Introduction to Manual Muscle Testing (MMT)

1. MANUAL MUSCLE
TESTING

2. MUSCLE TESTING
Muscle testing is the evaluation of
contractile units, including muscles and
tendons, and their ability to generate
forces.

3. STRUCTURE OF MUSCLE

4. Forms of muscle testing include manual
strength testing, functional tests, and
dynamometry.

5. MANUAL MUSCLE TESTING
 An evaluation system for diagnosis of
disease or dysfunction of the musculo-
skeletal and nervous systems
 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).

6. MANUAL MUSCLE TESTING
 MMT is the most vital part of motor
assessment performed in Medical
Examination.
 Manual Muscle Testing(MMT) is a
method diagnostic evaluation used by
physical therapists, chiropractors,
physiological researchers and others
concerned with establishing effective
treatment and tracking progress
throughout a specific regimen.

7. HISTORY
 First developed by Swedish
physiotherapists (1860-1880)
from the Royal Central Institute
of Gymnastics, Sweden.
 Dr. George H. Taylor (MD) from
USA learned the Swedish
medical gymnastics
(kinesiology) and wrote the
very first American book about
it in 1860 - "Exposition of the
Swedish Movement Cure" (New
York, 1860)

8. The very first, still
documented, Manual
Muscle Test was made
by the well-known
Swedish physiotherapist
and kinesiologist
Henrik Kellgren.
He was the
grandfather of James
Cyriax, who founded
what is called
Orthopedic Medicine.

9. This is the earliest
preserved image of a
manual muscle test,
anywhere in the
world.

10. FROM SWEDEN TO UNITED
STATES
 Manual Muscle Testing was
later further developed by the
physiotherapist Wilhelmine G
Wright and orthopedic
surgeon Robert W Lovett at
Harvard University in Boston,
in the early 1910s
 Manual muscle testing was
developed in response to the
need to assess muscle
strength losses during the
polio outbreaking.

11. DEVELOPERS OF MMT
Modern Manual Muscle
Testing pioneers: (1930-
1940)
 Henry Kendall & Florence
Kendall
 Lucille Daniels &
Catherine Worthingham

12. MMT was further
developed by
chiropractor George
Goodheart and
chiropractor Alan
Beardall in the 1960s
and 1970s.
The chiropractor Alan
Beardall did single-
handed develop more
manual muscle tests
than anyone else in the
world.

13. KENDALL SCALE

14. OXFORD MUSCLE GRADING

15. MEDICAL RESEARCH
COUNCIL SCALE

16. MODIFIED MRC SCALE

17. DESCRIPTION OF MODIFIED
MRC SCALE

18. THE COMPARISON

19. CRITERIA FOR EFFECTIVE MUSCLE
TESTING
Gonella pointed out that three criteria must be met to ensure the
success of any muscle testing method:
1) testing must be skillfully administered,
2) The method must allow for the collection of definitive data,
and
3) the method must have the facility for controlled, repeated
application.
(Guffey T, Burton B: A critical look at muscle testing. Clin Mgmt 1991 ;11 :15-19.)

20. APPROACHES OF MMT
Kendall and McCreary method The Daniels and Worthingham
method
Tests individual muscle’s action.
(Specific muscle action)
Tests specific muscle group activity in
particular joint motion. (Specific
muscle group motion )
Requires more specific knowledge
about particular muscle(i.e., Anatomy,
Kinesiology etc.,)
Relatively easy
Ex: Tendon injuries, Muscle rupture etc Ex: Spinal Cord Injuries, Myopathies,
Neuromuscular conditions etc
Zimny N, Kirk C. A comparison of methods of manual muscle testing.
Clin Mgmt 1987;7:6-11.

22. MMT CLINICAL VARIATION
 Individual muscle MMT – ex. tendon transfer.
 Gross MMT – ex Major muscles only as in case of
Amputation.
 Myotomal MMT – ex Neck or back pain with
neurological deficit/ SCI.

23. PURPOSES OF MMT
• Diagnostic
• Examine the improvement or deterioration
of a patient’s status over time
• Predictive or prognostic tool
• Determine the extent of strength loss
• Outcome measures in clinical research
• Determine the need for compensatory
measures or assistive devices
• Helps in the formulation of the treatment
plan
• Evaluates the effectiveness of treatment

24. WHY MMT IS PERFORMED
To get some answers such as:-
 Is a particular muscle is normal?
 Is it weak? (How much weak)
 Is it strong enough? (How much strong)
 Is it weak on both the side (bilateral symmetrical)?
 Is it weak only on one side (Unilateral)?
 Is proximal muscles are weaker than the proximal one?
 Is there any particular pattern of muscle weakness?

