MANUAL MUSCLE

TESTING
PAYAL JAHANGIRPURIA
(BPT, MPT IN MUSCULOSKELETAL
CONDITIONS)
 Definition
• MMT is a procedure for the evaluation of 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 resistances.
• USES AND NEEDS
– To determine the extent and degree of muscular weakness
resulting from diseases, injury or disuse.

– It helps in differential diagnosis, treatment planning and in

determining prognosis.

– The record obtained from these tests provide a base for

planning therapeutic treatment and periodic retesting.

– MMT is an important tool for all members of

Rehabilitation team.
 Principles of MMT
Grades of MMT

• Grades for a manual muscle test are recorded as

numerical scores ranging from zero (0), which
represents no activity, to five ( 5 ) , which
represents a "normal” or best-possible response to
the test or as great a response as can be evaluated
by a manual muscle test.
 Grading System
Numerical Score Qualitative Score
• 5 Normal
• 4 Good
• 3 Fair
• 2 Poor
• 1 Trace Activity
• 0 Zero ( No Activity)
 Grading System
• Normal -5: Ability to complete a full ROM
against maximal resistance
• Good – 4: Full range of Movement in against
gravity with Minimal resistance
• Fair – 3: Full range of Movement in against
gravity position
• Poor – 2: Full range of Movement in elimination
of gravity position
• Trace -1: Flicker of Contraction ( muscle can be
felt to tighten, but cannot produce
movement)
• Zero – 0: No contraction
 Grading Method - 2

• 0 – No Contraction
• 1 – Flicker of Contraction
• 1+ - One third of movement in eliminating gravity
position.

• 2 ( minus ): two third of movement in

eliminating gravity
• 2 - full range of movement in eliminating
gravity
• 2 ( plus): one third of movement against
gravity position
• 3 ( minus): Two third of movement in against
gravity position

• 3 - Full range of movement against

gravity position

• 3 ( plus ): One third of movement in against

gravity position with minimal resistance

• 4- full range of movement in against gravity

position with minimal resistance
• 5 - full range of movement in against gravity
position with maximal resistance
 The Break Test
• Manual resistance is applied to a limb or other body part after it
has completed its range of movement or after it has been placed at
end range by the examiner.

• The term "resistance" is always used to denote a force that acts in

opposition to a contracting muscle.

• Manual resistance should always be applied in the direction of the

"line of pull" of the participating muscle or muscles. At the end of
the available range, or at a point in the range where the muscle is
most challenged, the patient is asked to hold the part at that point
and not allow the examiner to "break" the hold with manual
resistance.
• For example, a seated subject is asked to flex the elbow to
its end range; when that position is reached, the examiner
applies resistance at the wrist, trying to force the elbow to
"break" its hold and move downward into extension.

• This is called a break test, and it is the procedure most

commonly used in manual muscle testing today.

• No effort is made to break the subject's hold if the examiner

has determined that the strength is normal. To continue
exerting force to make the muscle yield by performing a
break test is unnecessary and may even be injurious.
 Active Resistance Test

• An alternative to the break test is the application of

manual resistance against an actively contracting muscle
or muscle group (i.e., against the direction of the
movement as if to prevent that movement).

• This may be called an "active resistance" test. During the

motion, the examiner gradually increases the amount of
manual resistance until it reaches the maximal level the
subject can tolerate and motion ceases.
 Application of Resistance
• In MMT, the resistance is given at the end of the range in one-
joint muscles and at the midrange in two-joint muscles.

• The point on an extremity or part where the examiner should

apply resistance is near the distal end of the segment to which
muscle attaches.

• The longer lever gives greater challenge to muscles being tested.

• The application of manual resistance to a part should never be

sudden or uneven (jerky).

• Resistance should apply slowly and gradually, allowing it to

build to the maximum tolerable intensity.
 Influence of the examiner on the Test

• Knowledge of the location and anatomical features of the muscles

in a test. The examiner should be able to visualize the location of
the tendon and its muscle in relationship to other structures.

• Knowledge of the direction of muscle fibers and their "line of

pull" in each muscle.

• Knowledge of the function of the participating muscles (e.g.,

synergists, prime movers, accessories).

• Consistent use of a standardized method for each different test.

• Consistent use of proper positioning and stabilization (Internal and
External) techniques for each test procedure.

• Ability to identify patterns of substitution in a given test.

• Ability to detect contractile activity during both contraction and

relaxation, especially in minimally active muscle.

• Awareness of any deviation from normal values for range of

motion and the presence of any joint laxity or deformity.

• Understanding that the muscle belly must not be grasped at any

time during a manual muscle test except specifically to assess
tenderness or pain and muscle mass.
 Influence of the Patient on the Test
• There may be variation in the assessment of the true effort
expended by a patient in a given test.

• The patient's willingness to endure discomfort or pain may vary.

• The patient's ability to understand the test requirements may be

limited in some cases because of comprehension and language
barriers.

• The motor skills required for the test may be beyond some
patients, making it impossible for them to perform as requested.
• Lassitude and depression may cause the patient to be indifferent to the
test and the examiner.

• Cultural, social, and gender issues may be associated with palpation

and exposure of a body part for testing.

• The size and non comparability between big and small muscles can
cause considerable differences in grading, though not an individual
variation (e.g., the gluteus medius versus a finger extensor). There is a
huge variability in maximum torque between such muscles, and the
examiner must use care not to assign a grade that is not consistent
with muscle size and architecture.
 BASIC RULES OF PROCEDURE THAT
APPLY TO MUSCLE STRENGTH TESTING
• Place the subject in a position that offers the best fixation of
the body as a whole (usually supine, prone, or side-lying).

