The manual muscle testing procedure was described in this power point, indications, contraindications, limitations of MMT was included. the MMT grading system (scale) was explained well in this PPT.

1. MANUAL MUSCLE TEST
(MMT)
AJITH C
STUDENT OF DEPARTMENT OF PHYSIO
KMCH-COPT

2. SYNOPSE:
I

3. 1) INTRODUCTION:
 Manual muscle testing is used to determine 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 an important tool for
all members of health team dealing with physical residuals of disability.

4.  Muscular strength:
The maximal amount of tension or force that a muscle or muscle group can
voluntarily exert in a maximal effort; when type of muscle contraction, limb
velocity and joint angle are specified.
 Muscular endurance:
The ability of a muscle or a muscle group to perform repeated contractions
against resistance or maintain an isometric contraction for a period of time.
 Muscle power:
 Power is defined as the generate as much force as fast as possible.
 Power does require strength and speed to develop force quickly.
 POWER = strength speed.

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

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

9. GROUP OF MUSCLE ACTION:
1. Prime mover or agonist:
A muscle or muscle group that makes the major 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 as the agonist moves the part through a range of motion.
3. Synergist:
A muscle that contracts and works along with the agonist to produce the desired
movement.

11. There are three types 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 prevent any unwanted movement produced by the prime
mover. For example, when the long finger flexors contract to produce finger
flexion, the wrist extensors contract to prevent wrist flexion from occurring.

12. b) Conjoint synergists:
Two or more muscles work together to produce the desired movement. For
example, 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 group,
the deviation action is cancelled, and the common action occurs.

13. c) Stabilizing or fixating synergists:
These muscles prevent or control the movement at joints proximal to the
moving joint to provide a fixed or stable base, from which the distal moving
segment can effectively work. For example, 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 provide the elbow flexors with a fixed origin from which to pull. If the
scapular muscles do not contract, the object cannot be lifted as the elbow
flexors will act to pull the shoulder girdle downward.

14. 2) DEFINITION OF MMT:
 Manual muscle test (MMT) is a procedure for the evaluation of strength of
individual muscle or muscles group, based upon the effective
performance of a movement in relation to the forces of gravity or Manual
Resistance through the available Range of motion (ROM).
 MMT is the most vital part of motor assessment performed in Medical
Examination.

15.  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

16. Individual versus group muscle test:
 Muscles with a common action or actions may be tested as a group or each
muscle may be tested individually. For example, flexor carpi ulnaris and flexor
carpi radialis muscles may be tested together as a group in wrist flexion. Flexor
carpi ulnaris may be tested more specifically in the action of wrist flexion with
ulnar deviation. On the other hand, Flexor carpi radialis longus and brevis may
be tested more specifically in the action of wrist flexion with radial deviation.

17. 3) Purposes and uses of MMT:
 CLINICAL USES :
i. The severity of problem can be understand. (It is diagnostic Tool)
ii. We can 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 is an Important 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.

18.  WHY MMT IS PERFORMED? :
To get some answers such as:-
i. Is 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?

19. 4) GRADES OF MMT:
i. MRC Scale
ii. OXFORD Scale
iii. KENDALL Scale
iv. And Others .

20. MEDICAL RESEARCH COUNCIL
(MRC) SCALE:

22. OXFORD SCALE :

24. KENDALL SCALE:

26. + or – GRADES :

29. 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

30. 1) POSITION :
PATIENT POSITION:
 Patient is positioned Eliminated or Against gravity. (Patient depend upon 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
each test. It may be necessary to allow some patients to move 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 body weight or with help provided by the
examiner.

31. 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

33. 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 upon
performance.

36. 3) DEMONSTRATION:
 Demonstrate the desired movement.
 Therapist demonstrate the application 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.

37. 5) APPLICATIONS OF RESISTANCE:
 Resistance is applied slowly & gradually.
 Increasing or decreasing manual resistance.
 Increasing length of weight arm.
 Apply presence opposite to the line of pull (Grade 4,5)
 Apply force distally.
 It varies between the persons.
 Use long lever to applied resistance whenever it possible.

38. 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.

39. 8) DOCUMENTATION:
 Examiners complete testing documentation or Record first.
 This will help for next step of treatment applications.
 And help for checking improvement of treatment.

