Introduction to Presented by:

Manual Muscle Prof. Dr. Ibrahim Hamoda

Testing (MMT)
Lecture titles

Definition of
Purpose and use
Introduction manual muscle Grades of MMT
of MMT
test

+ and – grades of Principles of Indications of Contraindications

MMT MMT MMT of MMT

Precautions of Limitations of Factors affecting

Procedures
MMT MMT muscle strength

instrumentations
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.
• 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.
TYPES OF MUSCLE contraction:

• 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.
• Isotonic contraction: The muscle develops constant tension against a load
or resistance. There are two types:
• Concentric contraction: Tension is developed in the muscle and the
origin and insertion of the muscle move closer together; so the muscle
shortens.
• Eccentric contraction: Tension is developed in the muscle and the origin
and insertion of the muscle move further a part; so the muscle
lengthens.
TYPES OF MUSCLE WORK:
 RANGE OF MUSCLE WORK:

The full range in which a muscle work refers to the muscle work, 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.
GROUP OF MUSCLE ACTION:

• Prime mover or agonist:

A muscle or muscle group that makes the major contribution to movement at
the joint.
• 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.
• Synergist:
A muscle that contracts and works along with the agonist to produce the
desired movement.
 Synergistic muscles

• There are three types of synergists:

• Neutralizing or counter-acting synergist
• Conjoint synergist
• 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.
 Synergistic muscles

• 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.
Synergistic muscles

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.
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.
BASIC COMPONENTS OF MOTOR EXAMINATION:

*Importance of the Sequence

• Bulk of muscle
• Tone
• Reflexes
• Range of motion (ROM)
• Manual muscle test (MMT)
• Functional Assessment
Types of MMT

Individual Group Functional

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.
Functional muscle testing

• Used with special categories when the

prerequisites of individual MMT don't
apply
• E.g. pediatrics, geriatrics, stroke …..
Etc.
3) Purposes and uses of MMT:

• CLINICAL USES :
• The severity of problem can be understand. (It is diagnostic Tool)
• We can planning our treatment goals.

• Determine the extend & degree of muscular weakness resulting from disease, injury.
• Correlating muscle picture with in level innervations (myotomes) .
• MMT is an Important tool for all the members of the Rehabilitation team.
• Prevents deformities by locating problem areas.
• Help and Evaluate effectiveness of treatment to the therapist.
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?
4) GRADES OF MMT:

MRC OXFORD KENDALL And

Scale Scale Scale Others .
MEDICAL RESEARCH COUNCIL
(MRC) SCALE:
OXFORD SCALE :
KENDALL SCALE:
+ or – GRADES :
5) PRINCIPLES OF MMT:

Application of
Position Stabilization Demonstration
Grades

Checking
Application of
normal Objectivity Documentation
Resistance
strength
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.
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
2) STABILIZATION :
• Patient could stabilize our self during performed Antigravity position.
• The hand placement of the therapist is important.
• HAND PLACEMENT:
• PROXIMAL HAND – At Origin of muscle & proximal joint
giving stabilization.
• DISTAL HAND – Distally offering resistance or Assistance depend upon
performance.
3) DEMONSTRATION:
• Demonstrate the desired movement.
• Therapist demonstrate the application of movement or performance
to the patient.
• 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.
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.
6) CHECKING NORMAL STRENGTH:
• Therapist to check the strength of the muscle normal side first.

• OBJECTIVITY:
• Therapist ability to palpate and observe the tendon or muscle
response in very weak muscles.
7) OBJECTIVITY:
• Therapist to check the strength of the muscle normal side first.

• Therapist ability to palpate and observe the tendon or muscle

response in very weak muscles.
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.
6) INDICATIONS OF MMT:

• Lower Motor Neuron (LMN) Disease.

• Some other Neurological (Neuromuscular )disease. Such as,
• Multiple Sclerosis
• Muscular distrophy
• Amyotropic Lateral Sclerosis
• Myasthenia Gravis.
• Guillian - barre syndrome (GBS), etc....
• Some Musculoskeletal disorders.
7) CONTRAINDICATIONS OF MMT:

• Cerebral Palsy
• Cardio vascular disease / Brain injury
• Dislocated/ unhealed fracture
• Myositis ossifications
• Parkinson’s disease
• Pain
7) CONTRAINDICATIONS OF MMT:

• Inflammation /(inflammatory disease in muscles and or joints)

• Severe cardiac & respiratory disease .
• Subluxation joint
• Hemophelia
• Osteoporosis
8) PRECAUTION:

• Considered 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.
8) PRECAUTION:

• Abdomen surgery or hernia

• Newly united fracture
• Bony ankylosis
• Hematoma
• If patients take muscle relaxers and or pain medications
• Prolonged immobilization
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 patient's condition.
• Patient with extreme debility, for example,
• Malnutrition
• Malignancy
• And Severe COPD.
 9) 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.
 9) LIMITATION OF MMT:

• TYPES OF CONTRACTION :
• MMT gives idea about Quality of concentric contraction only. Eccentric which is
more functional).
• UNDERSTANDING OF COMMANDS:
• Pediatric Age group < 5 years – IQ - Higher functions.
• STRENGTH Vs ENDURANCE:
• MMT give knowledge about only the strength and not endurance.
10) • Explanation & Instruction
• Assessment of normal muscle strength
PROCEDURE:
• Properly positioned the patient
• Stabilization
• Substitution movements & Trick movements
• Conventional methods
• Alternating techniques.
Thank YOU