Manual Muscle Testing Chapter 2 PDF

**6** Chapter 1 \| Principles of Manual Muscle Testing 5\. All materials needed for the test must be at hand. This is particularly important when the patient is anxious for any reason or is too weak to be safely left unattended. Materials needed include the following: Manual muscle test docu...

**6** Chapter 1 \| Principles of Manual Muscle Testing 5\. All materials needed for the test must be at hand. This is particularly important when the patient is anxious for any reason or is too weak to be safely left unattended. Materials needed include the following: Manual muscle test documentation forms (Figure 1-1) Pen, pencil, or computer terminal Pillows, towels, pads, and wedges for positioning Sheets or other draping linen Goniometer Stopwatch Specific equipment for specific functional tests Test forms for functional tests Interpreter (if needed) Assistance for turning, moving, or stabilizing the patient Emergency call system (if no assistant is available) Reference material **SUMMARY** From the foregoing discussion, it should be clear that manual muscle testing is an exacting clinical skill. Practice, practice, and more practice create the experience essential to building the skill to an acceptable level of clinical proficiency, to say nothing of clinical mastery. **PREPARING FOR THE MUSCLE TEST** The therapist and the patient must work in harmony if the test session is to be successful. This means that some basic principles and inviolable procedures should be second nature to the therapist. 1\. The patient should be as free as possible from discomfort or pain for the duration of each test. It may be necessary to allow some patients to move or be positioned differently between tests. 2\. The environment for testing should be quiet and nondistracting. The temperature should be comfortable for the partially disrobed patient. 3\. The plinth or mat table for testing must be firm to help stabilize the part being tested. The ideal is a hard surface, minimally padded or not padded at all. The hard surface will not allow the trunk or limbs to "sink in." Friction of the surface material should be kept to a minimum. When the patient is reasonably mobile a plinth is fine, but its width should not be so narrow that the patient is afraid of falling or sliding off. Sometimes a low mat table is the more practical choice. The height of the table should be adjustable to allow the therapist to use proper leverage and body mechanics. 4\. 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 body weight or with help provided by the therapist. **MUSCL E T E S T** Chapter 2 \| Relevance and Limitations of Manual Muscle Testing **13** of the more common applications of MMT in various clinical and therapeutic settings, with emphasis on the specific challenges often seen in each. The reader should be aware that the examples provided here are not limited to these settings only. **Acute Care Facilities** Often patients seen in acute care facilities are either acutely ill or are postoperative patients. In the acutely ill patient, manual muscle testing may be used to assess the patient's mobility status in order to inform a discharge plan. A manual strength exam performed as part of a general assessment may provide information concerning the amount of assistance the patient requires and whether the patient will need an assistive device. Assessing the patient's strength to help ensure safe transfers from bed to chair, to a standing position, or on and off the toilet is an essential part of the acute-care patient management process. A strength assessment may also inform the therapist of the patient's ability to follow directions and/or to verbalize concerns such as following a stroke or in the presence of delirium or other cognitive loss.1,2 Strength assessment may also indicate the presence of pain before full-body movements such as transfers. Strength assessment could take the form of active movement followed by resistance, such as in a manual muscle test or in a 10-repetition maximum such as in a seated shoulder dip. Strength assessment in the postoperative patient informs the therapist of the integrity of the patient's nervous system. The therapist may be the first person requiring the patient to move actively after surgery, and thus may be the first one to observe the patient's ability to contract a muscle. Although this scenario is rare, clearly the consequences of assuming an attitude of "all is well" and finding out during a transfer that the patient cannot use part of an extremity would have avoidable consequences. Strength testing in this scenario might take the form of isometric contractions, especially if there are contraindications to joint movement, suspected postsurgical pain as in a newly repaired fractured hip, or in restricted range of motion such as in a total hip encouraging understanding and respect between therapist and patient. The patient is the best guide to a successful muscle test. **INFLUENCE OF THE PATIENT** **ON THE TEST** The intrusion of a living, breathing, feeling person into the testing situation may distort scoring for the unwary examiner. The following circumstances should be recognized: There may be variation in the assessment of the true effort expended by a patient in a given test (reflecting the patient's desire to do well or to seem more impaired than is actually the case). The patient's willingness to endure discomfort or pain may vary (e.g., the stoic, the complainer, the high competitor). 