Daniels and worthinghams muscle testing pdf free download

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See all reviews. Top reviews from other countries. Nice book. Report abuse. Your recently viewed items and featured recommendations. Back to top. Before the trials, Kolb and Jacobs were sent to Atlanta to train physicians to conduct the muscle tests, but it was decided that experienced physical therapists would be preferable to maintain the reliability of the test scores.

Kolb and Jacobs trained a group of 67 therapists in the use of the abridged muscle test. A partial list of participants was appended to the Lilienfeld paper in the Physical Therapy Review in Chapter 2 describes the purposes and limitations of manual muscle testing, placing manual muscle testing in the context of strength testing across settings. Chapters 3 through 7 present traditional and updated techniques for testing motions of skeletal muscle groups in the body region covered by that chapter.

Chapter 4 reflects additional changes to practice through the expansion of the trunk muscle strength testing section, particularly trunk endurance; the pelvic floor muscle testing section; and the respiratory muscle section. Chapter 7 describes methods of strength testing using equipment and instruments, and Chapter 8 is devoted to functional tests, which have become critical for successful documentation.

Students should learn manual muscle testing within the context of strength testing to avoid some of the limitations described in Chapter 2. Chapter 9 is completely new and describes manual testing using a handheld dynamometer and includes normative values where they exist. Chapter 10 provides case studies to describe different methods of strength testing in various patient populations and settings. For instant access to anatomical information without carrying a large anatomy text to a muscle testing session, see the Ready Reference Anatomy section on Evolve.

This chapter is a synopsis of muscle anatomy, muscles as part of motions, muscle innervations, and myotomes. To assist readers, each muscle has been assigned an identification number based on a regional sequence, beginning with the head and face and proceeding through the neck, thorax, abdomen, perineum, upper extremity, and lower extremity.

This reference number is retained throughout the text for cross-referencing purposes. Two lists of muscles with their reference numbers are presented, one alphabetical and one by region, to assist readers in finding muscles in the Ready Reference section.

These can also be found on the inside front and back covers of the book. The most formal usage and the correct form for many journal manuscripts is the terminology established by the Federative International Committee on Anatomical Terminology FCAT in However, common usage often neglects these prescribed names in favor of shorter or more readily pronounced names. The authors of this text make no apologies for not keeping strictly to formal usage.

Most of the muscles cited follow Terminologia Anatomica. Others are listed by the names in most common use. The alphabetical list of muscles see the inside front cover of the book gives the name used in this text and the correct Terminologia Anatomica term, when it differs, in parentheses. Because proficiency in muscle testing can only be achieved if the practitioner has a thorough understanding of anatomy, anatomical drawings are presented throughout the book, many in crosssection format, and descriptions of origins and insertions and functions are provided in multiple places, in detail and in abbreviated form.

The length and direction of the arrow indicates the relative excursion of the part. Black arrows in the text denote resistance by the examiner. It is important to remind the reader that mastery of muscle testing, whether performed manually or using a strength-testing device, requires substantial practice.

The only way to acquire proficiency in clinical evaluation procedures is to practice over and over again. As experience with patients matures over time, the nuances that can never be fully described for the wide variety of patients encountered by the clinician will become as much intuition as science. Muscle testing continues to be among the most fundamental skills of the physical therapist and others who are concerned with abnormalities of human motion. The skill of manual muscle testing is a critical clinical tool that every physical therapist must not only learn but also master.

A physical therapist who aspires to be recognized as a master clinician will not achieve that status without acquiring exquisite skills in manual muscle testing and precise assessment of muscle performance. Wright WG. Muscle training in the treatment of infantile paralysis. Boston Med Surg J. Lovett RW. Treatment of infantile paralysis. Preliminary report. Merrill J. Personal letter to Lucille Daniels dated January 5. Certain aspects of infantile paralysis and a description of a method of muscle testing.

Muscle Function. Paul B. Hoeber: New York; Treatment of Infantile Paralysis. Lowman CL. A method of recording muscle tests. Am J Surg. Muscle strength testing. Physiotherap Rev. Stewart HS. Physiotherapy: Theory and Clinical Application. Legg AT, Merrill J. Physical therapy in infantile paralysis. Prior: Hagerstown, MD; Principles and Practice of Physical Therapy. Kendall HO. Some interesting observations about the after care of infantile paralysis patients. J Excep Child. Public Health Bulletin No.

Government Printing Office: Washington, D. Brunnstrom S, Dennen M. Round table on muscle testing. Muscle Testing: Techniques of Manual Examination. Saunders: Philadelphia; Muscles: Testing and Function. Posture and Pain. The role of the physical therapist in the gamma globulin poliomyelitis prevention study. Phys Ther Rev.

Study of the reproducibility of muscle testing and certain other aspects of muscle scoring. Kolb ME. Personal communication. Because this text is based on actions e. The numeric 0 to 5 system of grading is the most commonly used muscle strength scoring convention across health care professions.

