Manual Muscle Testing Videos

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Manual Muscle Testing Grading System. Grading Scale Range: 0 to 5: 0: None: No visible or palpable contraction: 1: Trace: Visible or palpable contraction with no motion ( a 1 ) 2: Poor: Full ROM gravity eliminated: 3: Fair: Full ROM against gravity 4: Good. Manual muscle testing is used in rehabilitation and recovery to evaluate contractile units, including muscles and tendons, and their ability to generate forces. When used as part of rehabilitation, muscle testing is an important evaluative tool to assess impairments and deficits in muscle performance, including strength, power, or endurance.

Int J Chron Obstruct Pulmon Dis. 2016; 11: 1949–1956.
Published online 2016 Aug 18. doi: 10.2147/COPD.S111634
PMID: 27574419
This article has been cited by other articles in PMC.

Abstract

The respiratory diaphragm is the most important muscle for breathing. It contributes to various processes such as expectoration, vomiting, swallowing, urination, and defecation. It facilitates the venous and lymphatic return and helps viscera located above and below the diaphragm to work properly. Its activity is fundamental in the maintenance of posture and body position changes. It can affect the pain perception and emotional state. Many authors reported on diaphragmatic training by using special instruments, whereas only a few studies focused on manual therapy approaches. To the knowledge of the authors, the existing scientific literature does not exhaustively examines the manual evaluation of the diaphragm in its different portions. A complete evaluation of the diaphragm is mandatory for several professional subjects, such as physiotherapists, osteopaths, and chiropractors not only to elaborate a treatment strategy but also to obtain information on the validity of the training performed on the patient. This article aims to describe a strategy of manual evaluation of the diaphragm, with particular attention to anatomical fundamentals, in order to stimulate further research on this less explored field.

Keywords: diaphragm, osteopathic evaluation, manual therapy, chiropractic, physiotherapy

Introduction

Breathing is a systemic act, involving the whole body, the viscera, the nervous system, and emotions. The diaphragm muscle is the main breathing muscle, influencing with its contractions the respiratory activity. The diaphragm collaborates to various processes such as expectoration, vomiting, swallowing, urination, and defecation. It facilitates the venous and lymphatic return and helps the viscera above and below the diaphragm to work properly. Diaphragm’s activity is fundamental in the maintenance of posture and body position changes and influences the pain perception, usually decreased during the inspiratory apnoea., Diaphragmatic movements also change the body pressure, as it facilitates the venous and lymphatic return. This pressure modulation influences the blood redistribution, which could be probably correlated with the response of baroreceptors and the reduction of pain perception, although there are not scientific studies supporting this hypothesis yet.

The most important stimulus for the respiratory acts is provided by chemoreceptors, whose task is to maintain the biochemical balance of the body. Breathing is also influenced by internal and external conditions, with other ways of neural stimulation beyond the chemoreceptorial stimulation. The diaphragmatic activity is not only controlled by metabolic mechanism but also by emotional states such as sadness, fear, anxiety, and anger. Breathing stimulates mechanoreceptors of the diaphragm and the visceroceptors of viscera (moving during the respiratory acts), constituting the mechanism of interoception. Interoception is the awareness of the body condition obtained from information coming directly from the body itself. Diaphragmatic movements also stimulate the skin and the mediastinum; this complex of afferent information determines the central representation of breathing. The amygdala, which is part of the limbic system, is reciprocally connected to each of the respiratory areas, just as the medulla oblongata, and is considered the most important area that manages emotive breathing. A respiratory disorder certainly alters the emotional framework, such as depression and anxiety, as well as the emotional state can negatively affect the respiratory activity.

In case of systemic disease, the diaphragm is always involved, negatively contributing to the set of symptoms. In chronic heart failure, the diaphragm is weaker, more commonly placed in expiratory state, with more frequent movements.,

The pathological changes are seen in patients with chronic obstructive pulmonary disease (COPD).