40. 7) INDICATIONS OF MMT:
1)Lower Motor Neuron (LMN) Disease.
2) Some other Neurological (Neuromuscular )disease. Such as,
 Multiple Sclerosis
 Muscular distrophy
 Amyotropic Lateral Sclerosis
 Myasthenia Gravis.
 Guillian - barre syndrome (GBS), etc....
3) Some Musculoskeletal disorders.

41. 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 .

42. Cont.
9) Subluxation joint
10) Hemophelia
11) Osteoporosis

43. 9) PRECAUTION:
1) Considered contraindications
2) Do not harm (Be gentle)
3) Respect pain
4) Examiner know the available ROM.
5) Follow the principles of procedure
6) Take care of patient comfort
7) Record accurately.
8) Extra care taken to giving Resisted Exercise.

44. 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

45.  Extra care must be taken where Resisted movements might
aggravate the condition:
 Patients with history at risk of having cardiovascular problems.
 Abdominal surgery or herniation of abdominal wall to avoid stress on the
abdominal wall.
 Fatigue exacerbate the patients condition.
 Patient with extreme debility, for example,
 Malnutrition
 Malignancy
 And Severe COPD.

46. 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.

47. 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.

48. 7) Subjectivity (patient) HOOVERS sign
8)And following methods also Limit the MMT ;
 Showing the Co-ordination
 Showing pictures of gross / patient muscle contraction
 Showing the ability of client to use muscle power
 Showing the how much joint ROM the individual is working through.

49. 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.

50. PREPARATIONS:

51.  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 terrified of
falling or sliding off. When the patient is severely paretic, a mat table is the
more practical choice. The height of the table should be adjustable to allow the
examiner to use proper leverage and body mechanics.

52.  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

53. 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.

54. 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.

55. 3) STABILIZATION:
I. PROXIMAL HAND – At Origin of muscle & proximal joint giving
stabilization.
II. DISTAL HAND – Distally offering resistance or Assistance depend upon
performance.
 The plinth or mat table for testing must be firm to
help stabilize the part being tested.

56.  The site of attachment of the muscle origin should be stabilized, so the
muscle has a fixed point from which to pull. Substitutions and trick movements
are avoided by making use of the following methods:
a) The patient's normal muscles: For example, the patient holds the edge 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 is used to help fix the proximal parts (shoulder or
pelvic girdles) during movement of the distal ones.
c) The patient’s position: For example, when assessing hip abduction strength in
side lying, the patient holds the non-tested limb in hip and knee flexion in
order to tilt the pelvis posteriorly and to fix the pelvis and lumbar spine.

57.  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.

60. 4) CONVENTIONAL METHODS:
 Manual grading of muscle strength is based on three factors:
* Evidence of contraction: No palpable or observable muscle contraction (grade 0) or a palpable
or observable muscle contraction with no joint motion (grade 1).
* Gravity as a resistance: The ability to move the part through the full available range of motion
with gravity eliminated (grade 2) or against gravity (grade 3).
* Amount of manual resistance: The ability to move the part through the full available range of
motion against gravity and against moderate manual resistance (grade 4) or maximal
manual resistance (grade 5).
* Adding (+) or (-) to the whole grades: This is needed to denote variation in the range of
motion. Movement through less than half of the available range of motion is denoted by a “+”
(outer range), while movement through greater than half of the available range of motion is
denoted by “-“ (inner range).

61. CONVENTIONAL
GRADING:

62. Numerals Letters Description
Against gravity tests: The patient is able to move through:
5 N (normal) The full available ROM against gravity and against maximal manual resistance, with hold at the
end of the ROM (for about 3 seconds).
4 G (good) The full available ROM against gravity and against moderate manual resistance.
4- G - (good -) Greater than one half of the available ROM against gravity and against moderate manual
resistance.
3+ F + (fair +) Less than one half of the available ROM against gravity and against minimal manual resistance.
3 F (fair) The full available ROM against gravity.
3- F - (fair -) Greater than one half of the available ROM against gravity.
2+ P + (poor +) Less than one half of the available ROM against gravity.
Gravity eliminated tests: The patient is able to actively move through:
2 P (poor) The full available ROM with gravity eliminated.
2- P - (poor -) Greater than one half the available ROM with gravity eliminated.
1+ T + (trace +) Less than one half of the available ROM with gravity eliminated.
1 T (trace) None of the available ROM with gravity eliminated and there is palpable or observable flicker
contraction.
0 0 (zero) None of the available ROM with gravity eliminated and there is no palpable or observable muscle