Each numeric grade e. See table. Use of these qualitative terms is an outdated convention and is not encouraged because these terms tend to misrepresent the strength of the tested action. The numeric grades are based on several factors that will be addressed later in this chapter. The term resistance is always used to denote a concentric force provided by the tester that acts in opposition to contracting muscles.

Manual resistance should always be applied opposite to the muscle action of the participating muscle or muscles. The patient is asked to hold the body segment at or near the end of the available range, or at the point in the range where the muscle is most strongly challenged. This is called a break test, and it is the procedure most commonly used in manual muscle testing nowadays.

However, there are alternatives to the break test for grading specific muscle actions. As a recommended alternative procedure, the therapist may choose to place the muscle or muscle group to be tested in the end or test position, after ensuring that the patient can complete the available range Grade 3 , before applying additional resistance.

In this procedure the therapist ensures correct positioning and stabilization for the test. Make Test An alternative to the break test is the application of manual resistance against an actively contracting muscle or muscle group i. During the maximum contraction, the therapist gradually, over approximately 3 seconds, increases the amount of manual resistance until it matches the patient's maximal level.

The make test is not as reliable as the break test, therefore making the break test the preferred test. Active Resistance Test Resistance is applied opposite the actively contracting movement throughout the range, starting at the fully lengthened position. The amount of resistance matches the patient's resistance but allows 48 the joint to move through the full range. This kind of manual muscle test requires considerable skill and experience to perform and is not reliable; thus its use is not recommended as a testing procedure but may be effective as a therapeutic exercise technique.

Application of Resistance The principles of manual muscle testing presented here and in all published sources since follow the basic tenets of muscle lengthпїЅtension relationships, as well as those of joint mechanics. However, as flexion continues beyond that point, the biceps are short and their lever arm again decreases in length and efficiency. In manual muscle testing, external force in the form of resistance is applied at the end of the range or after backing off slightly from the end of range in the direction opposite the actively contracting muscle.

For some muscle actions e. Two-joint muscles are typically tested in mid-range where length-tension is more favorable. Ideally, all muscles and muscle groups should be tested at optimal length-tension, but there are many occasions in manual muscle testing where the therapist is not able to distinguish between Grades 5 and 4 without putting the patient at a mechanical disadvantage. Thus the one-joint brachialis, gluteus medius, and quadriceps muscles are tested at end range and the two-joint hamstrings and gastrocnemius muscles are tested in mid-range.

Critical to the accuracy of a manual muscle test are the location of the applied resistance and the consistency of application across all patients. The placement of resistance is typically near the distal end of the body segment to which the tested muscle attaches. There are exceptions to this rule. One exception is when resistance cannot be provided effectively without moving to a more distal body segment.

In the case of shoulder and hip internal and external rotators, this involves applying resistance through the hand placed on the distal forearm or lower leg. Another exception involves patients with a shortened limb segment as in an amputation.

Take for example a patient with a transfemoral amputation. Even if the patient could hold against maximum resistance while abducting the hip, the weight of the lower limb is so reduced and the therapist's lever arm for resistance application is so short, that a grade of 5 cannot be assumed regardless of the resistance applied.

A patient holding against maximum resistance may still struggle with the force demands of walking with a prosthesis. If a variation is used, the therapist should make a note of the placement of resistance to ensure consistency in testing. The application of manual resistance should never be sudden or uneven jerky. The therapist should apply resistance with full patient awareness and in a somewhat slow and gradual manner, slightly exceeding the muscle's force as it builds over 2 to 3 seconds to achieve the maximum tolerable intensity.

Applying resistance that slightly exceeds the muscle's force generation will more likely encourage a maximum effort and an accurate break test. The therapist also should understand that the weight of the limb plus the influence of gravity is part of the test response.

Heavier limbs and longer limb segments put a higher demand on the muscles that move them. Weakened muscles are tested in a plane horizontal to the direction of gravity with the body part supported on a smooth, flat surface in such a way that friction force is minimal Grades 2, 1, and 0.

A powder board may be used to minimize friction. For stronger muscles that can complete a full range of motion in a direction against the pull of gravity Grade 3 , resistance is applied perpendicular to the line of gravity Grades 4 and 5. Acceptable variations to antigravity and gravity-minimal positions are discussed in individual test sections.

Stabilization Stabilization of the body or segment is crucial to assigning accurate muscle test grades. Patients for whom stabilization is particularly important include those with weakness in stabilizing muscles 49 e. Numerous muscles, some seemingly remote, can contribute as stabilizers to the performance of tested muscle actions. However, muscle test performance is not meant to be dependent on muscles other than the prime movers.

To give an extreme example, shoulder abduction on the left side should not be dependent on the trunk muscles on the right side. Therefore a patient with weak trunk muscles and limited sitting balance should be supported and stabilized either through patient positioning or by a stabilizing hand on the right shoulder.

