lecture 1,INTRODUCTION TO MANUAL MUSCLE TESTING

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11/30/2010 RHS 221 1 Introduction to manual muscle testing Manual Muscle Testing RHS 221 Dr. Afaf Ahmed Shaheen

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A. VISUAL OBSERVATION

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What to look for: body posture muscle contour body proportions symmetrical or compensatory motion in functional activities * In order to do a proper assessment the body part being assessed must be exposed! (Clarkson, 2000)

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RHS 221 4 11/30/2010 B.PALPATION Examination by tactile sense – feel Palpation assesses: Bony and soft tissue contours Soft tissue consistency *Visual & palpatory assessment is important to locate bony landmarks for alignment of goniometers.

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RHS 221 5 11/30/2010 PALPATION CONT’D Palpation determines: 1. Presence or absence of muscle contraction therefore assessing strength 2. Locate structures in order to stabilize them to isolate joint movement. 3. To identify irregularities of bone and soft tissue. *All bodies are not alike thus the more you palpate the more proficient you become.

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RHS 221 6 11/30/2010 PALPATION CONT’D Palpation technique: patient must be comfortable keep patient warm body part well supported thus muscles are relaxed visual observation palpate with pads of index & middle finger - occasionally thumb finger nails must be short no sharp rings warm hands fingers are in direct contact with skin “not through clothing” use sensitive but firm touch palpate muscle & tendon by having patient isometrically contracts muscle against resistance followed by relaxation - palpate muscle & tendon during contraction & relaxation palpate tendons - fingers (index & middle) placed across long axis of tendon - roll across tendon (Clarkson, 2000)

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RHS 221 7 11/30/2010 SUPPORT PATIENT’S LIMB support the patients limb at its centre of gravity - near upper & middle 1/3 of segment all joints must be supported when lifting or moving the limb - don’t let a limb hang (Clarkson, 2000)

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RHS 221 8 11/30/2010 JOINT MOVEMENTS RANGE OF MOTION the amount of movement that occurs at a joint ACTIVE RANGE OF MOTION the amount of movement the patient voluntarily moves the body part through without any external assistance. PASSIVE RANGE OF MOTION the amount of movement that an external force (therapist) moves the body part through without any assistance from the patient

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RHS 221 9 11/30/2010 JOINT MOVEMENTS CONT’D In order to assess for ROM the therapist must have an understanding of the: Anatomy of the area involved The boney configuration of the joint The soft tissue in the area The movements that take place at the joint And the limiting factors of the joint (Clarkson, 2000)

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RHS 221 10 11/30/2010 ASSESSMENT CONTRAINDICATIONS AND PRECAUTIONS Active and Passive ROM Are Contraindicated: In a region where there is a recent dislocation or unhealed fracture. Immediately following surgery to tendons, ligaments, muscles, joint capsules or skin. When myositis ossificans is present.

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RHS 221 11 11/30/2010 Extra Care with AROM & PROM Infectious or inflammatory process in a joint Patient is on medication for pain or muscle relaxants Osteoporosis or fragile bones is a factor In assessing hyper mobile or subluxed joints Painful conditions Hemophilia Hematoma in the region especially in the elbow, hip or knee If bony ankylosis is suspected After an injury disrupting soft tissue (tendons, muscles or ligaments) In the region of a newly united fracture After prolonged immobilization of a part (Clarkson, 2000)

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RHS 221 12 11/30/2010 ASSESSMENT OF ACTIVE ROM Client performs AROM at affected joint & joints proximal and distal Therapist observes all joints separately, bilaterally and symmetrically

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RHS 221 13 11/30/2010 ASSESSMENT OF ACTIVE ROM CONT’D Provides info about: Patient’s willingness to move the joint. Coordination. Level of consciousness. Attention span. Joint ROM. Movements that cause or increase pain. Muscle strength. Ability to follow instructions. Ability to perform functional activities.

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RHS 221 14 11/30/2010 ASSESSMENT OF ACTIVE ROM CONT’D AROM maybe decreased due to: Restricted joint mobility. Muscle weakness. Pain. Inability to follow instructions. Unwillingness to move. (Clarkson, 2000)

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RHS 221 15 11/30/2010 ASSESSMENT OF PROM Determines: amount of movement at joint greater than AROM due to elastic stretch of muscle tissue and decreased bulk Perform PROM to: establish joints ROM determine quality of movement throughout ROM & end feel determine whether a capsule or noncapsular pattern is present presence of pain (Clarkson, 2000)

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RHS 221 16 11/30/2010 NORMAL LIMITING FACTORS & END FEELS unique anatomical structure of a joint determines the direction & magnitude of the joints ROM

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RHS 221 17 11/30/2010 NORMAL LIMITING FACTORS & END FEELS CONT’D Limiting Factors: Stretching of soft tissue Stretching of ligaments or joint capsule Apposition of soft tissue Bone contacting bone

