Manual Muscle Testing: A Method of Measuring Extremity Muscle Strength Applied to Critically Ill Patients

This procedure provides a simple, reliable, and inexpensive method to quantify muscle strength for patients during and after critical illness. First position the patient in a sitting position. Determine whether the test range of motion can be completed against gravity.

Then determine whether to provide resistance or change the patient's position to eliminate the force of gravity. Finally, provide resistance or palpate the muscle or tendon and assign a muscle strength grade. Ultimately, results can be obtained that quantify muscle strength through manual muscle testing.

The main advantages of manual muscle testing over existing methods such as isokinetic testing are that it is easily performed without additional equipment and can be administered in many settings, including the intensive care unit, outpatient clinics and patients'homes. Standardized manual muscle testing can be utilized in the diagnosis of ICU acquired weakness, provision of rehabilitation therapy services, and as an outcome measurement. In research studies, it can be reliably performed with appropriate training by both clinicians and non-clinician.

Grading of muscle strength follows the medical research council system. Test each muscle group bilaterally. First, ensure the patient is sitting upright and positioned to allow full movement of the joint against gravity.

For each muscle tested stand to the side being tested. Demonstrate the desired movement against gravity. Then request the patient to repeat the motion.

If the patient can move through the desired range of motion against gravity, apply resistance in the testing position while stating, hold it. Don't let me bend it. However, if the patient cannot move against gravity, reposition the patient to allow movement of the extremity with gravity eliminated.

If the patient cannot complete at least partial range of motion with gravity eliminated, observe the muscle or tendon and palpate for contraction. If necessary, shoulder MMT can be performed with central venous and dialysis catheters. To begin, demonstrate the test motion state, lift your arm out to the side to shoulder level.

Contour the hand giving resistance over the patient's arm just above the elbow with the other hand. Stabilize the shoulder above the shoulder joint. Now state hold it.

Don't let me push it down. Assess grades three, four, or five on the MMT scale. If weaker than grade three, position the patient to lie supine with arms at the side.

Now support the arm just above the elbow and at the wrist to assure that the shoulder does not externally rotate. Instruct the patient to try to move the arm out to the side. Assign grade two if the patient moves with gravity, eliminated if weaker than grade two.

Instruct the patient to try to move the arm out to the side and palpate the middle deltoid muscle for contraction and score as grade one or zero. In this test, supinate the patient's forearm, verbally instruct the patient to bend the elbow slightly more than 90 degrees. Contour the hand giving resistance over the flexor surface of the patient's forearm proximal to the wrist.

With the other hand. Apply counterforce by cupping the palm over the anterior superior aspect of the shoulder. Then state hold it.

Don't let me push it down. Note the MMT score if weaker than grade three. Abduct the shoulder to 90 degrees.

Support the arm under the elbow and if necessary, the wrist as well. Turn the forearm with the thumb facing the ceiling. Now instruct the patient to try to bend the elbow.

Grade two is assigned. If the patient can flex the elbow if weaker than grade two, supinate and position the forearm at the side in approximately 45 degrees of elbow flexion state. Try to bend your elbow.

Then palpate the biceps tendon and score as either grade one or zero. Position the patient's arm at the side with elbow flex to 90 degrees with the forearm pronated and the wrist extended verbally instruct the patient to bend the wrist up as far as possible. Now place the hand giving resistance over the back of the patient's hand just distal to the wrist.

Use the other hand to support the patient's forearm. Then state hold it. Don't let me push it down and score grades three, four, or five if weaker.

Then grade three. Flex the patient's elbow to 90 degrees and turn the forearm with thumb facing the ceiling while supporting the patient's forearm and wrist state. Bend your hand toward me.

Assign grade two if the patient can extend the wrist if weaker than grade two, state, bend your wrist toward me and palpate the two extensor tendons. One on each side of the wrist. Score as grade one or zero seat the patient with hands placed on the bed or table for stability.

Instruct the patient to raise the knee up as high as it will go. Now place a hand to give resistance on top of the patient's thigh just proximal to the knee with the other hand. Provide stability at the side of the hip.

Then state hold it. Don't let me push it down and score grades three, four, or five if weaker than grade three. Lay the patient down on the side not being tested.

Stand behind the patient with one arm cradling the leg being tested with the hand supporting under the knee. Use the opposite hand to maintain alignment of the trunk at the hip state to the patient. Bring your knee toward your chest.

Assign grade two if the patient can flex the hip if weaker than grade two. While the patient is supine. Point to the inner aspect of the hip joint and ask, may I touch your leg here with the patient's permission.

State, bend your hip and palpate the ilio sous tendon to score grade one or zero. Position the patient sitting upright with feet on the ground and instruct the patient to straighten the knee to zero degrees. Contour the hand giving resistance on top of the patient's leg just proximal to the ankle.

Place the other hand under the thigh above the knee. Then state hold it. Don't let me bend it.

And score grades three, four, or five if weaker than grade three. Lay the patient on the non-testing side. Stand behind the patient at knee level.

Allow the leg not being tested to flex for stability. Now with one arm cradle, the leg being tested around the thigh with the hand supporting the underside of the knee with the other hand. Hold the leg just above the ankle and state straighten your knee grade two is assigned.

If the patient can extend the knee if weaker than grade two while the patient is supine state, push the back of your knee down. Palpate the quadriceps tendon and score as grade one or zero for the bedridden patient. Position the patient in the same manner as for hip flexion and grade as described for knee extension.

Position the patient sitting with heel on floor and shoes and socks removed verbally instruct. Bend your foot up as far as possible. Confirm that the toes are relaxed during the test.

For resistance. Cup one hand over the top of the foot proximal to the toes. Contour the other hand around the front of the leg just proximal to the ankle.

Then state hold it. Don't let me push it down and score grade three, four or five if weaker than grade three, but visible partial range of motion against gravity. Then assign grade two if weaker than grade two.

Palpate the tibias anterior tendon and score as grade one or zero MMT Using this protocol has excellent interrater reliability when applied with both A RDS survivors and patients quality assurance of 19 trainees. Examining 12 muscle groups demonstrates an intraclass correlation coefficient of 0.99 agreement for detecting clinically significant weakness, demonstrated a CAPA of 1.00. This demonstration conveyed how to assess the strength of six muscle groups using manual muscle testing with the medical research counsel.

Scoring system manual muscle testing has value in critical care and rehabilitation settings to clinically evaluate ICU acquired weakness in both ICU patients and post ICU survivors.