The progressive limitation of the airflow in COPD patients causes a pathological adaptation of the diaphragm, although the reasons for these changes are not fully clear. These changes in position adversely affect the exercise tolerance; more in detail, the dome of the diaphragm is lowered, in inspiratory position. The contractile force is decreased, with electrical and metabolic alterations. The muscle thickness is increased, especially on the left side, with decreased mechanical excursion, probably due to fibers’ shortening., A decrease of anaerobic type fibers (type II) and an increase in aerobic fibers (type I) are observed; this process progressively increases with the pathology worsening. The increase in the oxidative process, however, does not correspond to an improvement of the diaphragmatic function. The rate of detectable myosin decreases, resulting in altered sarcomeric organization and further decreasing of the contractile strength. The phrenic activity is abnormal, presumably due to the nerve stretching caused by the chronic lowering of the diaphragm, resulting in such a neuropathy. The exercise intolerance in patients with congestive heart failure and COPD does not correlate with the common functional indexes (ejection frequency and forced expiratory volume in 1 second); rather it is the peripheral muscle adaptation, including that of the diaphragm, to have a heavy influence on the symptomatic scenario.,

As mentioned in the article, the diaphragm influences the patient’s emotional state. In patients with COPD, the incidence of depression varies from 8% to 80%, according to different studies. Depression may be considered a predictor of mortality during hospitalization for acute respiratory events. Depression and anxiety negatively affect the rehospitalization, but only 33% of patients are treated with a pharmacological process taking into account these psychiatric symptoms. Depression affects the physical status of the patient, as demonstrated by some authors who observed a worsening in the test of Cooper (12 minutes run) and an increased mortality rate. Anyway, there are not enough data exhaustively explaining this correlation. The copresence of depression and anxiety in patients with COPD increases the mortality rate (of 83% according to some authors)., The incidence of depression/anxiety increases with COPD worsening., Even in this case, the exact mechanisms leading to this correlation are unclear; probably the presence of dyspnea, systemic inflammation, and the effects on the brain system derived from the smoking cessation are involved. Anyway, improving respiratory function improves psychiatric symptoms, with exercise and manual therapy.,

To the knowledge of the authors, the existing scientific literature does not exhaustively examines the manual evaluation of the diaphragm in its different portions. A complete evaluation of the diaphragm is mandatory for several professional subjects, such as physiotherapists, osteopaths, and chiropractors not only to elaborate a treatment strategy but also to obtain information on the validity of the training performed on the patient. This article aims to describe a hypothesis of manual evaluation of the diaphragm, with particular attention to anatomical fundamentals, in order to stimulate further research on this less explored field.

Anatomy of the diaphragm: origin and insertion

An accurate knowledge of the anatomy of diaphragm is necessary in order to perform a proper manual evaluation of the muscle, with particular focus on hands’ positioning.

According to its insertions, the diaphragm can be divided in costal, lumbar, and sternal portions. The sternal part arises with two small fiber bundles from the posterior aspect of the xiphoid process, near to the apex; the costal (or lateral) portion arises from the inner and superior aspect of the last six ribs, with interdigitation with the transverse muscle of the abdomen. The lumbar portions arises from the medial, intermediate, and lateral ligaments of the diaphragm. The medial ligaments, before reaching the vertebral bodies, delimitate with their internal muscular bundles, at the level of D11, the esophageal hiatus for the passage of the esophagus and vagus nerves. The right medial ligament, thicker and longer than the left one, terminates in a flattened tendon on the anterior aspect of L2–L3 (sometimes up to L4). Laterally to the right ligament, there is a small ligament (called accessory or intermediate), whose tendon is inserted at the level of L1–L2. Between this ligament and the right medial one, there is a vertical split crossed by the large splanchnic nerve and the medial root of the azygos vein. The left medial ligament ends with a flattened tendon between L2 and L3; even in this case an accessory ligament is present, forming a split for the large splanchnic nerve and the medial root of hemiazygos vein. The tendons of these two ligaments constitute, at the level of D12, a tendinous arch (called the median arcuate ligament), through which the aorta and the thoracic duct cross the diaphragm. The lateral ligaments arise in the form of two thick tendons at the level of the arch of the psoas muscle, constituting the medial arcuate ligament; the latter passes above the psoas muscle, joining the vertebral body of L1 and its transverse apophyses, and more laterally, above the quadrates lumborum muscle, joining the transverse process of L1 and the apex of the 12° rib, forming the lateral arcuate ligament.