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RHS 221 18 11/30/2010 NORMAL LIMITING FACTORS & END FEELS CONT’D End Feel: the sensation transmitted to the therapist’s hands at the extreme end of the passive ROM indicates the structures that limit the joint movement - may be normal (physiological) or abnormal (pathological) 1. Normal End Feel when full Rom & normal anatomy of joint stops movement 2. Abnormal End Feel decrease or increase in the ROM or normal ROM exists but other structures other than the normal anatomy stop joint movement

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RHS 221 19 11/30/2010 Normal End Feel Examples: Hard (bony) bone contacts bone hard abrupt stop painless e.g. Elbow extension

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RHS 221 20 11/30/2010 Normal End Feel Examples Cont’d Soft (soft tissue apposition) soft compression of tissue (muscle) e.g. Knee & elbow flexion

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RHS 221 21 11/30/2010 Normal End Feel Examples Cont’d Firm (soft tissue stretch) firm or springy sensation with slight give feeling depends on the thickness of the tissue - Achilles has stronger give to it than that of wrist flexion e.g. Dorsi flexion with extended knee (gastrocnemius)

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RHS 221 22 11/30/2010 Normal End Feel Examples Cont’d Firm (capsular stretch) hard arrest to movement with some give when joint capsule or ligament stretched like stretching leather e.g. Passive external rotation of shoulder

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RHS 221 23 11/30/2010 Abnormal (Pathologic) End Feels Hard An abrupt hard stop to movement when bone contacts bone, or a bony grating sensation, when rough articular surfaces pass over each other. Loose bodies, degenerative joint disease, dislocations, or a fracture. Soft Boggy sensation that indicates the presence of synovitis or soft tissue edema.

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RHS 221 24 11/30/2010 Abnormal (Pathologic) End Feels Cont’d Firm A springy sensation or a hard arrest to movements with some give, indicating muscular, capsular or ligamentous shortening. Springy Block A rebound is seen or felt and indicates the presences of an internal derangement. e.g. knee with a torn meniscus.

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RHS 221 25 11/30/2010 Abnormal (Pathologic) End Feels Cont’d Empty No sensation (end feel) before the end of passive ROM due to pain. This may be caused by: Extra-articular abscess a neoplasm (abnormal growth of tissue) acute bursitis joint inflammation fracture Spasm A hard sudden stop to passive movement that is often accompanied by pain is indicative of an acute or subacute arthritis, the presence of a severe active lesion or fracture. If pain is absent a spasm end feel may indicate a lesion of the CNS with resultant increase muscular tonus. (Clarkson, 2000)

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RHS 221 26 11/30/2010 End feel Activity Find 2 of each of the following end feels Hard (bony) Soft (soft tissue apposition) Firm (soft tissue stretch) Firm (capsular stretch)

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RHS 221 27 11/30/2010 ROM Instrumentation Universal Goniometer OB Goniometer Tape measure

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RHS 221 28 11/30/2010 ASSESSMENT PROCEDURE Passive Joint Range of Movement: Expose the area Explanation and instruction explain verbally or demonstrate by passively moving patient’s limb through test movement. Assessment of the normal ROM uninvolved side first involved side * if uninvolved side can’t be used - rely on past experience taking into account age, sex, dominance & occupation Measurement procedure: patient position trick movements or substitute stabilization measurement

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RHS 221 29 11/30/2010 Universal Goniometer Most common device used to measure joint angles or ROM 180-360 degree protractor One axis which joins two arms One stationary arm One moveable arm Size of goniometer is determined by size of the joint being assessed

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RHS 221 30 11/30/2010 Measurement Procedure- universal goniometer Goniometer placement: The goniometer should be placed lateral to the joint, just off the surface of the limb . Axis: The axis of the goniometer should be placed over the axis of movement of the joint Eg. Bony prominance Anatomical landmark

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RHS 221 31 11/30/2010 Goniometer Placement Cont’d: Stationary arm: lies parallel to the longitudinal axis of the fixed proximal joint segment and/or points toward a distant bony prominence Movable arm: lies parallel to the to the longitudinal axis of the moving distal joint segment and/or points toward a distant bony prominence

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RHS 221 32 11/30/2010 Measurement using the Goniometer: Have the client actively move through joint ROM. Therapist identifies end feel at the joint being measured. Therapist aligns goniometer appropriately for the joint to be measured. If able, the therapist moves client through the final few degrees of PROM. Therapist records goniometer measurement.

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RHS 221 33 11/30/2010 MANUAL MUSCLE TESTING Definition: A procedure for the evaluation of the function and strength of individual muscles and muscle groups based on effective performance of a movement in relation to the forces of gravity and manual resistance.

