04/19/23 RHS 221 1

Introduction to manual muscle testing

Manual Muscle TestingRHS 221

Dr. Afaf Ahmed Shaheen

A. VISUAL OBSERVATION

Major part of physical assessment - constant gathering of information contributes to determining the patient’s problem thus formulating appropriate assessment plan

What to look for:

body posture muscle contour body proportions symmetrical or compensatory motion in functional

activities colour of skin condition of skin creases of skin (increased edema loss of crease)

* In order to do a proper assessment the body part being assessed must be exposed!

(Clarkson, 2000)

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Observation &PALPATION Examination by tactile sense – feel

Palpation assesses:• Bony and soft tissue contours• Soft tissue consistency• Skin temperature• Texture

*Visual & palpatory assessment is important to locate bony landmarks for alignment of goniometers.

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PALPATION CONT’D

Palpation determines:1.Presence or absence of muscle contraction

therefore assessing strength

2.Locate structures in order to stabilize them to isolate joint movement.

3.To identify irregularities of bone and soft tissue.

*All bodies are not alike thus the more you palpate the more proficient you become.

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PALPATION CONT’DPalpation technique: patient must be comfortable keep patient warm body part well supported thus muscles are relaxed visual observation palpate with pads of index & middle finger - occasionally thumb finger nails must be short no sharp rings warm hands fingers are in direct contact with skin “not through clothing” use sensitive but firm touch palpate muscle & tendon by having patient isometrically contracts

muscle against resistance followed by relaxation - palpate muscle & tendon during contraction & relaxation

palpate tendons - fingers (index & middle) placed across long axis of tendon - roll across tendon

(Clarkson, 2000)

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SUPPORT PATIENT’S LIMB support the patients limb at its centre of

gravity - near upper & middle 1/3 of segment

all joints must be supported when lifting or moving the limb - don’t let a limb hang

(Clarkson, 2000)

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JOINT MOVEMENTS

RANGE OF MOTION the amount of movement that occurs at a joint

ACTIVE RANGE OF MOTION the amount of movement the patient

voluntarily moves the body part through without any external assistance.

PASSIVE RANGE OF MOTION the amount of movement that an external

force (therapist) moves the body part through without any assistance from the patient

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JOINT MOVEMENTS CONT’D

In order to assess for ROM the therapist must have an understanding of the anatomy of the area involved. The boney configuration of the joint, the soft tissue in the area, the movements that take place at the joint and the limiting factors of the joint.

(Clarkson, 2000)

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ASSESSMENT CONTRAINDICATIONS

AND PRECAUTIONS

Active and Passive ROM Are Contraindicated:

In a region where there is a recent dislocation or unhealed fracture.

Immediately following surgery to tendons, ligaments, muscles, joint capsules or skin.

When myositis ossificans is present.

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Extra Care with AROM & PROM Infectious or inflammatory process in a joint Patient is on medication for pain or muscle relaxants Osteoporosis or fragile bones is a factor In assessing hyper mobile or subluxed joints Painful conditions Hemophilia Hematoma in the region especially in the elbow, hip or

knee If bony ankylosis is suspected After an injury disrupting soft tissue (tendons, muscles or

ligaments) In the region of a newly united fracture After prolonged immobilization of a part

(Clarkson, 2000)

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ASSESSMENT OF ACTIVE ROM

client performs AROM at affected joint & joints proximal and distal

therapist observes all joints separately, bilaterally and symmetrically

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ASSESSMENT OF ACTIVE ROM CONT’DProvides info about: Patient’s willingness to move the joint. Coordination. Level of consciousness. Attention span. Joint ROM. Movements that cause or increase pain. Muscle strength. Ability to follow instructions. Ability to perform functional activities.

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ASSESSMENT OF ACTIVE ROM CONT’D

AROM maybe decreased due to: Restricted joint mobility. Muscle weakness. Pain. Inability to follow instructions. Unwillingness to move.

(Clarkson, 2000)

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ASSESSMENT OF PROM

Determines: amount of movement at joint greater than AROM due to elastic stretch of muscle

tissue and decreased bulk

Perform PROM to: establish joints ROM determine quality of movement throughout ROM & end

feel determine whether a capsule or noncapsular pattern is

present presence of pain

(Clarkson, 2000)

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NORMAL LIMITING FACTORS & END FEELS unique anatomical structure of a joint

determines the direction & magnitude of the joints ROM

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NORMAL LIMITING FACTORS & END FEELS CONT’D

Limiting Factors: Stretching of soft tissue Stretching of ligaments or joint capsule Apposition of soft tissue Bone contacting bone

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NORMAL LIMITING FACTORS & END FEELS CONT’DEnd Feel: the sensation transmitted to the therapist’s hands at the

extreme end of the passive ROM indicates the structures that limit the joint movement - may be normal (physiological) or abnormal (pathological)

