Manual muscle testing is used by occupational therapists to evaluate muscles' ability to generate force and assess impairments. It involves instructing a patient to hold a limb against the therapist's opposing resistance through a range of motion. Grades from 0 to 5 are used to rate strength based on whether movement can be completed against gravity and additional pressure. While useful, manual muscle testing relies on a therapist's strength; dynamometry provides more objective strength measurements but requires expensive equipment. Both types of testing only approximate muscle function during daily activities.

1. Occupational Therapy
Manual Muscle Testing and Grading

2. Manual muscle testing
- Manual muscle testing is used in rehabilitation and recovery to
evaluate contractile units, including muscles and tendons, and their
ability to generate forces.
- When used as part of rehabilitation, muscle testing is an important
evaluative tool to assess impairments and deficits in muscle
performance, including strength, power, or endurance.
- Impairments in muscle function may result from a number of
issues including musculoskeletal injuries, cardiovascular,
pulmonary, or neuromuscular disease or disorders.
- Identifying impairment in specific muscles or muscle groups is an
important part in determining the course of a rehabilitation
regimen which may include therapeutic exercise, manual therapy,
bracing, or functional movement training.

3. - Manual Muscle Testing (MMT) is a method of valuable diagnostic
evaluation used by occupational therapist with establishing
effective treatment and tracking progress throughout a specific
regimen.
- Modern methods for doing kinesiological testing have adopted
standardly accepted procedures and grading systems that allow
occupational therapist to understand and communicate muscle
testing findings.
- Muscle testing can be performed using manual strength testing,
functional tests, and dynamometry.
- With manual muscle testing, the patient is instructed to hold the
corresponding limb or appropriate body part to be tested at the end
of its available range while the practitioner provides opposing
manual resistance.

4. PROTOCOLS FOR ACCURATE MANUAL MUSCLE TESTING RESULTS
- Make sure to communicate with the patient all the components of
the test and the results you are looking to obtain from the test.
- Work with the non-dominant (or non-injured) side first and keep
consistent when applying pressure.
- Remind your patient to breathe naturally during the test, because
breath holding can increase a forced result.
- Make sure the patient is dressed in loose clothing and has full
range of movement.
- Place the patient in an adequately supported position, so they are
able to completely concentrate their effort on the body part being
test.

5. PROTOCOLS FOR ACCURATE MANUAL MUSCLE TESTING RESULTS
- Always test first in an antigravity position. If muscles are too weak
to function against gravity, they are then tested in the horizontal
plane.
- Resistance needs to be applied directly opposite the “line of pull” of
the muscles being tested.
- Plan out the test first, testing all the muscles that should be
examined in one position before changing to another. This reduces
any inefficiency during testing and makes the most of treatment
time.
- Always provide adequate stabilization to unrelated joint/s so as to
avoid unnecessary compensation. For example, stabilization of the
shoulder will prevent extra movements when the patient is resisting
elbow bending (flexion).

6. PROTOCOLS FOR ACCURATE MANUAL MUSCLE TESTING RESULTS
- Always test both sides in order to compare strength or muscle grade
of both limbs to get the most accurate picture of strength and/or
impairment.
- What to Avoid When Performing Manual Muscle Testing
 Avoid doing jerking movements when applying resistance to your
patient’s during testing
 Discontinue testing if patient complains of pain or discomfort
 Do not leave patient unattended

7. - Traditional grading uses either descriptive terms “zero,” “trace,”
“poor,” “fair,” “good,” and “normal,” or uses a numerical scale
from 0 through 5.
- A grade is determined by a patient’s ability to move the tested body
part through its full range of motion (against gravity) and whether
they can hold in the test position.
- This ability earns a grade of fair, or 3, and is the most objective
observation made during testing due to the consistency of gravity.
- However, a poor grade, or 2, is given when a patient is able to move
throughout the full range of motion, only when gravity has been
removed.
- Trace grades, or 1, is given when a patient is unable to move
throughout the range of motion, however a slight contraction is
noticeable upon palpitation. When there is no evidence of even a
slight contraction, a grade of zero is given.

9. Manual Muscle Test Grades
Grade 5 (Normal; 100%) :
- This grade means the patient is able to comfortably withstand
pressure in the test position.
- Patient is also able to complete the whole range of motion
(movement) against gravity while the practitioner applies maximum
resistance at the end-range of movement.