A muscle or muscle group that is particularly strong may also require patient stabilization if the full capacity of a muscle group is to be accurately tested. However, the same patient, properly stabilized by the tester, an assistant, or a belt during testing, may not be able to hold against maximum tester resistance and thus break the muscle contraction, indicating that the patient has a muscle test grade of 4 rather than 5.

Criteria for Assigning a Muscle Test Grade The grade given on a manual muscle test comprises both subjective and objective factors. Subjective factors include the therapist's impression of the amount of resistance given during the actual test and then the amount of resistance the patient actually holds against during the test. Objective factors include the ability of the patient to complete a full range of motion or to hold the test position once placed there, the ability to move the part against gravity, or an inability to move the part at all.

All these factors require clinical judgment, which makes manual muscle testing a skill that requires considerable practice and experience to master. An accurate test grade is important not only to establish the presence of an impairment but also to assess the patient's longitudinal status over time. Clinical reasoning is necessary for the therapist to determine the causes for the lack of ability to complete the full range or hold the position, ascertain which is most applicable, and decide whether manual muscle testing is appropriate.

Consistent with a typical orthopedic exam, the patient is first asked to perform the active movement of the muscle to be tested. Active movement is performed by the patient without therapist or mechanical assistance.

This active movement informs the therapist of the patient's willingness and ability to move the body part, of the available range in the related joint s , and whether there are limitations to full range, such as pain, excess tone, or weakness. Active movement without resistance is the equivalent of a Grade 3. Active movement is also called active range of motion and begins every muscle test to help determine the appropriate test position and amount of resistance to apply.

Grade 5 Muscle A grade of 5 is assigned when a patient can complete full active range of motion active movement against gravity and hold the test position against maximum resistance. If the therapist can break a patient's hold, a grade of 5 should not be assigned.

Overgrading will prevent the differentiation of a weak from a strong muscle and the identification of muscles that do, versus do not, get stronger over time. In general, a student learns manual muscle testing by practicing on classmates, but this provides only minimal experience compared with what is needed to master the skill.

A therapist may not be aware of underestimation of a muscle contraction unless quantitative measures of strength are also used, such as in a sit-to-stand test. In addition, contributing to an underestimation of weakness is the inability of some therapists, particularly those who are women, to apply adequate resistance.

When maximal resistance results in a break or give, irrespective of age or disability, the muscle is assigned a grade of 4. However, if pain limits the ability to maximally resist the force applied by the therapist, evaluation of actual strength may not be realistic and should be documented as such.

Sharrard counted remaining alpha motor neurons in the spinal cords of individuals with poliomyelitis at the time of autopsy.

Appropriate stabilization is critical to determine the true difference between a Grade 5 and Grade 4 muscle. Grade 3 Muscle The Grade 3 muscle test is based on an objective measure.

The muscle or muscle group can complete a full range of motion against the resistance of gravity. Grade 2 Muscle The Grade 2 is assigned to a muscle group that can move the body segment when gravity is minimized.

This position is typically described as the horizontal plane of motion. Movement in this plane may be eased by use of a powder board or other such friction-eliminating surface. Grade 1 Muscle The Grade 1 is assigned when the therapist can detect visually or by palpation some contractile activity in one or more of the muscles that participate in the action being tested provided that the muscle is superficial enough to be palpated.

The therapist also may be able to see or feel a tendon pop up or tense as the patient tries to perform the movement.

However, there is no movement of the part as a result of this contractile muscle activity. Patient positioning is less important in Grade 1 testing because a Grade 1 muscle can be detected in almost any position.

When a Grade 1 muscle is suspected, the therapist should passively move the part into the test position and ask the patient to hold the position and then relax; this will enable the therapist to palpate the muscle or tendon, or both, during the patient's attempts to contract the muscle and also during relaxation. Care should be taken to avoid substitution of other muscles. Grade 0 Muscle The Grade 0 muscle is assigned when palpation or visual inspection fail to provide evidence of contraction.

This does not mean there is no muscle activation. In fact, electromyography may demonstrate that some activation is present. Avoiding the use of plus or minus signs restricts manual muscle test grades to those that are meaningful, defendable, and reliable. The use of pluses and minuses adds a level of subjectivity that lacks reliability, especially for grades of 3 or greater. However, in the case of Grade 2, described above, there is a considerable difference between the muscle that can complete full range in a gravityminimized position horizontal position and the one that cannot complete full range but can achieve some joint movement.

Therefore the grade of 2- is acceptable when the muscle can complete partial range of motion in the horizontal plane, gravity minimized. The difference between Grade 2 and Grade 1 muscles represents such a broad functional difference that a minus sign may be important in assessing even minor improvements in function. The therapist is encouraged to supplement the grade with descriptive documentation of the quality of movement.