The respiratory diaphragm muscle is innervated by the phrenic nerve (C3–C5) and the vagus nerve (cranial nerve X); the first receives pulses from groups of medullary neurons of the pre-Bötzinger complex and from neurons of the parafacial retrotrapezoid complex (correlated in turn with the retroambiguus nucleus of the medulla); however, it is worth to mention that these connections are still unclear. The vagus nerve is part of the parasympathetic autonomic system, originating from the ambiguus nucleus of the medulla.

The normal position of the diaphragm can be seen in the chest X-ray. On the anterior–posterior projection, the dome of the right hemidiaphragm is located at the level of 5°–6° rib for what regard the anterior part, whereas the posterior one usually lies at the level of the 10° rib. The left hemidiaphragm is slightly higher (about one intercostal space). In 10% of people, both domes have the same height, becoming difficult to be differentiated in the lateral projection. Computed tomography and magnetic resonance imaging are also useful in the morphological evaluation of the diaphragm, even though they are used in second analysis, due to their costs and availability. Fluoroscopy and ultrasounds are techniques employed for the real-time evaluation of the moving diaphragm, even though affected by visibility limitations. In most cases, the diaphragm shows a symmetrical respiratory excursion of ~2–10 cm, not related to the vital capacity of the lungs. The ribs open out laterally in caudal direction during inspiration, and the opposite during expiration. By aging, the diaphragm becomes thinner and more frequently located in expiratory position, especially in males.

Physiotherapy and diaphragm

In literature, there are many physiotherapeutic approaches based on diaphragm’s adaptability. The resistance training in anaerobic regimen, or other training programs in aerobic regimen, with different devices, can be used with increased diaphragm performance in patients affected by respiratory diseases.,

The respiratory rehabilitation improves the diaphragmatic motion in both sides (using fluoroscopy imaging) in COPD patients and improves the performance, structural, and metabolic characteristics of the respiratory muscle (muscle strength [PI {max}, cm H2O]), endurance (inspiratory threshold loading, kPa), exercise capacity (Borg scale for respiratory effort, modified Borg scale, work rate maximum, W), dyspnea (transition dyspnea index).–

Several tools such as bikes or cycle ergometers for the upper limbs, or breathing stimulators (with different resistances to be overcome during the inspiration), are usually employed. Diaphragm training (with the aim to improve lung capacity) is also used in other pathologic scenarios, such as in patients who have undergone sternotomy for cardiac surgery, and in patients affected by stroke., Diaphragm training also improves other symptoms, such as those cause by gastroesophageal reflux, and improves muscle proprioception of the lumbar–sacral region.,

Currently, the literature shows that there are no significant differences in the rehabilitation results of the physical therapy in patients with COPD, in terms of comparison between the use of endurance and resistance training.–

Manual therapy and diaphragm

A few studies examined the manual evaluation of the diaphragm; although a review of the literature was not among the aims of this paper, some short texts on the topic need to be mentioned.

Potential therapeutic approaches involving the diaphragm muscle have been proposed among gentle myofascial release techniques, in the context of the therapeutic techniques addressed to other diaphragms of the human body., The myofascial technique is the application of a low load, long duration, stretch into the myofascial complex, with the aim to restore the optimal length of this complex. The operator palpates the fascial restriction and the pressure is applied directly to the skin, into the direction of the restriction, until resistance (the tissue barrier) is manually perceived. Once found, the collagenous barrier is engaged for a few minutes, without sliding over the skin or forcing the tissue, until the band starts to yield the complex and a sensation of softening is achieved.

Other types of manual (osteopathic) techniques employ myofascial approaches, in particular by placing the hands under the chondrocostal junctions, inducing and facilitating respiratory acts., The same techniques are also used in other fields, such as to improve the symptoms of gastroesophageal reflux, and to alleviate somatic symptoms in pregnant women.,

There are several studies evaluating the effects of the manual therapy in COPD. The approach to the patient varies widely, both in terms of techniques and time management: thoracic spinal mobilization, lymphatic drainage or pump, diaphragmatic release trigger points, massage, articulation techniques for ribs, myofascial release to the thoracic outlet, suboccipital decompression, and muscular stretching., The results of the various respiratory parameters are always positive, but we have not enough information to draw definitive conclusions.

Only recently, physiotherapy and manual therapy have been used together in the treatment of patients with COPD. A previous study aims to assess the effect of these two therapeutic strategies, showing that the combination of rehabilitation and osteopathy led to better results in comparison with the single approach (increase in forced expiratory volume in 1 second, 6-minute walk test, decrease in residual volume).

