Tests and

measurements (1)

course code:- (PTBA 2118)

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 Introduction to MMT
Part2
By
Dr. Ahmed B. Abo Elatta (PT, PhD)

Lecturer of Physical Therapy, Basic Sciences

Department, Horus University in Egypt
[email protected]
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sequence of manual muscle strength testing procedures (Break Test)

Ask the patient to make

movement against gravity

Full available ROM Partial ROM No movement

Gravity-minimized position+ ↓ friction

Hold test Yield against Can’t tolerate
position against
max. manual
max. manual any manual
Full available ROM Partial ROM No movement
resistance (4-5 s) resistance* resistance
confirm

2- (Poor -)
5 (Normal) 4 (Good) 3 (Fair) 2 (Poor) 2 (Poor)
Visible/ palpable No
Prepared by: Dr. Ahmed Elnahhas (PT, PhD) discernable
contraction *
Reference: Avers, D., & Brown, M. (2019). Daniels and contraction

Worthingham's Muscle Testing: Techniques of Manual

Examination and Performance Testing. Elsevier 1(Trace) 0 (Zero)
Health Sciences

N.B.: Grades 1 & 0 don’t depend on patient position

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Notes on MMT grading criteria:
• Criteria of grading:- not affected by age or ability of patient.
• Resistance should be perpendicular to distal segment.
• < G 5: weak & A “Good” MS. is not always good.
• G 5= -ve Break Test (therapist CANNOT break patient’s hold).
• Palpation can be in G 5& 4: to ensure contraction & exclude
substitutions.
• NO assistance in MMT + No motion in the direction of gravity.
• Friction can be decreased by using powder.
• G 1: palpation for superficial ms. by pads of index & middle
fingers, no gloves.
• G 1 can be detected in any position in any agonist.
• Always start MMT with grade 3 in patients, and grade 5 in
healthy or athletes.

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Practical example of muscle palpation

(during contraction & during relaxation)

Ex. Palpate your biceps in full extension & during push your desk.

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How to prevent substitution in MMT?

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•Proper Positioning

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•Adequate stabilization

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•Observing test action

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Preparing for the muscle test
• patient should be free as possible from discomfort or pain

• Quiet, comfortable environment

• Testing surface: firm, wide, smooth, adjustable to give therapist

mechanical advantage ( resistance / body mechanics)

• Avoid frequent change of position of patient (organize)

• All materials needed should be at hand

• Explanation and instruction to the patient:-

A. Passive Movement during instruction: for demonstration &

detection of available ROM.

B. Test non-involved side first (considered as a reference).

C. Patient position either gravity minimized or against gravity 39

• Warming-up

• Allow a rest of at least 30 sec. between efforts.

• N.B. Screening test:- quick general environmental

evaluation of the patient ( how to walk , sit , then listen
, then touch through specific muscle test)

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Factors affecting muscle strength:
1. Age
2. Gender
3. Fatigue
4. Pain
5. Psychological status (depression)
6. Length-tension relationship
7. Velocity of movement (fast motions are easy to be
performed)

8. Muscle cross-sectional area

9. Type of muscle fibers
10.Long periods of immobilization

Which factors can be controlled?

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Other factors affecting muscle strength:
1. Type of contraction
2. Angle of ms. pull
3. Temperature
4. Dominance (Normal difference up to 22%)
5. Occupation
6. Diurnal variation (time variation)
7. Therapist’s voice
8. Patient’s cognitive ability
9. Language barriers

Which factors can be controlled?

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Subjective vs objective

• Objective measurements should be reliable and valid

• What make test is a good test is its reliability and validity
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Limitations of manual muscle testing
• Population variation:
• Because of this wide variation, it is necessary to modify grading
procedures but not testing technique.
• MMT is NOT suitable for infants/ severe UMNL.
• suitable for Adult, geriatrics, MSK problems, LMNL.

• Subjectivity: dependent on the judgement of examiner

(amount of resistance, qualitative terms).

• Reliability: “amount of consistency between successive

measurements of the same variable, on the same individual,
under the same conditions.”
• A- INTER- RATER RELIABILITY:- same results done by others
therapist.