Grade 4 Muscle Revisited Historically, manual muscle testing has used two grading systems, one using numbers and the other using descriptors normal to zero. The assumption is that if strength is adequate, then the patient is not in need of rehabilitation. Evidence of this has already been presented. If this goal is not met, patients especially aging individuals may lose their independence or find themselves incapable of returning to a desired sport or activity because their weak muscles fatigue too quickly.

Athletes who have not fully recovered their strength before returning to a sport are far more likely to suffer a reinjury, potentially harming themselves further.

There are numerous instances in which a Grade 4 muscle cannot meet its functional demands. When the gluteus medius is Grade 4, a patient will display a positive Trendelenburg sign. When the soleus is Grade 4, the heel rise fails to occur during the latter portion of the stance phase of gait, which reduces gait speed. Repeatedly there is a disconnect between what patients can functionally accomplish and the manual muscle strength grade the therapist assigns, particularly in older adults. Muscle grades that are inaccurate based on the patient's age, gender, and presumed strength or because the therapist cannot apply adequate resistance must be avoided.

If this range in sitting can be completed with maximal resistance, the grade assigned would be a 5. If the patient cannot actively complete that range, the grade assigned MUST be less than 3. The patient then should be repositioned in the side-lying position to ascertain the correct grade. Screening Tests In the interests of time and cost-efficient care, it is often unnecessary to perform a muscle test on each muscle of the body.

As the strength of various muscle actions tend to be correlated and internally consistent,6 a systematic testing of a limited number of muscle actions often will suffice. Three screening indexes warrant mentioning. Each was developed with a specific diagnostic group in mind and allows for the calculation of a total score.

The first, the Motricity Index, was developed for patients with stroke and includes three muscle actions of the upper limb shoulder elevation, elbow flexion, and hand grasp and three muscle actions of the lower limb hip flexion, knee extension, and ankle dorsiflexion.

It includes most of the actions included in the Motricity Index shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, ankle dorsiflexion.

If a nonspecific strength exam is performed e. To screen for muscles that need definitive testing, the therapist can use a number of maneuvers to identify movements that do and do not need testing. Observation of the patient before the examination will provide valuable clues to muscular weakness and performance deficits.

Preparing for the Muscle Test 53 The therapist and the patient must work in harmony if the test session is to be successful. This means that some basic principles and inviolable procedures should be second nature to the therapist. 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. The environment for testing should be quiet and nondistracting. The ambient temperature should be comfortable for the partially disrobed patient. The testing surface must be firm to help stabilize the part being tested. The ideal is a firm surface, minimally padded or not padded at all.

When the patient is reasonably mobile, a plinth is fine, but its width should not be so narrow that the patient is afraid of falling or sliding off. Sometimes a low mat table is the more practical choice. The height of the table should be adjustable to allow the therapist to use proper leverage and body mechanics.

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 therapist.

All materials needed for the test must be at hand. This is particularly important when the patient is anxious for any reason or is too weak to be safely left unattended. These exercises should be considered challenging and used later in the rehabilitation process. The therapist should also be aware of the different types of contractions applied in muscle testing and exercise. See Box 1.

Box 1. Concentric activity is generally the primary motion of the muscle. Eccentric contraction refers to the lowering phase of an exercise, when the muscle lengthens, as in lowering the weight to the chest during the bench press or lowering oneself into a chair.

Eccentric muscle activity is seen in many mobility-related functional tasks such as stepping down a curb or in gait. Isometric contraction refers to the creation of muscle tension without joint movement. Isometric contractions are often used when the limb is immobilized, such as post surgery. Isometric contractions are used with handheld dynamometry, discussed in Chapter 9. Prime Movers Within each chapter are tables indicating the muscles involved in the action that is tested e. When prime movers have been identified for a particular action, they are in boldface type.

For example, the prime mover of shoulder flexion is the anterior deltoid muscle and therefore this muscle is bolded. In other instances, there is no distinct prime mover and thus no bolding.

The movement of back extension, for example, involves a dozen muscles, none of which is a prime mover, and therefore there are no muscle names bolded. Our intent in highlighting the prime movers is to help the student more readily understand which muscles are critical for many important movements and to have a better understanding of which muscles to strengthen when weakness is present.

Summary From the foregoing discussion, it should be clear that manual muscle testing is an exacting clinical skill. Practice, practice, and more practice on a variety of patient types create the experience essential to building the skill to an acceptable level of clinical proficiency, to say nothing of clinical mastery.

Bohannon RW. Measuring knee extensor muscle strength. Am J Phys Med Rehabil. LeVeau BF. Williams and Lissner's Biomechanics of Human Motion. WB Saunders: Philadelphia; Soderberg GL.

Kinesiology: Application to Pathological Motion. Muscular strength as an index of response to therapy in childhood dermatomyositis. Arch Phys Med Rehabil. The effect of stabilization on isokinetic knee extension and flexion torque production. J Athlet Train. Bohannon RW, Corrigan D.