1. Normal End Feel when full Rom & normal anatomy of joint stops movement

2. Abnormal End Feel decrease or increase in the ROM or normal ROM exists but

other structures other than the normal anatomy stop joint movement

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Normal End Feel Examples:

Hard (bony) bone contacts bone hard abrupt stop painless

e.g. Elbow extension

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Normal End Feel Examples Cont’d

Soft (soft tissue apposition) soft compression of tissue (muscle)

e.g. Knee & elbow flexion

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Normal End Feel Examples Cont’d

Firm (soft tissue stretch) firm or springy sensation with slight give feeling depends on the thickness of the

tissue - Achilles has stronger give to it than that of wrist flexione.g. Dorsi flexion with extended knee

(gastrocnemius)

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Normal End Feel Examples Cont’d Firm (capsular stretch) hard arrest to movement with some give

when joint capsule or ligament stretched like stretching leather

e.g. Passive external rotation of shoulder

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Abnormal (Pathologic) End Feels

Hard An abrupt hard stop to movement when bone

contacts bone, or a bony grating sensation, when rough articular surfaces pass over each other. Loose bodies, degenerative joint disease, dislocations, or a fracture.

Soft Boggy sensation that indicates the presence of

synovitis or soft tissue edema.

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Abnormal (Pathologic) End Feels Cont’d

Firm A springy sensation or a hard arrest to

movements with some give, indicating muscular, capsular or ligamentous shortening.

Springy Block A rebound is seen or felt and indicates the

presences of an internal derangement. e.g. knee with a torn meniscus.

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Abnormal (Pathologic) End Feels Cont’dEmpty No sensation (end feel) before the end of passive ROM due to pain.

This may be caused by: Extra-articular abscess a neoplasm (abnormal growth of tissue) acute bursitis joint inflammation fracture

Spasm A hard sudden stop to passive movement that is often accompanied

by pain is indicative of an acute or subacute arthritis, the presence of a severe active lesion or fracture.

If pain is absent a spasm end feel may indicate a lesion of the CNS with resultant increase muscular tonus.

(Clarkson, 2000)

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End feel Activity

Find 2 of each of the following end feels

1. Hard (bony)

2. Soft (soft tissue apposition)

3. Firm (soft tissue stretch)

4. Firm (capsular stretch)

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ROM Instrumentation

Universal Goniometer

OB Goniometer

Tape measure

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ASSESSMENT PROCEDURE Passive Joint Range of Movement: 1. Expose the area2. Explanation and instruction

explain verbally or demonstrate by passively moving patient’s limb through test movement.

3. Assessment of the normal ROM uninvolved side first involved side

* if uninvolved side can’t be used - rely on past experience taking into account age, sex, dominance & occupation

4. Measurement procedure: patient position trick movements or substitute stabilization measurement

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Universal Goniometer Most common device used to measure

joint angles or ROM 180-360 degree protractor One axis which joins two arms

One stationary armOne moveable arm

Size of goniometer is determined by size of the joint being assessed

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Measurement Procedure-universal goniometer Goniometer placement: The goniometer

should be placed lateral to the joint, just off the surface of the limb .

Axis: The axis of the goniometer should be placed over the axis of movement of the jointEg. Bony prominanceAnatomical landmark

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Goniometer Placement Cont’d: Stationary arm: lies parallel to the

longitudinal axis of the fixed proximal joint segment and/or points toward a distant bony prominence

Movable arm: lies parallel to the to the longitudinal axis of the moving distal joint segment and/or points toward a distant bony prominence

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Measurement using the Goniometer:

1. Have the client actively move through joint ROM.

2. Therapist identifies end feel at the joint being measured.

3. Therapist aligns goniometer appropriately for the joint to be measured.

4. If able, the therapist moves client through the final few degrees of PROM.

5. Therapist records goniometer measurement.

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Lets try it ROM will be covered in detail during Occth 583 however you should

attempt to learn the basics as you will have very little time to practice. Measurements are actually quite simple.

Shoulder Flexion Wrist radial and ulnar deviation Finger MCP flexion Hip Flexion Ankle Dorsiflexion / Plantarflexion Abduction of the Great Toe

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MANUAL MUSCLE TESTING

Definition: 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 resistance.