• Stabilize the part proximal to the tested part or, as in the case
of the hand, adjacent to the tested part. Stabilization is
necessary for specificity in testing.

• Place the part to be tested in precise antigravity test position,

whenever appropriate, to help elicit the desired muscle action
and aid in grading.
• Use test movements in the horizontal plane when testing muscles
that are too weak to function against gravity. Use test movements in
antigravity positions for most trunk muscle tests in which body
weight offers sufficient resistance.

• Apply pressure directly opposite the line of pull of the muscle or the
muscle segment being tested. Like the antigravity position, the
direction of pressure helps to elicit the desired muscle action.

• Apply pressure gradually but not too slowly, allowing the subject to
"get set and hold."
• Apply uniform pressure; avoid localized pressure that can
cause discomfort.

• Use a long lever whenever possible, unless contraindicated.

The length of the lever is determined by the location of the
pressure along the lever arm.

• Better discrimination of strength for purposes of grading is

obtained through use of a long lever.

• Use a short lever if the intervening muscles do not provide

sufficient fixation for use of a long lever.
 TERMS USED IN DESCRIPTION
OF MUSCLE STRENGTH TESTS
• Position:

– The position is important in relation to the test in two

respects. First, insofar as practical, the position of the body
should permit function against gravity for all muscles in
which gravity is a factor in grading.

– Second, the body should be placed in such a position that the

parts not being tested will remain as stable as possible.
• Fixation:

– Stability of the body or body part, which is necessary to

insure an accurate test of a muscle or muscle group.

– It can be internal or external

– Sometimes only Body weight may furnish the necessary

fixation.

– The examiner must be able to differentiate between the

normal action of these muscles in fixation and the
abnormal actions that occur when substitution or muscle
imbalance is present.
• Test Position:
– Test position is the position in which the part is placed by
the examiner and held (if possible) by the patient.

– It is the position used for the purpose of evaluating strength

for most muscles.

– The optimal test position is at the completion of range for

one-joint muscles and for two or multi-joint muscles that
act like one-joint muscles.

– The optimal test position for other two or multi-joint

muscles is at midrange of overall length
• Use of the test position also enables the examiner to detect
substitution movements.

• Placing the part in the test position expedites grading the

muscle strength. As the effort is made to hold the test position,
the ability or inability to hold the position against gravity is at
once established. If it fails to hold, the examiner tests for
strength below the fair grade: If the position is held, the
examiner then applies pressure to grade above fair.
• Test Movement:

– Test movement is a movement of the part in a

specified direction and through a specific arc of
motion.

– For strength tests of extremity muscles that are too

weak to act against gravity (i.e., muscles that grade in
the range of poor), tests are done in the horizontal
plane.
• Resistance:

– The term resistance refers to the external force that opposes

the test movement.

– The resistance may be the force of gravity, Body weight or

a force that is supplied by the examiner.

– Resistance may vary according to body weight (i.e., back

extensor test), arm position (i.e., upper abdominal test), or
leg positions (i.e., lower abdominal test).
• Substitution:

– Substitution results from one or more muscles attempting to

compensate for the lack of strength in another muscle or
group of muscles.

– Substitution is a good indication that

• the tested muscle is weak,
• adequate fixation has not been applied,
• the subject has not been given adequate instruction
concerning how to perform the test.

– Muscles that normally act together in movements may act in

substitution. These include fixation muscles, agonists and
antagonists.
• Available Range of Motion

– When any condition limits joint range of motion, the patient

can perform only within the range available.

– In this circumstance, the available range is the full range of

motion for that patient at that time, even though it is not
"normal." This is the range used to assign a muscle testing
grade.
• For example,
– The normal knee extension range is 135° to 0°. A patient
with a 20° knee flexion contracture is tested for knee
extension strength. This patient's maximal range into
extension is - 2 0 ° .

– If this range (in sitting) can be completed with maximal

resistance, the grade assigned would be a 5 (Normal). If the
patient cannot complete that range, the grade assigned
MUST be less than 3 (Fair).

– The patient then should be repositioned in the side-lying

position to ascertain the correct grade.
 Indications
• To determine the amount of muscle strength available and
thus,

– To establish a baseline for intervention

– To know how muscle weakness is limiting performance in
ADLs and IADLs
– To prevent deformities which can result from imbalances
of muscle strength
– To determine the need for assistive devices
– To evaluate the effectiveness of exercise or modalities
– To aids in selection of occupations within the client’s
capabilities
 Contraindications

• Inflammation
• Pain
• Dislocation/ unhealed fracture
• Recent surgery (musculoskeletal structure)
• Myositis ossificans
• Bone carcinoma
• Any fragile bone conditions
 Precautions
• When it can aggravate the client’s condition as might occur
with

– Osteoporosis
– Subluxation
– Hypermobility
– Haemophilia
– Cardiovascular disorder
– Abdominal surgery
 Limitations
• It can not measure muscle endurance and muscle co-ordination

• MMT is not appropriate for patients who have spasticity caused

by UMN disorders such as stroke or cerebral palsy

• It is subjective evaluation – it depends on the knowledge and

skill of the examiner

• Difficult to determine maximum load taken by patient if the

muscle is too large and strong
• MMT requires client’s complete involvement in the testing
procedure

– Therefore, the therapist must need to check the client’s

willingness,

• To expend true effort

• To endure some discomfort
• To understand the requirement of the test
THANK
YOU...!