A recent study on COPD patients shows that many parameters (mobility, exercise capacity, maximal respiratory pressure, and vital capacity) are improved by working the anterior chondrocostal arch with manual diaphragm release technique.

We need to find the correct technique to manually evaluate the diaphragm, in order to improve the complementary use of the usual rehabilitation and manual therapy.

Proposal of a manual evaluation technique for the diaphragm muscle

Testing

The technique for the manual evaluation of the diaphragm proposed in the present article arises from the growing need to combine physiotherapy with manual therapy, considering the new clinical data.

It is well known that, in patients with COPD or congestive heart failure, the diaphragm has a specific preferred position, which can be measured with different clinical tools. According to a recent study, human touch can distinguish any slight variation, measurable in microns.

Manual Muscle Testing Videos

We can strongly speculate on the possibility to train the therapist, in terms of palpation technique, to check the mobility and function of the inspiratory muscle, in order to obtain additional clinical information on the therapeutic approach, before and after the physiotherapy (as usually happens for doctors in osteopathy).42

This manual evaluation is based on the experience of authors, consisting in >20 years of clinical practice with patients affected by respiratory and cardiac diseases; the proposed method for COPD patients obviously need to be deepened with further studies. It is important to remember that, as for many other therapeutic techniques, whether manual or otherwise, scientific proof is not available for every existing treatment, this does not mean that, in absence of scientific evidence, something is not valid; otherwise there would not be new treatments or any improvement in rehabilitative practice. In this regard, we wish to recall that the evidence-based medicine, originated in the second half of the 19th century, is based on the individual clinical expertise, best external evidence, patient values, and expectations:

External clinical evidence can inform, but can never replace, individual clinical expertise, and it is this expertise that decides whether the external evidence applies to the individual patient at all and, if so, how it should be integrated into a clinical decision.

There are no previous papers dealing with a comprehensive evaluation of the diaphragm through manual approach, and a description of techniques to be performed to evaluate this muscle in all its portions is currently missing. We do not have complete data on what happens in the different anatomical areas of the diaphragm in patients with respiratory disease; this text could be used as a guideline for researchers for further evaluation.

The patient is supine, in comfortable position. The first step deals with the assessment of the costal movement; this should consist of lateralization during inspiration, with a caudal direction, and the opposite during expiration. In case of dysfunction of the diaphragm, this costal movement is usually limited.45 The hands must be gently hold on the lateral sides of the costal margins, in order to have a palpatory feedback of the costal behavior during breathing (Figure 1).

The hands must be gently placed on the lateral sides of the costal margins to receive palpation feedback of the costal behavior during breathing.

In the following evaluation, respecting the previously described anatomy, the hands can be hold on the costal margins, anteriorly, with the thumbs being at the margin’s level and the other fingers lying on the upper ribs. Since the diaphragm muscle is lowered during inspiration, and then rises during expiration, this manual position can be used to assess the diaphragmatic excursion (Figure 2).,

The hands can be held anteriorly on the costal margins, with the thumbs being at the level of the margins and the other fingers placed across the upper ribs. This manual position can be used to assess the diaphragmatic excursion.

The following manual positions deal with the evaluation of the various portions of the diaphragm: domes, posterolateral area, xyphocostal area, medial ligament, and lateral ligament.

To evaluate the diaphragmatic domes, the operator’s forearm has to be hold parallel to the abdomen of the patient, with the thenar and hypothenar eminences of the hand at the level of the anterior margin of the costal arch; a gentle push must be performed in cranial direction, so as to record the elastic response of the tissue, for the right side as well as for the left one (Figure 3). As usually observed in manual tests, the elasticity of the tissue is reduced when a reduced movement is obtained in response to the applied stimulus.42

To evaluate the diaphragmatic domes, the operator’s forearm has to be held parallel to the abdomen of the patient, with the thenar and hypothenar eminences of the hand at the level of the anterior margin of the costal arch; a gentle push must be performed in the cranial direction, so as to record the elastic response of the tissue, for both right and let sides.

To evaluate the posterolateral area, the hand must be hold as previously described for the domes, but with the forearm forming an angle of 45° with the patient’s abdomen; a gentle push must be applied obliquely, following the line of the same forearm (Figure 4). This step needs to be repeated for the other side also. This portion of the diaphragm shows higher movement excursion during the respiration and has a more vertical inclination in comparison with the domes.