10. Manual Muscle Test Grades
Grade 4 (Good;75%) :
- This grade means the testing subject is able to successfully perform
the test with moderate to strong pressure.
- Patient is also able to complete the whole range of motion
(movement) against gravity while the practitioner applies moderate
resistance at the end-range of movement.
- Don’t forget to consider both sides to evaluate whether you are
applying adequate force on the tested limb.
Grade 3+ (Fair+) :
- The patient can complete the motion against gravity with minimal
resistance applied by the examiner at end-range.

11. Manual Muscle Test Grades
Grade 2+ (Poor +) :
- This grade is given when a patient is able to move through 50% of
motion or less in an anti-gravity position or is able to hold position
against resistance in a position without gravity.
- For example, when a gravity is eliminated, such as performing the
motion in side-lying, if the patient is able to perform the movement
at full range of motion with ease, but then gives way immediately
with the application of resistance, then the grade is a 2+.

12. Manual Muscle Test Grades
Grade 3 (Fair;50%) :
- This is considered the mid-range grade, in which a patient can
perform the movement without any additional pressure.
-
- With Grade 3, the patient can only complete the range of motion
against gravity.
- If the practitioner applies force, the patient is unable to complete the
test.
- For example, when testing the strength of the left knee extensors
(quadriceps femoris/quads). If the patient is able to straighten their
leg fully from a seated position, without force but then gives way
upon the application of force, the grade is considered a 3.

13. Manual Muscle Test Grades
Grade 2+ (Poor +) :
- This grade is given when a patient is able to move through 50% of
motion or less in an anti-gravity position or is able to hold position
against resistance in a position without gravity.
- For example, when a gravity is eliminated, such as performing the
motion in side-lying, if the patient is able to perform the movement
at full range of motion with ease, but then gives way immediately
with the application of resistance, then the grade is a 2+.

14. Manual Muscle Test Grades
Grade 2 (Poor;25%) :
- In this grade, a patient is able to complete movement completely in a
horizontal plane.
- In this grade, patients are unable to perform movements against
gravity, but can move once the pull of gravity is eliminated, as long
as resistance is not applied.
- Grade 2 - (Poor -)This grade indicates a patient can only complete
movement partially in a horizontal plane.
- In this grade, movement is dependent on the elimination of gravity,
but can only be completed partially, even without resistance

15. Manual Muscle Test Grades
Grade 1 (Trace) :
- This grade indicates that no visible movement of the tested body part
is detected except a slight contraction.
- In this grade, the patient is not able to move the body part at all,
even without resistance or gravity.
- Upon, closer examination with palpation, the therapist will be able
to detect a slight muscle contraction.
- Grade 0 (Zero; No trace)This grade indicates a complete lack of
contraction. Either by visual examination or even with physical
therapist's palpation (touch).

16. - While manual muscle testing is an essential component in
rehabilitation, it can have its downsides. For example, testing results
may be hampered by a practitioner’s ability to provide adequate
resistance.
- Isokinetic dynamometry uses a measurement device, like a
handheld dynamometer, to evaluate the force of the patient’s
contraction of a particular muscle group.
- These types of measurement devices increase efficiency because they
are able to apply maximal resistance at all points in the body part’s
range of motion at a specified speed, while being able to objectively
assess strength, power and endurance.

17. - These tests offer a more complete picture for rehabilitation
purposes.
- In order to look at peak torques, strength is assessed using a slower
velocity.
- Power is assessed using a fast velocity setting in order to look at the
amount of force performed during a specified amount of time.
- When testing for endurance, the practitioner assesses the patient’s
ability to maintain force output during several repetitions during
higher velocities.

18. - Advantages of isokinetic testing include the ability to maximally load
the muscle throughout its range of motion; stabilization of proximal
body parts to prevent substitute motions; measurement of concentric
and eccentric loading; and objectivity.
- As in manual muscle testing, however, isokinetic testing does not
necessarily provide an accurate picture of how a muscle will
function during actual activities of daily living or sports.
- In addition, unlike manual muscle testing, it requires expensive
equipment and space.

19. - Advantages of isokinetic testing include the ability to maximally load
the muscle throughout its range of motion; stabilization of proximal
body parts to prevent substitute motions; measurement of concentric
and eccentric loading; and objectivity.
- As in manual muscle testing, however, isokinetic testing does not
necessarily provide an accurate picture of how a muscle will
function during actual activities of daily living or sports.
- In addition, unlike manual muscle testing, it requires expensive
equipment and space.

23. Shoulder Internal and External Rotation

24. Shoulder Flexion and Extension

25. Horizontal Adduction and Horizontal Abduction

26. Scapular Depression and Retraction

27. Scapular Retraction

28. Shoulder Abduction and Adduction

29. Scapular Retraction and Downward Rotation

30. Scapular Protraction and Upward Rotation

31. Scapular Elevation