• B- INTRA- RATER RELIABILTY:- same results done by same

therapist.
• Reliability is increased by adhering to the same procedure for each test.
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• Validity: “The degree to which an instrument measures what
is supposed to measure.”
• G≥ 4 has poor validity x H.H.D. & isokinetic.
• MMT appears to be both reliable and valid in the presence of
profound weakness, such as that seen in neuromuscular diseases.

• Sensitivity: “percent of error”

• among examiners, and in successive tests with the same
examiner, the results should be within one-half of a grade (or
within a plus or minus of the base grade).
• within ½ of a grade.

• Ceiling effect: MMT has wide variability in the range of

forces reported for a given grade. ( no numbers)
• Thus, it is not recommended that MMT be used as an objective
measure of progress greater than the grade of 3 because it is not
an accurate measure.
• (HHD) may address some of the aspects of reliability.
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•Tester strength: A break test in MMT requires
the tester to exert greater force than the patient.
• When testing a strong individual, such as a weightlifter a
great amount of force is required. Women traditionally
have 35% less upper body strength than men (differences
in forces between female and male testers, leading to an
underestimation of the patient's strength)

• Conclusions
1. G≥ 4 use HHD & ISOKINETIC.
2. G> 4 use MMT.

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How to increase the reliability of MMT?
• Proper positioning & Adequate stabilization.
• Clear instructions & a monotone command such as “push, push, push”.

• Quiet & comfortable environment.

• Observe the way the patient assumes & maintains test position.
• Use consistent timing, pressure & position (same standardized
procedures).
• Avoid preconceived impressions regarding the test outcome.
• Use nonpainful contact & provide for a nonpainful execution of
test.
• Same therapist: “intra-rater reliability”.
• Same time of the day.
• Using “Break Test” rather than “Make Test”.
• Avoiding the use of plus or minus signs (especially for grades ≥ 3).
• Adequate training, practice & experience of the examiner.

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REMEMBER
Any test

Do it right
OR
Don’t do it

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Alternatives to MMT
(Especially in research)
• One-repetition maximum (1-RM)
• Multiple-repetition maximum (e.g., 10-
RM)
• Isokinetic testing
• Handheld dynamometry (HHD)
• Functional strength assessment
Alternatives to MMT
One/ multiple-repetition maximum test
Sitting Unilateral Knee Extension Test (for quadriceps)

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Alternatives to MMT
One/ multiple-repetition maximum test
Free Weights Testing
(Biceps Curl)
Notes:
• Free weights are the gold standard
for reliability and validity of the 1-
RM method because of their ease of
application and specificity.
• Greater control is required through
all planes of movement because of
the stabilization required.
• Free weights can challenge the
entire kinetic chain, thus stressing
the “weakest link” rather than the
targeted muscle or movement,
unless proper stabilization is
provided.
• Spotting is necessary because the
weight can be unexpectedly
dropped, potentially causing injury.

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Alternatives to MMT
Isokinetic testing
Isokinetic: (e.g.,
Cybex, Biodex,
KinCom)

High reliability

Obtain peak torque

through ROM

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Alternatives to MMT
Grip strength dynamometry

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In summary
Advantages of MMT (Break Test)→
• Possible isolation of muscle action.
• Test more muscles (almost any movement can be
tested).
• Fixed muscle length & fixed velocity.
• Can test multiplanar movements (e.g., Thumb
opposition, sartorius & peronei).
• Safe & non-expensive & not time consuming
• Readily available in any clinical setting (portable)
• Valid & reliable in assessing lower grades of
strength > HHD & isokinetic testing*
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In summary
Disadvantages of MMT (Break Test)→
• Subjective resistance
• Can’t test eccentric strength, endurance nor power
• Test muscle strength at only 1 point in ROM.
• Test muscle strength in open-kinetic chain only (except calf
& lat. dorsi)
• Limited by examiner strength
• Poor validity in grades ≥ 4
• ceiling effect
• Not suitable for all populations (e.g., Infants & severe
UMNL)
• Lack of accuracy to identify impairments related to function.
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References:

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QUESTIONS

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THANK YOU

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