To evaluate the posterolateral area, the hand must be held as previously described for the domes, but with the forearm forming a 45° angle with the patient’s abdomen; a gentle push must be applied obliquely, following the line of the same forearm.

The evaluation of the xyphoid-costal area is used to assess whether, during inspiration and expiration, there is regular elasticity of the tissue, which is necessary for normal breathing; in fact, this area is usually more rigid in case of abnormal diaphragmatic activity.45 The hand and the forearm are positioned as in the evaluation of the domes, but in the xyphoid area; a gentle push must be applied cranially (Figure 5).

The evaluation of the xyphoid-costal area is used to assess whether there is regular elasticity of the tissue during inspiration and expiration, which is necessary for normal breathing. The hand and the forearm are positioned as in the evaluation of the domes, but in the xyphoid area; a gentle push must be applied cranially.

For medial ligaments, the spinal elasticity needs to be evaluated, with the patient being supine. The operator hold the last phalanges of the fingers (of one or both hands) placed in the interspinous spaces of D11 and D12; by using a gentle push toward the ceiling, a passive extension of the vertebra is obtained, in order to deduce information on its elasticity (Figure 6).42 The same technique is used to evaluate the lumbar vertebral bodies up to L4.42 The medial ligaments play an important role in the mechanics of the dorsolumbar region, in synergy with the abdominal wall muscles and the thoracolumbar fascia.,

For medial ligaments, the spinal elasticity needs to be evaluated, with the patient being supine. The operator should hold the last phalanges of the fingers (of one or both hands) placed in the interspinous spaces of D11 and D12; by using a gentle push towards the ceiling, a passive extension of the vertebra is obtained, in order to deduce information on their elasticity.

The lateral ligaments are evaluated by actively soliciting the last rib. On the opposite side compared to the rib to be evaluated, the body of the rib must be hold with one hand, and a gentle traction must be performed toward the operator (Figure 7). The lateral ligaments play an important role in managing the tension affecting the diaphragm and the thoracolumbar fascia.,

The lateral ligaments are evaluated by actively involving the last rib. On the opposite side of the rib to be evaluated, the body of the rib must be held with one hand, and a gentle traction must be performed toward the operator.

The main purpose of using such manual evaluation is to understand whether there is a restriction of movement in a specific area of the diaphragm muscle, in order to plan a manual treatment focused on the dysfunctional area, combining the manual approach to the usual rehabilitation process (Figure 8). The combination of several techniques in a multidisciplinary process can be of benefit for the improvement of the respiratory performance.,

Anatomical model.

Notes: (1) center tendon, (2) anterior diaphragmatic dome, (3) xiphoid area, (4) costal area, (5) medial ligaments, (6) lateral ligaments, and (7) aorta.

We hope that this article could contribute to the state of the art, representing a starting point, and enhancing the need for further research in this field.

Conclusion

The breath is a systemic activity, able to involve several body parts. The health of the diaphragm muscle is critical for many patients, not just those with respiratory diseases. A proper training of the main respiratory muscle can be of benefit in several clinical scenarios; however, there are not so many authors reporting on therapeutic techniques focused on manual approaches and, more in detail, on the manual evaluation of the diaphragm. This article aims to describe a hypothesis of manual evaluation of the diaphragm, with particular attention to anatomical fundamentals. The technique for the manual evaluation of the diaphragm proposed in the present article arises from the increasing need to combine physiotherapy with manual therapy, considering the new clinical data. We do not have complete knowledge on what happens in the different anatomical areas of the diaphragm in patients with respiratory disease; this text could be used as a guideline for researchers for further evaluation.

Footnotes

Disclosure

The authors report no conflicts of interest in this work.

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Published online 2011 Apr 12. doi: 10.3791/2632
PMID: 21505416
This article has been cited by other articles in PMC.