63. SCREENING TEST:
 A screen test is a method used to control muscle strength assessment, avoid unnecessary
testing and avoid fatiguing and / or discouraging the patient. The therapist may screen the
patient through the information 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 example, shaking the patients
hand may indicate the strength of grasp (finger flexors).
4. All muscle testing procedures must begin at a particular grade; this is usually grade “fair”. The
patient is instructed to actively move the body part through full range of motion against
gravity. Based upon the results of this initial test, the muscle test is either stopped or
proceeds.

64. FACTORS AFFECTING STRENGTH:
1). Age:
A decrease in strength occurs with increasing age due to deterioration in muscle
mass. Muscle fibers decrease in size and number; there is an increase in
connective tissue and fat and the respiratory capacity of the muscle decreases.
Strength apparently increases for the first 20 years of life, remains at this level
for 5 or 10 years and then gradually decreases throughout the rest of life. The
changes in muscular strength by aging are different for different groups of
muscles. The progressive decrease in strength is clearer in the forearm flexors
and muscles that raise the body (anti-gravity muscles).

65. 2). Sex:
Males are generally stronger than females. The strength of males
increases rapidly from 2 to 19 years of age at a rate similar to
weight and more slowly and regularly up to 30 years. After that, it
declines at an increased rate to the age of 60 years. The strength
of females is found to increase at a more uniform rate from 9 to 19
years and more slowly to 30 years, after which it falls off in a
manner similar to males. It has been found that women are more
28 to 30% weaker than men at 40 to 45 years of age.

66. 3). Type of muscle contraction:
More tension can be developed during an eccentric contraction than during an
isometric contraction. The concentric contraction has the smallest tension
capability.
4). Muscle size:
The larger the cross-sectional area of a muscle, the greater the strength of this
muscle will be. When testing a muscle that is small, the therapist would expect
less tension to be developed rather than if testing a large, thick muscle.

67. 5). Speed of muscle contraction:
When a muscle contracts concentrically, the force of contraction decreases as
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 up on the ability of the nervous system to
activate the muscle mass. Strength may increase as one becomes familiar
with the test situation. The therapist must instruct the patient well, giving him
an opportunity to move or be passively moved through the test movement at
least once before muscle strength is assessed.

68. 7). Joint position:
It depends on the angle of muscle pull and the length-tension relationship. The tension
developed within a muscle depends upon the initial length of the muscle. Regardless of the type
of muscle contraction, a muscle contracts with more force when it is stretched than when it is
shortened. The greatest amount of tension is developed when the muscle is stretched to the
greatest length possible within the body (if the muscle is in full outer range).
8). Fatigue:
As the patient fatigues, muscle strength decreases. The therapist determines the strength of
muscle using as few repetitions as possible to avoid fatigue.
The patient's level of motivation, level of pain, body type, occupation and dominance are other
factors that may affect strength.

69.  BREAK TEST:
 Resistance applied at the end of tested range is termed as BREAK TEST.
 For one joint muscle resistance is applied at End of ROM.
 For two joint muscle resistance is applied at Mid Range.
 The isometric hold (break test) shows the muscle to have a higher grade than the
make test.
 MAKE TEST:
Resistance is applied throughout the test is called MAKE TEST.

70.  INDICATIONS OF BREAK TEST:
1. When movement is contraindicated
2. When there is pain in movement
3. When we have to assess the quality of strength and not the quantity?.

71. INTRUMENTATION:
 Instrument chosen to assess muscle strength depends on the degree of accuracy
required in the measurement.

72. 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.

75. PINCH GAUGE:
pinch is a strength
measurement using pinch
dynamometer.

77. 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.

79. REFERENCE :
 Daniels and Worthingham’s -MUSCLE TESTING.
 MUSCLE TESTING AND FUNCTION – 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.