When we need to assess the standard of strength and not the quantity?.
50. INTRUMENTATION:  Instrument chosen to assess muscle strength depends on the degree of accuracy required within the measurement.
51. HAND HELD DYNAMOMETER: This Device operate on principle of compression. Application of external force to the dynamometer compress a steel spring and moves a pointer.
52. PINCH GAUGE: pinch may be a strength measurement using pinch dynamometer.
53. CABLE TENSIOMETER: Force during knee extension increased force on cable depresses a riser over which cable passes, this deflects the pointer and indicates amount of force applied.
54. REFERENCE :  Daniels and Worthingham’s -MUSCLE TESTING.  MUSCLE TESTING and performance – Florence Peterson Kendall, Elizabeth Kendall McCreary, Patricia Geise Provance.  MUSCULOSKETAL ASSESSMENT- Hazel M.Clarkson,  ESSENTIAL OF EXERCISE PHYSIOLOGY – Victor C.Katch, William D. McArdle, Frank I. Katch.