A broad range of forces is encompassed by the maximum manual muscle test grade of five. Percept Mot Skills. The ability of male and female clinicians to effectively test knee extension strength using manual muscle testing. J Orthop Sports Phys Ther. Sharrard WJW. Muscle recovery in poliomyelitis. J Bone Joint Surg Br. Motor evaluation in hemiplegia. Eur Neurol. Beasley WC. Normal and fair muscle systems: Quantitative standards for children 10 to 12 years of age. Influence of method on estimates of normal knee extensor force among normal and post-polio children.

Perry J. Gait Analysis: Normal and Pathological Function. Slack, Inc. Electromyographic analysis of four popular abdominal exercises. J Athl Train. Prediction of functional outcome by motor capability after spinal cord injury. Manual muscle strength testing of critically ill patients: feasibility and interobserver agreement.

Crit Care. Rhomboid muscle electromyography activity during 3 different manual muscle tests. Electromyographical analysis of selected lower extremity muscles during 5 unilateral weight-bearing exercises.

Core muscle activation during Swiss ball and traditional abdominal exercises. A brief history of MMT is described elsewhere in this text. MMT serves unique purposes that can vary according to the setting in which it is practiced. Although MMT is an essential and foundational skill in a therapist's examination techniques, it also has its limitations. Appreciating these limitations and learning how to compensate for them helps to make MMT as relevant nowadays as it was when first conceptualized during the polio era.

The Examiner and the Value of the Muscle Test The knowledge and skill of the examiner determine the accuracy and defensibility of a manual muscle test. In addition to knowing the muscle attachments, the examiner should be able to visualize the location of the tendon and its muscle in relationship to other tendons and muscles and other structures in the same area e.

Stabilization of the proximal segment of the joint being tested is achieved in several ways. These include patient position via body weight , the use of a firm surface for testing, patient muscle activation, manual fixation by the examiner, or external fixation such as with a belt. One such pitfall for the novice tester is to inaccurately assign a lower muscle grade when the patient could not successfully perform a test at a higher grade without actually testing in the position required for the lower grade.

For example, when testing trunk flexion, a patient just partially clears the scapula from the surface, with the hands resting lightly on the side of the head the position for the Grade 5 test , thus not earning a Grade 5. The good clinician never ignores a patient's comments and must be a good listener, not just to the patient's questions but also to the meaning of the words the patient uses.

This quality is an essential element of good communication and is the primary means of encouraging understanding and respect between therapist and patient. The patient is the best guide to a successful muscle test. Early Kendall Examination Accuracy in giving examinations depends primarily on the examiner's knowledge of the isolated and combined actions of muscles in individuals with normal muscles, as well as in those with weak or paralyzed muscles.

The fact that muscles act in combination permits substitution of a strong muscle for a weaker one. For accurate muscle examinations, no substitutions should be permitted; that is, the movement described as a test movement should be done without shifting the body or turning the part to allow other muscles to perform the movement for the weak or paralyzed group.

The only way to recognize substitution is to know normal function and realize the ease with which a normal muscle performs the exact test movement. Washington, DC: U. Government Printing Office; Influence of the Patient on the Test The intrusion of a living, breathing, feeling person into the testing situation may distort scoring for the unwary examiner.

There is a huge variability in maximum torque between such muscles, and the examiner must use care not to assign a grade that is inconsistent with muscle size and architecture. In this section, we will discuss some of the more common applications of MMT in various clinical and therapeutic settings, with emphasis on the specific challenges often seen in each. The reader should be aware that the examples provided here are not limited to these settings only. Acute Care Facilities Often patients seen in acute care facilities are either acutely ill or are seen postoperatively.

In the acutely ill patient, MMT may be used to assess the patient's mobility status to inform a discharge plan. A manual strength exam performed as part of a general assessment may provide information concerning the amount of assistance the patient requires and whether the patient will need an assistive device. Assessing the patient's strength to help ensure safe transfers from bed to chair, to a standing position, or on and off the toilet is an essential part of the acute-care patient management process.

Identifying painful muscles before asking a patient to do an activity, such as transfers, will save time in the long run and potential embarrassment. Strength assessment can take the form of active movement followed by resistance, such as in a manual muscle test or in a repetition maximum such as in a seated shoulder dip. Strength assessment in the postoperative patient informs the therapist of the integrity of the patient's nervous system.

The therapist may be the first person requiring the patient to move actively after surgery and thus may be the first one to observe the patient's ability to contract a muscle. Strength testing in this scenario might take the form of isometric contractions, especially if there are contraindications to joint movement, suspected postsurgical pain as in a newly repaired fractured hip, or in restricted range of motion such as in a total hip arthroplasty.

If testing is done in a manner that differs from the published directions, documentation should describe how the test was performed. Functional tests that might be useful in assessing the patient include gait speed, chair stand, timed transfer, or the timed up-and-go test see Chapter 8. Special considerations for the acute care setting may include the patient's rapid fluctuations in response to medications, illness, or pain.