25. PRINCIPLES OF MMT
 Position
 Stabilization
 Demonstration
 Application of Grades
 Application of Resistance
 Checking normal strength
 Objectivity
 Documentation

26. POSITIONING
 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.

27. JOINT POSITIONING
 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 2

28. POSITIONING

29. 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.

30. STABILISATION

31. DEMONSTRATION
Demonstrate the desired movement.
Therapist demonstrate the
application of movement or
performance to the patient.

32. APPLICATIONS OF GRADES
Always start with GRADE 3.
Based on the response, plan
accordingly

33. MMT FLOW CHART

34. 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.

35. METHODS FOR
PERFORMIMG MMT
 Break testing is when resistance is applied to the
body part at the end of the available range of
motion. It's called the break test because when a
therapist provides resistance the objective for the
patient is to not allow the therapist to "break" the
muscle hold.
 Active Resistance testing/Make Test is when
resistance is applied through the body part
through the available range of motion. This type of
manual muscle testing requires skill and experience
and is not the recommended practice.

36. BREAK TEST VS MAKE TEST

37. CHECKING NORMAL STRENGTH
Therapist to check the strength of the
muscle normal side first.

38. OBJECTIVITY
Therapist ability to palpate and
observe the tendon or muscle
response in very weak muscles.

39. 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. MATERIALS NEEDED FOR
DOCUMENTATION
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

41. MMT ASSESSMENT FORM

43. DIAGNOSIS

44. CONTRAINDICATIONS OF MMT:
(ABSOLUTE/RELATIVE)
 Spastic Cerebral Palsy
 Cardio vascular disease / Brain injury
 Dislocated/ unhealed fracture
 Myositis ossifications
 Parkinson’s disease
 Pain
 Inflammation /(inflammatory disease in muscles
and or joints)
 Severe cardiac & respiratory disease .
 Subluxation joint
 Hemophelia
 Osteoporosis

45. PRECAUTIONS
 Relative contraindications
 Do not harm (Be gentle)
 Respect pain
 Examiner know the available
ROM.
 Follow the principles of
procedure
 Take care of patient comfort
 Record accurately.
 Extra care taken to giving
Resisted Exercise.
 Newly united fracture
 Bony ankylosis
 Hematoma
 If patients take muscle relaxers
and or pain medications
 Prolonged immobilization
 Abdomen surgery or hernia

46. LIMITATION OF MMT
 UMN LESIONS :
Spastic muscle have poor control from higher centers thus its better to
go for voluntary control assessment rather than MMT.
 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.
 TYPES OF CONTRACTION :
MMT gives idea about Quality of concentric contraction only. (Not
Eccentric which is more functional).

47. LIMITATION OF MMT
 UNDERSTANDING OF COMMANDS:
 Paediatric Age group < 5 years
 IQ
 STRENGTH Vs ENDURANCE:
MMT give knowledge about only the strength
and not endurane
 Subjectivity (patient) HOOVERS sign

48. TO GET STANDARDIZED
RESULTS
 Proper training and education
 Knowledge base of anatomy, physiology and
neurology of muscle function
 Follow precise testing protocol
 Practice, Practice, Practice
 A skill developed and maintained with number of
cases

49. MMT IN CHILDREN
 The following are suggested commands for manual muscle testing
in pediatric patients.
 I’m going to see how strong you are. When I tell you hold and don’t
let me push you, you try
 really, really hard not to let me move you. You need to be strong like
a tree or a power ranger
Ex: Biceps brachii: Bend your elbow, now don’t let me pull your arm
down. Hold it hard and don’t let me pull it out.

50. ACTIVE MOVEMENT SCALE/
TORONTO MUSCLE GRADING SYSTEM
(SCALE FOR CHILDREN)

51. SCALE FOR MEASURING HAND MUSCLES
For evaluating the strength of the intrinsic hand muscles, a small
modification to the standard MRC grading has been made so that
grade 3 indicates ‘full active range of motion’ as compared to
‘movement against gravity’
Brandsma JW, Schreuders TA (2001)

52. MODIFIED MMT
INSTRUMENTED MUSCLE TESTING

53. CABLE TENSIOMETER

54. MYOMETER

55. GRIP STRENGTH DYNAMOMETER

56. PINCH METER

57. STRAIN GAUGE

58. HAND-HELD DYNAMOMETER

59. MODIFIED SPHYGMOMANOMETER

60. ISOKINETIC DYNAMOMETER

61. FUNCTIONAL MUSCLE
TESTING
 Functional muscle testing allows
for the assessment of muscles
to perform components of, or
entire, tasks related to daily
activities.
Categories of functional muscle
testing include the following:
Single leg squat, Gower’s Sign,
Intrinsic plus hand, balance,
excursion, lunge, step-up, step-
down, jump and hop tests.

62. THANK YOU