MMT: Evaluation of strength based on the relationship between gravity and manual resistance in the available ROM for that joint.

2 Schools:

1.) Kendall (0-10 scale).

2.) Daniels & Worthingham (0-5 scale).

Break Test: Apply manual resistance until the PT overpowers the patient.

• An eccentric contraction begins.

• Force applied until the muscle “breaks” (gives way).

• The resistance should be slow and gradual.

• Resistance should slightly exceed the muscle’s force generation.

• Ramp up strength over 2-3 seconds to max intensity.

Make Test: Apply manual resistance while the patient moves through the ROM.

• Concentric contraction against maximal resistance.

• Highly skilled test that is NOT as reliable as the Break test.

Weakness:

• Move body parts in a gravity-minimized plane.

• During MMT stabilize at the proximal segment to avoid substituion.

Grading Scale:

In gravity-minimized position:

• Zero: 0/5: No muscle contraction.

• Trace: 1/5: Muscle contracts but not moving through ROM.

• Poor: 2/5: Muscle moves through full ROM in gravity-minimized position.

In Gold-Standard Position:

• Fair: 3/5: Can tolerate no resistance other than the weight of available ROM.

• Good: 4/5: Muscles can tolerate resistance but yield/give way against maximal resistance, but can tolerate moderate resistance.

• Normal: 5/5: Muscle remains in position against maximal resistance.

• Ordinal scale where order matters, we know that 5/5 is more than 3/5 but they are NOT related.

Statistics:

• Intratester reliability of MMT: Good for trained PTs.

• Intertester reliability of MMT: varies more widely.

Order of Operations:

1.) Observe the muscle bulk.

2.) Position the patient and the joint.

3.) Check AROM.

4.) Give clear instructions.

5.) Demonstrate the movement.

6.) Test the uninvolved.

• Always start with a grade of 3/5 (able to resist against gravity).

• Evaluate your audience: kids under the age of 7 may not be able to follow directions OR dementia patients may not understand the instructions.

• If the patient cannot move through their normal AROM first, then PROM with minimal discrepancy would automatically be less than 3/5 (move into modified position).

Contraindications to MMT:

• Risk: Subluxation, Dislocation, Fracture.

• If motion causes further damage:

  • RA inflammation.

  • Acute surgery.

  • Acute injury.

• If muscle fatigue would exacerbate the patient’s current condition (MS, ALS).

Precautions to MMT:

• Muscle relaxers or pain medications.

• Post-op.

• Valsalva maneuver: cardiovascular issues, following eye surgery, IV disc injury, hernias of the abdominal wall.

Sensory Testing:

• Pressure: light, sharp, dull, discriminate.

• Temperature.

• Vibration: tactile information in relation to injury.

Semmes Weinstein Monofilament: Asses light touch sensation, compression neuropathy.

Green: Normal

Blue: Residual texture

Purple: Residual protective sensation

Red: Loss of protective sensation.

Used to help diagnose conditions such as:

• Diabetic neuropathy

• Peripheral nerve injury

• Carpal tunnel

How to use them:

1.) Demo on the uninvolved side first (for comparison).

2.) Support the testing body part.

3.) Vision occluded.

4.) Progress from the thinnest to thickest until correctly perceives 3 touches of one level

• Apply perpendicular to the skin until the monofilament bends.

• Apply it slowly.

• Hold for 1.5 seconds then lift slowly.

• Patient reports feelings.

5.) Begin distally and move proximally.

6.) Record sensation.

Two-Point Discrimination: How sensitive an area is.

• Very discriminating: fingers, hands, face.

  • Nerve endings are close together, so this indicates injury to areas.

• Less discriminating: back, other thighs.

  • May only have one nerve providing sensation to one area.

How to test:

• Body parts relaxed and supported.

• Apply a 2-point esthesiometer until the skin blanches.

• Allow the patient to distinguish between one or two prongs.

• Record the smallest distance perceived as two separate points.

• (+) test = inability to detect a distance of 6mm or more.

Vibration: Tuning Fork (128 or 256 Hz).

Vibrations sense/neuropathy.

Rudimentary and quick screen for bone injury:

• Bone bruise.

• Fracture (128 Hz).

• Stress fracture (256 Hz).

• Looking for pain in the area where the bone was hit.