Muscle Strength Testing

University of the Philippines Manila

COLLEGE OF ALLIED MEDICAL PROFESSIONS
PT 142 Assessment in Physical Therapy
Mitch B. Encabo, MPA, PTRP
Edited for instruction by:

Aila Nica J. Bandong, PTRP

LEARNING OBJECTIVES
At the end of the session the students 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
Discuss modified tests used in assessing muscle strength
 Instrumental muscle strength testing
 Functional muscle strength testing

Discuss probable conditions that require

modifications of the standard technique
MUSCLE STRENGTH TESTING
Refers to the determination of the strength
of a muscle or muscle group
Does not reflect muscle function
Test based on the
Effective performance of movement
Manual resistance
Gravity
MUSCLE STRENGTH TESTING
Purpose
Diagnostic
Examine the improvement or deterioration of a
patient’s status over time
Predictive or prognostic tool
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
Evaluates the effectiveness of treatment
MUSCLE STRENGTH vs
ENDURANCE
Muscle Strength Muscle Endurance
Force production Repeated contractions
Voluntary exertion in Maintenance of
one maximal effect isometric contraction
Results in isotonic or
isometric contractions
Gross indicator of
functional ability
MUSCLE WEAKNESS
Any reduction of the normal ability of the
muscle to generate force
Causes:
Muscle strain
Pain, reflex inhibition
PNI, Nerve root lesion, UMNL
Tendon pathology, avulsion, rupture
Prolonged disuse/immobilization
Psychological overlay
Test Performance
Muscle origin, insertion and action
Function of participating muscles
Patterns of substitution
Ability to detect contractile activity
Ability to palpate muscle or tendon
Ability to detect atrophy
Recognize abnormal position or movement
Test Performance
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
Evaluation of Muscle Strength
Detect substitution whenever weakness
exist
Accurate grading of muscle strength
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 position that offers the best fixation of
the body as a whole
Use antigravity positions as applicable
Two jointed muscles
Stabilization
Proximal attachment of muscles
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:
Muscle tension
Gravitational pull
External pressure from
manual stabilization
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 gradually, but not to slowly, to allow
the patient to “get set and hold”
Applied uniformly
Long lever arm vs Short lever arm
Break test vs Active resistance test
Validity and Reliability
Inherent limitation
Types of muscle contractions
Rate of tension development
Affected by
Difference in testing methods
Magnitude of resistance
Force application, point of application, speed
Factors
Patient factors
Therapist factors
Environmental factors
Others
 Validity and Reliability
Patient Factors Therapist factors Environmental
Age Experience factors
Gender Manner and Temperature
Pain content Distractions
Fatigue of instructions Other factors
Lower motor Interaction Muscle factors
neuron disease Psychological
Spasticity factors
Methodological
factors
METHODS
METHODS
OF
MMT
What is being tested?

Resistance

Type of Contraction

Method of Grading
 Daniels and Worthingham
MMT
Criteria used in assigning a muscle grade
Factors considered include the following:
Subjective Objective Factors Other Factors
Factors  Ability of the  Amount of manual
 Examiner’s patient to move the resistance applied
impression of the body part against  Ability of the
amount of gravity muscle to move the
resistance to give  Ability of the part through the
before the actual patient to complete full ROM
examination full range of  Effect of gravity
 Amount of motion  Evidence of
resistance that the  Ability of the contraction
patient tolerates patient to hold the
during the actual
Daniels and Worthingham 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
Daniels and Worthingham MMT:
GRADING

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
How to Document???

All muscles of the trunk and extremities are

grossly graded 5/5 EXCEPT:
® Shoulder abductors – 3/5
® Knee flexors – 3/5

Significance: Muscle weakness 2 to

deconditioning
How to Document???
BREAK TEST

All the muscles of the wrist and hand are grossly

graded 5/5 EXCEPT:
® wrist flexors – 4/5
® radial deviators – 4/5 ( 10 deg )

Significance: Muscle weakness 2 to pain brought

about by reflex inhibition
How to Document???
RANGE TEST

All of the muscles of the lower limb are

grossly graded as 5/5 EXCEPT for
® hip extensors = 4/5 (0-90 degrees)
® hip adductors = 4/5 (0-20 degrees)