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RHS 221 34 11/30/2010 PREREQUISITES TO MANUAL MUSCLE TESTING: Knowledge of joint motion Origin and insertion of muscles Function of muscles and substitution patterns Ability to palpate the muscle or its tendon To distinguish between normal and atrophied contour Grading parameters

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RHS 221 35 11/30/2010 CONTRAINDICATIONS: (same as for ROM and PROM) Inflammation Pain Joint instability Increased tone-unreliable

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RHS 221 36 11/30/2010 EXTRA CARE MUST BE TAKEN: History of Cardiovascular problems Abdominal surgery or herniation of the abdominal wall In conditions where fatigue or overwork may be detrimental (MS)

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RHS 221 37 11/30/2010 DEFINITIONS: Muscle strength maximal amount of tension or force that a muscle or muscle group can voluntarily exert in one maximal effort, when type of muscle contraction, limb velocity, and joint angle are specified. Muscle endurance the ability of a muscle or a muscle group to perform repeated contractions, against a resistance, or maintain an isometric contraction for a period of time.

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RHS 221 38 11/30/2010 Range of muscle work the full range in which a muscle works refers to the muscle changing from a position of full stretch and contracting to a position of maximal shortening.

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RHS 221 39 11/30/2010 Outer range A position where the muscle is on full stretch to a position halfway through the full range. Inner range A position halfway through the full range to a position where the muscle is fully shortened. Middle range The portion of full range between the midpoint of the outer range and the mid point of the inner range.

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RHS 221 41 11/30/2010 Passive insufficiency ROM is limited by length of muscle e.g. Hamstrings.

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RHS 221 42 11/30/2010 Active insufficiency when a muscle crosses two or more joints it performs simultaneous actions at all the involved joints. The muscle is unable to produce effective tension at all joints = active insufficiency.

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RHS 221 43 11/30/2010 Muscle Contractions: Isometric (static) contraction tension developed within a muscle but the muscle does not change length. Isotonic contraction constant tension against a load of resistance. Concentric contraction tension developed within the muscle and the muscle shortens. Eccentric contraction tension developed within the muscle and the muscle lengthens.

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RHS 221 44 11/30/2010 FACTORS AFFECTING STRENGTH: Age Sex Type of muscle contraction Muscle size Speed of muscle contraction Previous training effect Joint position Length - Tension Relations Temperature Fatigue Motivation, level of pain, body type, occupation and dominance are other factors that may affect strength. (Clarkson, 2000)

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RHS 221 45 11/30/2010 JOINT POSITIONS Close-Packed Position joint surfaces are fully congruent and cannot be pulled apart - maximal tension in joint capsule and ligaments *Avoid close-packed position when muscle testing as joint can be locked into position in the presents of a weak prime mover.

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RHS 221 46 11/30/2010 JOINT POSITIONS CONT’D Loose-Packed Position joint surfaces are least congruent greatest laxity of capsule and ligament resting position of joint

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RHS 221 47 11/30/2010 TERMS USED IN MUSCLE TESTING: Prime movers Patient position: allows for function A.G. - movements upward in vertical plane G.E. - movements in the horizontal plane Stabilization Test Position and Test Movement

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RHS 221 48 11/30/2010 TERMS USED IN MUSCLE TESTING CONT’D Resistance Palpation Substitution Methods: a) Isometric Holdings: Force applied after the motion is completed during inner range. (combination isotonic-isometric resistance) b) Isotonic contraction: Resistance to the ongoing movement.***

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RHS 221 49 11/30/2010 TERMS USED IN MUSCLE TESTING CON’T Grading: Manual muscle grading is based on 3 factors a. The ability of the muscle or muscle group to move the part through a complete ROM: against gravity, gravity eliminated etc. b. The amount of manual resistance that can be given to a contracted muscle or muscle group. c. Evidence of the presence or absence of a contraction in a muscle or muscle group.

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RHS 221 51 11/30/2010 MMT - CONVENTIONAL GRADING 5 (Normal): full ROM against gravity with maximum resistance 4 (Good): full ROM against gravity with moderate resistance 3 (Fair): ROM against gravity with no resistance 2 (Poor): full ROM with gravity eliminated 1 (Trace): No ROM - palpable or observable flicker (Evidence of slight contractility) 0 (Zero): No palpable or visible flicker

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RHS 221 52 11/30/2010 MMT - CONVENTIONAL GRADING Cont’d 5 AG full ROM with maximum resistance 4 AG full ROM with moderate resistance 4- AG greater than ½ ROM with moderate resistance 3+AG less than ½ ROM with minimum resistance 3 AG full ROM with no resistance 3- AG greater than ½ ROM 2+ AG less than ½ ROM 2 GE full ROM 2- GE greater than ½ ROM 1+ GE less than ½ ROM 1 No ROM - palpable or observable flicker 0 No palpable or visible flicker

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RHS 221 53 11/30/2010 MMT - CONVENTIONAL GRADING hands and feet (No AG or GE positions) 5 - Full ROM with maximum resistance 4 - Full ROM with moderate resistance 3 - Full ROM with no resistance 2 - Part of available ROM 1 - No ROM - palpable or observable flicker 0 - No palpable or visible flicker

Summary: Muscle testing,RHS,221

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