Reassessment may be necessary when any changes in strength are documented along with therapist's insights into why the changes are occurring. Clearly, strength gains are not possible in the short time a typical patient is in acute care but rather should be attributed to increased confidence in moving, less pain, better understanding of the 65 movement to be performed, motor learning, and so forth.

Acute Rehabilitation Facilities Strength assessment in the acute rehabilitation setting may be performed as a baseline assessment to determine progress over time and to identify key impairments that affect the patient's mobilityrelated and other functional goals.

Knowledge of community-based norms for mobility such as chair stands, distance walked, stair climbing speed, floor transfer ability, and gait speed will inform the therapist's clinical decision-making. See Chapter 8 for a more complete description of these tests. As in the acute care setting, assessment of strength for mobility tasks is critical in the acute rehabilitation setting. Recognition of the importance of key muscle groups in specific mobility tasks, such as the plantar-flexors in gait speed, is key to informed clinical decision-making.

Special considerations for the acute rehabilitation setting often include rapid change over a short period. Positive changes may be attributed to increased comfort and less pain, less apprehension, neuroplasticity, and a change in medications.

Negative changes may be attributed to, for example, a decline in medical status, pain, or depression. Muscle fatigue resulting from an extended inpatient stay, poor fitness, and excessive sedentary behavior or general body fatigue related to frailty or postпїЅacute care implications may affect the perception of strength.

The patient may not be able to assume a proper test position because of postsurgical restrictions or a lack of range of motion, requiring the therapist to do a strength-screen rather than a strength test.

Although a screen may be appropriate, the screen cannot serve as an accurate baseline because of the lack of standardization. Functional testing may be more informative and accurate in these situations. The therapist should take special care to document any deviations from the standardized manual muscle test. Long-Term Care Facilities Strength testing and assessment approaches used in long-term care settings are similar to those used in acute rehabilitation. Strength assessment can serve as a baseline to identify key impairments that impact a patient's fall risk, mobility, and other functional goals as well as to determine the patient's progress over time.

Strength screening can be part of a required annual assessment for long-term residents. Strength in the form of a chair stand test or grip strength is a key component of the diagnosis of frailty and therefore can inform prognosis. Box 2. Based on these criteria, strength assessment and functional testing are essential in the examination and intervention of nursing home residents. Range of Motion Two-joint muscle. No specific range of motion can be assigned solely to the tensor.

Table 6. Muscle Tensor fasciae latae Origin Iliac crest outer lip Fasciae latae deep Anterior superior iliac spine lateral surface Insertion Iliotibial tract between its two layers, ending Function of the way down Hip flexion Hip internal medial rotation Others Gluteus medius Gluteus minimus The tensor fascia lata TFL helps to stabilize and steady the hip and knee joints by putting tension on the iliotibial band of fascia. It helps to maintain one foot in front of the other as in walking.

It is tiny muscle, inferior to the iliotibial band. If successful, place hand for resistance on lateral surface of the thigh just above the knee. Hand providing stabilization is placed on the crest of the ilium Fig. Resistance is given downward toward floor from the lateral surface of the distal femur. Don't let me push it down. Grade 4: Holds test position against strong to moderate resistance. Grade 3: Completes movement; holds test position but without resistance Fig.

Note: Fig. One hand supports the limb under the ankle; this hand will be used to reduce friction with the surface as the patient moves but should neither resist nor assist motion.

The other hand palpates the tensor fasciae latae on the proximal anterolateral thigh where it inserts into the iliotibial band. Grade 1 and Grade 0 Position of Patient: Long sitting. Instructions to Therapist: One hand palpates the insertion of the tensor at the lateral aspect of the knee.

The other hand palpates the tensor on the anterolateral thigh Fig. Grade 0: No discernable palpable contractile activity. The adductor longus may be more active during open chain activities than the adductor magnus. The adductor magnus is most active in weight-bearing tasks such as sit-to-stand and walking up stairs and during loading and initial contact phases of gait. Instructions to Therapist: Stand behind patient at knee level. Alternatively, the upper limb can be placed on a padded stool straddling the test limb and approximately 9 to 12 inches high not shown.

Ask the patient to lift the bottom leg to the uppermost one. If successful, place hand giving resistance on the medial surface of the distal femur of the lower limb, just proximal to the knee joint.

Resistance is directed straight downward toward the table Fig. Hold it. Don't let it drop! Grade 3: Completes full range; holds test position but without resistance Fig.

The non-test limb is positioned in some abduction to prevent interference with motion of the test limb. Instructions to Therapist: Stand at side of test limb at knee level. One hand supports the ankle and elevates it slightly from the table surface to decrease friction as the limb moves across the table Fig.

The therapist uses this hand neither to assist nor to resist motion. The opposite hand palpates the adductor mass on the inner aspect of the proximal thigh.

