MMT

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MANUAL MUSCLE TESTING

Course objectives:
After completing this session, the students should be able to
1. Recite the origin, insertion, nerve innervation, and action of the skeletal muscles in each joint;
2. Demonstrate the ability to correctly grade muscle strength with adequate techniques; and
3. Demonstrate the ability to record and explain the result and procedure of manual muscle testing.

Evaluation:
Quiz 【參照 textbook 肌肉編號】
9/13: hip and knee joint muscles 【174-202】
9/16: foot and ankle, scapula and shoulder muscles 【124-139; 203- 225】
9/23: U/E except scapula and shoulder muscles 【140-173】
9/27: trunk muscles (cervical to lumbar) 【56-123】
9/30: facial muscles 【1-55】

Midterm examination (writing exam and practicum)

Textbook: Hislop HJ, Avers D, and Brown M (2018). Daniels and Worthingham’s Muscle Testing:
Techniques of Manual Examination. 10th Edition. St. Louis, USA, Elsevier Inc..

Practicum

選擇一位有周邊神經或顏面神經損傷之病人，或其他原因造成肌力下降情形之病患，簡
述受測者病史、診斷、以及肌力檢查結果。

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WHAT IS MUSCLE TESTING

1. Components
a. muscle length
b. muscle strength
c. functional performance
2. Aims
a. Diagnosis
b. Prognosis
c. Guide and evaluation of treatment program
3. Types of muscle strength testing
a. Quantitative: dynamometer, isokinetic machine (Cybex, KINCOM) etc.
b. Qualitative: MMT, manual muscle testing
4. Comparisons of different testing methods
a. Subjective vs. objective
b. Type of muscle contraction
c. Simple vs. complex
d. Cost and availability

HISTORY – DEVELOPMENT OF MANUAL MUSCLE TESTING

 Ms. Wihelmine Wright and Dr. Robert W. Lovett were the originators of the muscle
testing system that incorporated the effect of gravity.

1912 Ms. Wright --- first used MMT at Dr. Lovett’s office; first publication of MMT
1917 Dr. Lovett --- method of grading muscle strength established (a scale of 0 to 6)
1925 Stewart HS --- a resistance-based grading system: maximum resistance for a normal
muscle; completing of the motion against gravity with no other resistance for a grade of
Fair.
1927 Dr. CL Lowman --- another numerical scale in muscle testing; his system covered the
effects of gravity and the full ROM on all joints and was particularly helpful for assessing
extreme weakness.
1931 Signe Brunnstrom & Marjorie Dennen --- a system of grading movement rather than
individual muscles
1932 Legg and Janet Merrill --- a comprehensive system of muscle testing; muscles were
graded on a scale of 0 to 5, and a “+” or “-“ to all grades except 1 and 0.
1936 Henry and Florence Kendall --- organize muscle testing with sound and documented
kinesiologic procedures.

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 Lucille Daniels, Marian Williams, and Catherine Worthingham: 1 st edition published in

1946 --- a comprehensive handbook and easy to use.
 The Kendalls --- first book published in 1949; earlier, the Kendalls had developed a
percentage system ranging from 0 to 100 to express muscle grades as a reflection of
normal; later they reduced the emphasis on this scale; however, in the latest edition (1993),
this idea was returned (0-10 scale).
 Famous example of using MMT --- polio
 Current trend --- establishing norms of muscular strength and function (e.g. Willis
Beasley, Marian Williams, Helen J Hislop etc.)
 People who can be tested by manual muscle testing
Normal persons
People with weakness and paralysis
 Cautions: to people with disturbance of the higher neural centers (may be interfered
abnormal sensation or disturbed tone or motor control).

MANUAL MUSCLE TESTING

 Art and Science
 Knowledge, skill and experience

Consideration
 Test - movement
 Individual muscle vs. muscle groups
 Prime movers vs. accessory muscles
 Agonist(s) vs. antagonist(s)
 Single joint muscle vs. multi-joint muscle

PRINCIPLES OF MANUAL MUSCLE TESTING

Patient: disease condition / testing position

Muscle action
With/without gravity
Comfort and safety of the patient
The therapist’s body mechanics

Stabilization
Hand position

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Do NOT grasp or press on the muscles to be tested

Test movement
1. To complete available end range or to hold the limb/body segment at the optimal position
for testing based on muscle length-tension relationship.
2. The therapist sometimes moves the limb/body segment to the testing position and asks the
patient to hold it.

Pressure and resistance

A break test: at the end of the available range, or at a point in the range where the muscle is
most challenged, the patient is asked to hold the part at that point and not allow the examiner to
“break” the hold with manual resistance.
 When? After a body segment completed its range of movement or after it has been placed at end
range by the examiner. For one-joint muscles, the application of resistance is at the end of the
range; for two-joint muscles the point of maximum resistance is generally at or near midrange.
 Where? Distal end to the muscle insertion or to the joint to be tested. Exceptions: hip abductors,
scapular muscles.
 How? In the direction of the “line of pull”, opposite to the contraction.
 How much? To “break” the hold, gradual and not to be jerky.

Grading system

5 point score Qualitative score 10 point score

5 Normal (N) 10
4+ G+ 9
4 Good (G) 8
4- G- 7
3+ F+ 6
3 Fair (F) 5
3- F- 4
2+ P+ 3
2 Poor (P) 2
2- P- 1
1 Trace activity (T) T
0 Zero (no activity) (0) 0
Criteria for assigning a muscle testing grade
 Normal (grade 5): full ROM, against gravity, against maximum resistance
 Good (grade 4): full ROM, against gravity, “gives” or “yields” to some extent at the end of
its range with its maximum resistance (>50% of the pool of motor neurons to a muscle group
were gone).
 Fair (grade 3): full ROM, against gravity, no resistance (85% of the innervating neurons
were gone); functional threshold.

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 Fair + (grade 3+): full ROM against gravity, mild resistance

 Poor (grade 2): full ROM in gravity-minimized position.
 Poor + (grade2+): for plantar flexors only, given when complete partial heel rise in
weightbearing position, or complete full available range in non-weightbearing position with
maximum resistance.
 Poor – (grade 2-): partial ROM in gravity-minimized position.
 Trace (grade 1): visualization or palpation of contractile activity.
 Zero (grade0): completely quiescent on palpation or visual inspection.

Special considerations
 Substitution of movement
 Available ROM (contracture, shortness / tightness, active / passive insufficiency): when
any condition limits joint range of motion, the patient can perform only within the range
available. In this circumstance, the available range is the full range of motion for that
patient at that time.
 Neuromuscular condition: muscle tone, etc.
 Neurological condition: cognition, etc.

Factors influencing the results of MMT

 From examiner
1. Background knowledge regarding the anatomical features and functions of the testing muscles
2. Familiarity with the testing procedures (positioning, stabilization etc)
3. Ability to identify patterns of substitution
4. Ability to detect contractile activity
5. Awareness of any deviation from normal values of ROM
6. Ability to identify muscles with the same innervation
7. Knowledge of the relationship of the diagnosis to the sequence and extent of the test.
8. Ability to modify test procedure when necessary
9. Knowledge of the effects of fatigue, sensory loss etc on the testing
10. When testing patients with open wound, gloves may blunt the palpation skills.
 From patients
1. Willingness
2. Understanding of the test requirements
3. Lassitude and depression of the patient
4. Pain, fatigue etc

Screening tests
Observation of gait, position changes, walking on the toes, gripping force, body symmetry, etc.

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