Significance: Muscle weakness due to

prolonged immobilization, range
test was used 2 to contractures of
the hip flexors and adductors
Daniels and Worthingham MMT:
LIMITATIONS
Presence of UMNL/ Spasticity
Presence of joint instability due to chronic flaccidity
Presence of severe contractures
Daniels and Worthingham MMT:
AREAS/CONDITIONS THAT REQUIRE
MODIFICATIONS

Hands and toes

Face
Neck
Weight bearing muscles
Children
Hands and Toes
Weight is minimal so effect of gravity is
unimportant and need not be considered
Tested in either gravity eliminated or gravity-
assisted position
Grading:
5 Full range with max resistance
4 Full range with mod resistance
3 Full ROM (whether gravity eliminated or assisted)
2 Partial ROM (whether gravity eliminated or assisted)
1 Palpable or observable flicker of muscle contraction
Face
Not always practical or possible to palpate
muscle, apply resistance, or position the patient
Grading:
N/F (N)or light impairment
Completes test movement with ease and control
WF Moderate impairment that affects the degree of
active motion
Performs test with difficulty
NF Severe impairment
Minimal muscle contraction
0 Absent
Neck
Using gravity eliminated position when
testing for neck flexion and extension is
impractical
A muscle grade of 2 is assigned when the
patient can complete partial ROM while in a
gravity resisted position
Weight Bearing Muscles
To be resisted maximally, some muscles
require the assistance of body weight
For gastrocnemius and soleus only
Children
May not cooperate with standard MMT
procedures
2-5 y/o can initiate test position, but they
cannot sustain it because they don’t
understand the concept of exerting
counterforce vs examiners resistance
Needs to be modified for 4-6 y/o
Daniels and Worthingham:
MODIFIED TESTS
Combined tests for the extremities
Quickie tests
Squatting
Walking on heels and toes
Break test
Movement cannot be totally prevented but can be
minimized by telling the patient “don’t let me move
you”
Evaluation of functional activities
Donning and doffing
Gripping the examiners hand
Daniels and Worthingham:
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
Quiet non-distracting well ventilated environment
Adequately firm and wide plinth with adjustable height
Minimal position changes
Presence of all materials needed for the test
Instrumented Muscle Testing
Advantage: increases the level of accuracy
and reliability of strength testing
Instruments/ devices
Cable tensiometer
Strain gauge
Hand-held dynamometer
Modified sphygmomanometer
Grip strength dynamometer
Pinch meter
Cable Tensiometer
Strain Gauge
Hand-held Dynamometer
Modified Sphygmomanometer
Pinch Meter
Instrumented Muscle Testing:
LIMITATIONS
Measures isometric strength only
Not useful for testing trunk strength

Instrumented Muscle Testing:

CONSIDERATIONS
Reliability is reasonable
Important to standardize strength
Instruments are not interchangeable
 Dynamic Muscle Testing
Makes more sense since muscles function dynamically
Machine use: Isokinetic machines
Isokinetic Testing Machine:
LIMITATIONS
Validity has not yet been established
Movement occurring at constant speed is
artificial
Positions and movement constraints are not
realistic
 Functional Muscle Testing
Utilized in cases when muscle strength
cannot be tested by MMT:
Presence of spasticity and flaccidity
Patients with poor comprehension
Patients who are unable to follow instructions
Observations and description of certain
movements or activities of the patient
REFERENCES
Clarkson & Gilewich(1989), Musculoskeletal Assessment. Joint Range of Motion
and Manual Muscle Strength: Williams & Wilkins.
Erickson and McPhee(1993) Clinical Evaluation. In Delisa: Rehabilitation
Principles and Practice (2nd ed). Philadelphia: JB Lippincott Company.
Harms - Ringdahl(1993)International Perspectives in Physical Therapy.Muscle
Strength. New York: Churchill Livingstone.
Hislop and Montgomery(2002): Daniels and Worthingham’s Muscle Testing:
Techniques of Manual Examination(7th ed) Philadelphia:WB Saunders
Company.
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.
Tobis and Hong (1990) Muscle Testing in Kottke and Lehmann: Krusen’s
Handbook of Physical Medicine and Rehabilitation (4th Ed) Philadelphia:WB
Saunders Company