In the supine test position for Grades 2, 1, and 0, the weight of the opposite limb stabilizes the pelvis, so there is no need for manual stabilization of the non-test hip. Toes stay pointed toward the ceiling. Grade 1 and Grade 0 Position of Patient: Supine. Instructions to Therapist: Stand on side of test limb. One hand supports the limb under the ankle.

The other hand palpates the adductor mass on the proximal medial thigh Fig. Grade 0: No discernable palpable contraction. Substitution Hip flexor substitution: The patient may attempt to substitute the hip flexors for the adductors by internally rotating the hip Fig.

The patient will appear to be trying to turn supine from sidelying. Maintenance of true side-lying is necessary for an accurate test. When the hip is flexed, the adductors augment the other extensor muscles. Trunk may be supported by placing hands flat or fisted at sides of chair or table [Fig. Ask the patient to turn the leg in. If sufficient range is present, position leg in mid position between internal and external rotation.

Place the hand providing resistance on the medial aspect of the ankle just above the malleolus Fig. The other hand, which will offer counter-pressure, is contoured over the lateral aspect of the distal thigh just above the knee. Stabilization is provided in a medially directed force at the knee counteracting the resistance provided at the ankle.

The two forces are applied in counter-directions for this rotary motion see Fig. Grade 4: Holds test position in midrange against strong to moderate resistance. Grade 3: Able to complete full range of motion with mild to no resistance this is a gravity-eliminated position, so if the patient is able to exert mild resistance, grade the effort a 3 Fig. Care needs to be taken to ensure that gravity is not the predominant force. Test limb is in internal rotation. Instructions to Therapist: Stand at side of limb to be tested.

The therapist may need to support the limb in internal rotation because gravity tends to pull the limb into external rotation. Test: Patient externally rotates hip in available range of motion Fig.

One hand may be used to maintain pelvic alignment at lateral hip. As the hip rolls past the midline, minimal resistance can be offered to offset the assistance of gravity. Grade 1 and Grade 0 Position of Patient: Supine with test limb placed in internal rotation.

Test: Patient attempts to externally rotate hip. If there is any discernable movement contractile activity , a grade of 1 should be given; otherwise, a grade of 0 is assigned on the principle that whenever uncertainty exists, the lesser grade should be awarded. It is imperative therefore that a patient's accurate range in each test position be known before manual muscle testing takes place.

Muscles that are lengthened often test weak, which is why testing in the mid position between ER and IR is recommended. Lift the contralateral buttock off the table or lean in any direction to lift the pelvis; b. Increase flexion of the test knee; c. Abduct the test hip. Grade 5, Grade 4, Grade 3, and Grade 2 Position of Patient: Short sitting with thighs fully supported on table and legs hanging over the edge. Trunk may be supported by placing hands flat or fisted at sides.

Instructions to Therapist: Sit or kneel in front of patient. Ask the patient to move leg out, away from the other leg while maintaining hip stabilization. Place the hand providing resistance on the lateral surface of the ankle just above the malleolus Fig.

The other hand, which offers counter-pressure, is contoured over the medial surface of the distal thigh just above the knee. Stabilization is provided in a medially directed force at the knee counteracting the lateral resistance provided at the ankle.

Give resistance in a medially directed force at the ankle. Test limb in partial external rotation. Instructions to Therapist: Stand next to test leg. Palpate the gluteus medius proximal to the greater trochanter and the tensor fasciae latae Fig.

As the hip rolls inward past the midline, minimal resistance can be offered to offset the assistance of gravity. Grade 1 and Grade 0 Position of Patient: Patient supine with test limb placed in external rotation. Test: Patient attempts to internally rotate hip. One hand is used to palpate the gluteus medius over the posterolateral surface of the hip above the greater trochanter.

The other hand is used to palpate the tensor fasciae latae on the anterolateral surface of the hip below the ASIS. Grade 0: No discernable contractile activity. These motions contaminate the test by offering visual distortion to the therapist. Adduct the test hip. The hamstring muscles act as hip extensors and knee flexors during both stance and swing phase of sprinting, the most common mechanism of injury in track and field athletes.

They work eccentrically during the late stance phase of gait and during the late swing phase of overground running. The therapist should test first for the aggregate of the three hamstring muscles with the foot in midline. Only if there is deviation or asymmetry in the movement or a question in the therapist's mind is there a need to test the medial and lateral hamstrings separately.

The hamstrings are two joint muscles, and should be tested in mid-range. Hamstring Muscles in Aggregate Position of Patient: Prone with legs straight and toes hanging over the edge of the table.

A towel roll placed just above the knee may make this position more comfortable not shown in Figue 6. Instructions to Therapist: Stand next to limb to be tested. Ask the patient to flex the knee as far as possible. Observe possible tightness in the rectus femoris that may be indicated by limited knee flexion or the hip flexing.

Hand provides resistance on posterior surface of the leg just above the ankle Fig. The other hand provides stabilization over the hamstring tendons on the posterior thigh optional. Firm pressure with the stabilizing hand may offset any cramping of the hamstring muscles.