Abstract

Survivors of acute respiratory distress syndrome (ARDS) and other causes of critical illness often have generalized weakness, reduced exercise tolerance, and persistent nerve and muscle impairments after hospital discharge.1-6 Using an explicit protocol with a structured approach to training and quality assurance of research staff, manual muscle testing (MMT) is a highly reliable method for assessing strength, using a standardized clinical examination, for patients following ARDS, and can be completed with mechanically ventilated patients who can tolerate sitting upright in bed and are able to follow two-step commands. 7, 8

Manual Muscle Testing Videos

This video demonstrates a protocol for MMT, which has been taught to ≥43 research staff who have performed >800 assessments on >280 ARDS survivors. Modifications for the bedridden patient are included. Each muscle is tested with specific techniques for positioning, stabilization, resistance, and palpation for each score of the 6-point ordinal Medical Research Council scale.7,9-11 Three upper and three lower extremity muscles are graded in this protocol: shoulder abduction, elbow flexion, wrist extension, hip flexion, knee extension, and ankle dorsiflexion. These muscles were chosen based on the standard approach for evaluating patients for ICU-acquired weakness used in prior publications. 1,2.

Download video file.(60M, mov)

Protocol

1. Introduction

During manual muscle testing (MMT), each muscle group is tested bilaterally. For demonstration purposes, only one side is tested in this video for each of the 6 muscle groups. One hand of the examiner applies resistance or palpates the muscle or tendon for contraction while the other hand stabilizes the extremity being tested to keep it in the test position. The test is repeated if the patient does not understand the instructions or is not applying maximum effort.

2. Grading follows the Medical Research Council (MRC) system (Table 1).1

Figure 1 illustrates an algorithm for the MRC muscle strength scoring system. If the subject is missing a limb, has a cast, or is unable to be placed in the correct testing position, muscle strength is graded as 'unable to assess'. If the patient has a fixed contracture, but can otherwise perform the test, the muscle is graded. Medical devices, such as catheters and drains, and mechanical ventilation usually do not impede muscle testing, unless a joint is immobilized to ensure proper functioning of a device.

Figure 1. Manual Muscle Testing Algorithm

Manual Muscle Testing For Ankle

3. Procedure

  1. For each muscle tested, the examiner stands to the side being tested, and the patient is sitting upright and positioned to allow full movement of the joint against gravity. The examiner demonstrates the desired movement against gravity. The examiner then requests the patient to repeat the motion.

  2. If the patient can move through the desired range of motion against gravity, the examiner attempts to apply resistance in the testing position while stating 'Hold it, don't let me push it down' or 'Hold it, don't let me bend it' (Figure 2). If the patient tolerates no resistance, the muscle score is Grade 3. If the patient tolerates some resistance, the score is Grade 4, and full resistance, Grade 5.

  3. If the patient cannot move against gravity, the patient is repositioned to allow movement of the extremity with gravity eliminated. If supporting the limb, the examiner provides neither assistance nor resistance to the patient's voluntary movement. This gravity-eliminated positioning will vary for each muscle tested. If the patient cannot complete at least partial range of motion with gravity eliminated, the muscle or tendon is observed and/or palpated for contraction.

  4. For a bedridden patient who cannot sit up in a bed placed in the chair position or on the edge of the bed, alternate positions for testing the lower extremity are included in this protocol.

4. Shoulder Abduction

  1. Testing position - arm out from the side at shoulder level. The examiner demonstrates the motion, then states 'Lift your arm out to the side to shoulder level.' The hand giving resistance is contoured over the patient's arm just above the elbow. The other hand stabilizes the shoulder above the shoulder joint. The examiner states 'Hold it, don't let me push it down.' To assess grades 3, 4, or 5, please see section 3.2 above.

  2. If weaker than Grade 3, the patient lies supine with arms at the side. The examiner supports the arm just above the elbow and at the wrist to assure that the shoulder does not externally rotate (turn outward). The patient attempts to move the arm out to the side. The examiner states: 'Try to move your arm out to the side'. Grade 2 is assigned if the patient moves with gravity eliminated.

  3. If weaker than Grade 2, the examiner states ' Try to move your arm out to the side ' and palpates the middle deltoid muscle, as demonstrated, for contraction, and scores as Grade 1 or 0 as previously defined.

  4. Shoulder MMT can be performed with central venous catheters (e.g., subclavian and jugular) in place, including those used for dialysis. (Figure 2)

Videos Of Manual Muscle Testing

The remaining assessments will be completed similarly to above using specific test positions for the patient and examiner, and specific instructions for the patient's movement.