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PREREQUISITES TO MANUAL MUSCLE TESTING:

1. Knowledge of joint motion

2. Origin and insertion of muscles

3. Function of muscles and substitution patterns

4. Ability to palpate the muscle or its tendon

5. To distinguish between normal and atrophied contour

6. Grading parameters

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CONTRAINDICATIONS: (same as for ROM and PROM)

1. Inflammation

2. Pain

3. Joint instability

4. Increased tone-unreliable

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EXTRA CARE MUST BE TAKEN:

1. History of Cardiovascular problems

2. Abdominal surgery or herniation of the abdominal wall

3. In conditions where fatigue or overwork may be detrimental (MS)

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DEFINITIONS:

Muscle strength maximal amount of tension or force that a

muscle or muscle group can voluntarily exert in one maximal effort, when type of muscle contraction, limb velocity, and joint angle are specified.

Muscle endurance the ability of a muscle or a muscle group to

perform repeated contractions, against a resistance, or maintain an isometric contraction for a period of time.

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Range of muscle work the full range in which a muscle works

refers to the muscle changing from a position of full stretch and contracting to a position of maximal shortening.

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Outer range A position where the muscle is on full stretch to

a position halfway through the full range.

Inner range A position halfway through the full range to a

position where the muscle is fully shortened.

Middle range The portion of full range between the midpoint of

the outer range and the mid point of the inner range.

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Passive insufficiency ROM is limited by length of muscle e.g.

Hamstrings.

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Active insufficiency when a muscle crosses two or more joints

it performs simultaneous actions at all the involved joints. The muscle is unable to produce effective tension at all joints = active insufficiency.

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Muscle Contractions:

Isometric (static) contraction tension developed within a muscle but the

muscle does not change length.Isotonic contraction constant tension against a load of resistance.Concentric contraction tension developed within the muscle and the

muscle shortens.Eccentric contraction tension developed within the muscle and the

muscle lengthens.

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FACTORS AFFECTING STRENGTH: Age Sex Type of muscle contraction Muscle size Speed of muscle contraction Previous training effect Joint position Length - Tension Relations Diurnal Variation Temperature Fatigue Motivation, level of pain, body type, occupation and

dominance are other factors that may affect strength.(Clarkson,

2000)

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JOINT POSITIONS

Close-Packed Position joint surfaces are fully congruent and cannot be

pulled apart - maximal tension in joint capsule and

ligaments

*Avoid close-packed position when muscle testing as joint can be locked into position in the presents of a weak prime mover.

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JOINT POSITIONS CONT’D

Loose-Packed Position joint surfaces are least congruentgreatest laxity of capsule and ligamentresting position of joint

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TERMS USED IN MUSCLE TESTING: Prime movers Patient position: allows for function

A.G. - movements upward in vertical plane G.E. - movements in the horizontal plane

Stabilization Test Position and Test Movement

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TERMS USED IN MUSCLE TESTING CONT’D Resistance Palpation Substitution Methods:

a) Isometric Holdings: Force applied after the motion is completed during inner range. (combination isotonic-isometric resistance)

b) Isotonic contraction: Resistance to the ongoing movement.***

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TERMS USED IN MUSCLE TESTING CON’T Grading: Manual muscle grading is based on

3 factorsa. The ability of the muscle or muscle group to move

the part through a complete ROM: against gravity, gravity eliminated etc.

b. The amount of manual resistance that can be given to a contracted muscle or muscle group.

c. Evidence of the presence or absence of a contraction in a muscle or muscle group.

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MMT - CONVENTIONAL GRADING5 (Normal): full ROM against gravity with maximum resistance

4 (Good): full ROM against gravity with moderate resistance 3 (Fair): ROM against gravity with no resistance 2 (Poor): full ROM with gravity eliminated

1 (Trace): No ROM - palpable or observable flicker (Evidence of slight contractility)

0 (Zero): No palpable or visible flicker

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MMT - CONVENTIONAL GRADING Cont’d5 AG full ROM with maximum resistance

4 AG full ROM with moderate resistance

4- AG greater than ½ ROM with moderate resistance

3+AG less than ½ ROM with minimum resistance

3 AG full ROM with no resistance

3- AG greater than ½ ROM

2+ AG less than ½ ROM

2 GE full ROM

2- GE greater than ½ ROM

1+ GE less than ½ ROM

1 No ROM - palpable or observable flicker

0 No palpable or visible flicker

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MMT - CONVENTIONAL GRADING hands and feet (No AG or GE positions)

5 - Full ROM with maximum resistance

4 - Full ROM with moderate resistance

3 - Full ROM with no resistance

2 - Part of available ROM

1 - No ROM - palpable or observable flicker

0 - No palpable or visible flicker

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Testing procedure (pg 109 manual)

1. Screen - Put client in against gravity (AG) position for segment being tested.

2. Have them do the movement – find the muscle (palpate)

3. If able to go through full range = min 3, if partial movement grade accordingly

4. Add resistance – give grade according to the amount of resistant provided

5. If unable to move AG then put in gravity eliminated position (GE) and have them do the movement – grade the muscle accordingly

Note for hands and feet there is no GE