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 those possessed by 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 noncompatibility 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 inconsistent with muscle size and architecture. **USE OF MANUAL MUSCLE TESTING IN** **VARIOUS CLINICAL SETTINGS** Manual muscle testing is used in many different types of health care settings. In this section, we will discuss some Accuracy in giving examinations depends primarily on the examiner's knowledge of the isolated and combined actions of muscles in individuals with normal muscles as well as in those with weak or paralyzed muscles. The fact that muscles act in combination permits substitution of a strong muscle for a weaker one. For accurate muscle examinations, no substitutions should be permitted; that is, the movement described as a test movement should be done without shifting the body or turning the part to allow other muscles to perform the movement for the weak or paralyzed group. The only way to recognize substitution is to know normal function, and realize the ease with which a normal muscle performs the exact test movement. **Kendall HO, Kendall FP** **Early Kendall Examination** From Care During the Recovery Period in Paralytic Poliomyelitis. Public Health Bulletin No. 242. Washington, DC: U.S. Government Printing Office; 1939: 26. **RE L EVANCE AND L IMI TAT IONS** **14** Chapter 2 \| Relevance and Limitations of Manual Muscle Testing tasks, such as the plantar-flexors in gait speed, is key to informed clinical decision-making. *Special considerations* for the acute rehabilitation setting often include rapid change over a short period. Positive changes may be attributed to increased comfort and less pain, less apprehension, neuroplasticity, and a change in medications. Negative changes may be attributed to a decline in medical status, pain, or depression, for example. Muscle fatigue resulting from poor fitness and excessive sedentary behavior or general body fatigue related to frailty or post--acute care implications may affect the perception of strength. The patient may not be able to assume a proper test position because of postsurgical restrictions or a lack of range of motion, requiring the therapist to do a strength-screen rather than a strength test. This screen cannot serve as an accurate baseline because of the lack of standardization. Functional testing may be more informative and accurate in these situations. The therapist should take special care to document any deviations from the standardized manual muscle test. **Long-term Care Facilities** Strength testing and assessment approaches used in longterm care settings are similar to those used in acute rehabilitation. Strength assessment can serve as a baseline to identify key impairments that impact a patient's fallrisk, mobility, and other functional goals as well as to determine the patient's progress over time. Strength screening can be part of a required annual assessment for long-term residents. Strength in the form of a chair-stand test or grip strength is a key component of the diagnosis of frailty and therefore can inform prognosis.3 Frailty is a common geriatric syndrome, characterized by decreased reserve and increased vulnerability to adverse outcomes including falls, hospitalization, institutionalization, and death.4 The majority of residents in long-term care are considered frail.5 Lack of strength is a significant cause of frailty and serves as a diagnostic criterion. Box 2-1 lists the diagnostic criteria for frailty. Based on these criteria, strength assessment and functional testing can be valuable in the intervention of nursing home residents.4 arthroplasty. If testing is done in a manner that differs from the published directions, documentation should describe how the test was performed. For example, if isometric testing was done at the hip because the patient was not permitted to move the hip through full range after a hip arthroplasty, the therapist should document the test accordingly: "Patient's strength at the hip appeared to be under volitional control, but pain and postsurgical precautions prevented thorough assessment." *Key movements* that should be assessed for viability and for the strength necessary to perform transfers or gait include elbow extension, grip, shoulder depression, knee extension, hip abduction, ankle plantar, and dorsiflexion. Functional tests that might be useful in assessing the patient include gait speed, chair stand, timed transfer, or the timed up-and-go test (see Chapter 9). *Special considerations* for the acute care setting may include the patient's rapid fluctuations in response to medications, illness, or pain. Reassessment may be necessary when any changes in strength are documented along with therapist's insights into why the changes are occurring. Clearly, strength gains are not possible in the short time a typical patient is in acute care, but rather should be attributed to increased confidence in moving, less pain, better understanding of the movement to be performed, motor learning, and so forth. **Acute Rehabilitation Facilities** Strength assessment in the acute rehabilitation setting may be performed as a baseline assessment to determine progress over time and to identify key impairments that affect the patient's mobility-related and other functional goals. Knowledge of community-based norms for mobility such as chair stands, distance walked, stair climbing speed, floor transfer ability, and gait speed will inform the therapist's clinical decision-making. (See Chapter 9 for a more complete description of these tests.) A standard manual muscle test and/or a 10-repetition maximum (10-RM) strength assessment are other methods used to assess relevant strength abilities. As in the acute care setting, assessment of strength for mobility tasks is critical in the acute rehabilitation setting. Recognition of key muscle groups in specific mobility Diagnostic criteria for frailty include the presence of three or more of the following:4,10 1\. Unintentional weight loss (\>10 lb in past year) 2\. General feeling of exhaustion on 3 or more days/ week (self-report) 3\. Weakness (grip strength in lowest 20%; \