5. Elbow Flexion

  1. Test position - forearm supinated and flexed slightly more than 90 degrees. Verbal instructions: 'Bend your elbow slightly more than 90 degrees'. The hand giving resistance is contoured over the flexor surface of the forearm proximal to the wrist. The examiner's other hand applies counterforce by cupping the palm over the anterior superior aspect of the shoulder. The examiner then states: 'Hold it. Don't let me push it down' and scores Grades 3, 4, or 5 as previously described.

  2. If weaker than Grade 3, the shoulder is abducted to 90 degrees. The examiner supports the arm under the elbow and, if necessary, the wrist as well. The forearm is turned with the thumb facing the ceiling. With the elbow extended, the patient attempts to flex the elbow. The examiner states: 'Try to bend your elbow.' Grade 2 is assigned if the patient can flex the elbow.

  3. If weaker than Grade 2, the forearm is supinated and positioned at the side in approximately 45 degrees of elbow flexion. The examiner states 'Try to bend your elbow', palpates the biceps tendon and scores as either Grade 1 or 0.

6. Wrist Extension

  1. Test position - arm at the side, elbow flexed to 90 degrees with the forearm pronated and the wrist fully extended. Verbal instructions: 'Bend your wrist up as far as possible.' The examiner's hand giving resistance is placed over the back of the patient's hand just distal to the wrist. The examiner's other hand supports the patient's forearm. The examiner then states: 'Hold it. Don't let me push it down' and scores Grades 3, 4 or 5.

  2. If weaker than Grade 3, the elbow is flexed to 90 degrees and forearm turned with thumb facing the ceiling. The forearm and wrist are supported by the examiner. The examiner states: 'Bend your hand toward me'. Grade 2 is assigned if the patient can extend the wrist.

  3. If weaker than Grade 2, the examiner states 'Bend your wrist toward me' and palpates the two extensor tendons, one on each side of the wrist, as demonstrated, and scores as Grade 1 or 0. The examiner is careful not to palpate the tendons in the middle of the wrist.

  4. This test is not performed if there is an ipsilateral radial arterial catheter in place.

7. Hip Flexion

  1. Test position - sitting with the hip fully flexed and knee bent. The patient may place their hands on the bed or table for stability. Verbal instructions: 'Raise your knee up as high as it will go.' The examiner's hand giving resistance is placed on top of the thigh just proximal to the knee. The other hand provides stability at the side of the hip. The examiner then states: 'Hold it. Don't let me push it down' and scores Grades 3, 4 or 5.

  2. If weaker than Grade 3, the patient lays down on the side not being tested. For example, the patient lays on the right side to test the left hip. The examiner stands behind the patient with one arm cradling the leg being tested with the hand supporting under the knee. The opposite hand maintains alignment of the trunk at the hip. The examiner states:'Bring your knee toward your chest.' Grade 2 is assigned if the patient can flex the hip.

  3. If weaker than Grade 2, the patient is supine. The examiner asks, 'May I touch your leg here?' (pointing to the inner aspect of the hip joint). With the patient's permission, the examiner states 'Bend your hip' and palpates the iliopsoas tendon, as demonstrated, and scores as Grade 1 or 0.

  4. In a bedridden patient, grades 5, 4, and 3 are tested with the bed in the chair position, or the head of the bed elevated as far as possible. Pillows are placed under the knee to flex the hip to 90 degrees. The examiner assures that the foot is lifted off the bed when asking the patient to raise the knee off the bed. Grades 2 and 1 are scored as previously described.

  5. This test can be performed in patients with intact and well secured femoral intravascular catheters.

8. Knee Extension

  1. Test position - sitting upright with the knee fully extended to 0 degrees. Avoid knee hyperextension. Verbal instructions; 'Straighten your knee'. The hand giving resistance is contoured on top of the leg just proximal to the ankle. The other hand is placed under the thigh above the knee. The examiner then states 'Hold it. Don't let me bend it' and scores Grades 3, 4 or 5.

  2. If weaker than Grade 3, the patient lays on the non-testing side. The examiner stands behind the patient at knee level. The leg not being tested may be flexed for stability. One arm cradles the leg being tested around the thigh with the hand supporting the underside of the knee. The other hand holds the leg just above the ankle. The examiner states: 'Straighten your knee.' Grade 2 is assigned if the patient can extend the knee (Figure 3).