Resistance is applied in the direction of knee extension for Grades 5 and 4. Don't let me straighten it. Leg in internal rotation toes pointing toward midline. Instructions to Therapist: Therapist resists knee flexion at the ankle using a downward and outward force Figure 6. Leg is in external rotation toes pointing laterally. Instructions to Therapist: Therapist resists knee flexion at the ankle using a downward and inward force Fig. Grade 4 for All Three Tests: Holds test position against strong to moderate resistance.

Lower limb flexed for stability. One arm is used to cradle thigh, providing hand support at medial side of knee. Other hand supports the leg at the ankle just above the malleolus Fig. Limbs are straight with toes extending over end of table. Knee is partially flexed and supported at ankle by therapist. Instructions to Therapist: Stand next to test limb at knee level. Therapist shown on opposite side to avoid obscuring test position. One hand supports the flexed limb at the ankle Fig.

The opposite hand palpates both the medial and the lateral hamstring tendons just above the posterior knee. Grade 0: No discernable contraction of the muscles; tendons do not stand out. The buttock on the test side will rise as the hip flexes, and the patient may appear to roll slightly toward supine Fig. Similarly, if the semitendinosus and semimembranosus are the stronger components, the leg will internally rotate during knee flexion. This is the situation that, when observed, indicates asymmetry and the need to test the medial and lateral hamstrings separately.

Muscle Rectus femoris Vastus intermedius Origin Insertion Ilium anterior inferior iliac spine Acetabulum groove above Capsule of hip joint Aponeurosis anterior Aponeurosis posterior Patella base via quadriceps tendon Tibial tuberosity via ligamentum patellae Femur shaft, upper lateral and anterior surfaces Intermuscular septum lateral Vastus lateralis Vastus medialis longus two parts Vastus medialis oblique considered part of the vastus medialis see Fig.

None of the four muscle heads can be separated from any other by manual muscle testing. The rectus femoris may be partially isolated from the other quadriceps during a hip flexion test. The shorter the hamstrings, the greater the backward trunk lean in short sitting.

A combined force of 1. Place a towel roll under the patient's distal thigh for comfort. The patient's hands rest on the table on either side of the body for stability or may grasp the table edge. The patient should be allowed to lean backward slightly to relieve hamstring muscle tension. Do not allow the patient to hyperextend the knee because this may lock the knee into position, thus masking weakness. Ask the patient to straighten the knee. Place the palm of the hand providing resistance over the anterior surface of the distal leg just above the ankle, using a straight arm technique because of the potential strength of these muscles.

For Grades 5 and 4, resistance is applied in a downward direction toward the floor Fig. Don't let me bend it. The therapist should not be able to break the Grade 5 knee extensors. Lowermost limb may be flexed for stability. The hip should be in full extension. One arm cradles the test limb around the thigh with the hand supporting the underside of the knee Fig.

The other hand holds the leg just above the malleolus. The therapist supporting the limb provides neither assistance nor resistance to the patient's voluntary movement. Instructions to Therapist: Stand next to limb to be tested at knee level.

The therapist also may want to palpate the patellar tendon just below the knee Fig. No joint movement occurs. Substitution When the patient is side-lying as in the Grade 2 test , he or she may use the hip internal rotators to substitute for the quadriceps, thereby allowing the knee to fall into extension.

These tests have age- and sex-appropriate norms. The two ankle plantar flexors make up the triceps surae group. They differ in structure, anatomical position, function, and fiber-type characteristics.

The medial gastrocnemius is the larger of the two heads. This difference in fiber type makes the gastrocnemius more amenable to faster, more explosive movements while the soleus is more active during lower intensity and longer duration activities. The soleus is isolated by flexing the knee during heel rise Fig. Patient is likely to need external support; thus, fingers can be placed on the wall, above shoulder height.

Alternatively, no more than one or two fingers should be used on a table or other horizontal surface Fig. Demonstrate heel rise to patient. Then stand or sit with a lateral view of test limb to ascertain height of heel rise. Ask patient to lift heel while keeping knee straight. If patient can clear the floor by 2 inches, ask the patient to continue lifting the heel until the patient can no longer achieve 1 inch of rise.

This is when the test is terminated. Patient should not bear weight through arms. Lift your heel. Now down. Repeat this as many times as possible, lifting your heel as high as you can. Grading Grade 5: Patient successfully completes 25 heel rises through full range of motion without a rest between rises. However, a more recent study suggests that the average number of repetitions in the sample studied is less than 25 repetitions Table 6.

The criterion for Grade 4 is not well defined. Grade 3: Able to hold body weight once in a heel up position, but unable to raise body weight from neutral more than one time. If the patient cannot complete at least one correct full-range heel rise in the standing position, the grade must be less than 3.

Regardless of the force of resistance in a non-standing position for any reason, the patient must be given a grade of less than 3.

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