  3. If weaker than Grade 2, the patient is supine and the examiner states:'Push the back of your knee down' or 'Tighten your knee cap' and palpates the quadriceps tendon, and scores as Grade 1 or 0.

  4. For the bedridden patient, in scoring Grades 3, 4,and 5, the patient is positioned in the same manner as for hip flexion and graded as described above for knee extension (Figure 4).

9. Ankle Dorsiflexion

  1. Test position - sitting, with the heel on floor, foot in full dorsiflexion, and shoes and socks removed. Verbal instructions: 'Bend your foot up as far as possible.' The toes are relaxed during the test. The hand giving resistance is cupped over the top of the foot proximal to the toes. The other hand is contoured around the front of the leg just proximal to the ankle. The examiner then states 'Hold it, don't let me push it down' and scores Grade 3, 4 or 5.

  2. If weaker than Grade 3, but there is partial range of motion against gravity, assign Grade 2.

  3. If weaker than Grade 2, palpate the tibialis anterior tendon, and score as Grade 1or 0.

  4. The bedridden patient is tested supine, with the leg extended and a pillow placed under the knee.

  5. This test can usually be applied with an intact and secured pedal intravascular catheter. Be careful not to dislodge the catheter.

10. Representative Results:

MMT using this protocol has excellent inter-rater reliability when applied with both ARDS survivors and simulated patents. Quality assurance of 19 trainees examining 12 muscle groups demonstrated an intraclass correlation coefficient (95% confidence interval [CI]) of 0.99 (0.97-1.00).8 Agreement (kappa; 95% CI) for detecting clinically significant weakness (i.e., composite MRC score <80% of maximum) was 1.00 (0.55-1.00). Previous studies have shown high inter-rater reliability with stroke, amyotrophic lateral sclerosis (ALS), Guillain-Barre, and other critically ill patients.12-14

Figure 2. ICU patient with a left shoulder abduction contracture. MMT with a left radial arterial line, cardiac monitoring, and continuous dialysis through a right internal jugular catheter. The patient is positioned for shoulder abduction MMT Grades 3, 4 and 5.

Figure 3. ICU bedridden patient with a right internal jugular catheter for continuous dialysis. The patient is positioned on the right side for knee extension MMT Grade 2.

Figure 4. ICU bedridden patient with a left knee flexion contracture. The patient is positioned supine with a pillow under the knee for knee extension MMT Grades 3, 4 and 5.

Table 1. Manual Muscle Test 3
Grade Manual Muscle Test
5Movement against gravity plus full resistance
4Movement against gravity plus some resistance
3Completes the available test range of motion against gravity, but tolerates no resistance
2The patient completes full or partial range of motion with gravity eliminated
1Slight contractility without any movement
0No evidence of contractility (complete paralysis)

Discussion

Depending on the diagnostic criteria, 9 – 87% of ICU patients develop neuromuscular complications, which are associated with prolonged mechanical ventilation, increased hospital stay and rehabilitation time, and potentially associated with increased mortality.1,2,16-18 Periodic reassessment of muscle strength, using a reliable method which minimizes inter-rater variability is helpful to detect changes over time. An important limitation of MMT using the MRC score system is the 6-point ordinal scale. Muscle strength testing using a hand held dynamometer is less commonly used but has the advantage of using a ratio scale for measurement.19 In addition, some ICU patients may not be awake enough to tolerate a MMT exam.2 However, in our experience, once a patient is awake and cooperative, there are only a small number of patients who do not tolerate the exam. If this intolerance is due to poor endurance, the exam can be completed in smaller portions, rather than all at once. The muscle strength grading described in this video has been administered to ICU survivors and to cooperative, critically ill patients even while undergoing mechanical ventilation with intravascular devices in place that do not interfere with joint motion . Recent developments in ICU clinical practice whereby deep sedation is avoided, enhances the ability of mechanically ventilated patients to participate in MMT examination, rehabilitation therapies, and even ambulate while mechanically ventilated.20 Manual muscle testing of the 6 muscle groups described in this video is a simple, reliable, inexpensive method of obtaining a quantitative muscle strength evaluation for patients during and after critical illness.

Acknowledgments

Supported by NIH grant # R01HL088045. Drs. Eddy Fan and Michelle Kho are each supported by a Fellowship Award from the Canadian Institutes of Health Research.

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