Highly Influenced. View 4 excerpts, cites background and methods. Complementary Medicine Research. PloS one. A narrative review of manual muscle testing and implications for muscle testing research. Journal of chiropractic medicine. Muscle strength in adults with spinal cord injury: a systematic review of manual muscle testing, isokinetic and hand held dynamometry clinimetrics. Common errors and clinical guidelines for manual muscle testing: "the arm test" and other inaccurate procedures.
Association of manual muscle tests and mechanical neck pain: results from a prospective pilot study. Journal of bodywork and movement therapies. View 3 excerpts, cites results. PURPOSE: The purpose of this study was first to develop a Korean version of pediatric functional muscle testing for children with a motor developmental disorder who have a communication problem and … Expand.
Clinical evaluator reliability for quantitative and manual muscle testing measures of strength in children. A comparison of muscle strength testing techniques in amyotrophic lateral sclerosis. Setting: Pathokinesiology laboratory. Participants: Adult volunteers recruited from local community and outpatient clinics. Manual muscle testing MMT as a method of diagnosis for spinal dysfunction has not been well utilized.
This paper will present evidence that the MMT can be a legitimate and useful evaluation tool for the assessment of the musculoskeletal and nervous systems. There are many ways of examining the nervous system and the musculoskeletal system. It has been proposed that the term neuromusculoskeletal system be adopted because examination of the one may reflect the status of the other [ 1 , 2 ].
The evaluation methods of many manipulative therapists often focus at either end of the nervous system, and this paper suggests that MMT provides a method of examining both the central and the peripheral ends. MMT is the most commonly used method for documenting impairments in muscle strength. Limited muscle testing methods are taught in a number of chiropractic schools around the world, however in a major "stand alone" chiropractic technique that employs MMT for the evaluation of patients known as applied kinesiology chiropractic technique AK , turned 42 years old.
We propose in this review to look at the research status of MMT in the manual examination of the nervous system's status. The early years of the AK method are related elsewhere in detail [ 3 ]. The specific protocols and clinical objectives of the technique have been described in previous publications [ 3 — 9 ].
AK has therefore been used by a proportion of the chiropractic profession for over 42 years and is now used by other healing professions. In a survey by the National Board of Chiropractic Examiners in , T4H was one of the first public self-help programs and there are claims that it is the fastest growing "body work" program in the world, used by over 10 million people [ 14 ]. In this paper we pose the following questions: 1 "Is the MMT approach worthy of scientific merit? Another main objective of this literature review was to investigate the evidence for intraexaminer reliability, interexaminer reliability, and validity of MMT in the assessment of patients.
After abstracts were selected for relevance and the papers acquired and reviewed, the literature was sorted according to relevance and quality. Inclusion criteria were that the report had a Cohen's kappa coefficient of 0.
This selection criteria is consistent with the one suggested by Swinkels et al for the evaluation of the quality of research literature [ 15 ].
Studies with a control group a randomized clinical trial , examiner blinding, and pre- and post-test design are indicated in the descriptions of each study. Duplicates and articles published in non-peer-reviewed literature were excluded. Statistical presentations of the data are presented showing the average correlation coefficients of MMT examination upon the different patient populations for each study.
In order to be meaningful, all measurements must be based on some type of operational definition. An operational definition is a description of the methods, tools, and procedures required to make an observation i. Kaminsky and Fletcher et al provide clinicians with some strategies to critically analyze the scientific merit of manual therapies [ 16 , 17 ]. A basic understanding of operational definitions is required in order to make judgments about the methods used in articles and to know which research findings should be implemented in practice.
For example, how should we judge the value of the MMT for the gluteus maximus or gluteus medius muscles in cases of sacroiliac joint pain and dysfunction, knowing that statements range from "weakness of the gluteals is usually present in dysfunction of the sacroiliac joint" Janda [ 18 ] to "the results of this study cast doubt on the suitability of manual muscle testing as a screening test for strength impairments"? Bohannon [ 19 ]. This requires that the examiner be trained in the anatomy, physiology, and neurology of muscle function.
The action of the muscle being tested, as well as the role of synergistic muscles, must be understood. Manual muscle testing is both a science and an art. To achieve accurate results, muscle tests must be performed according to a precise testing protocol. The following factors must be carefully considered when testing muscles in clinical and research settings:. In physical therapy research, the "break test" is the procedure most commonly used for MMT, and it has been extensively studied [ 20 — 22 ].
This method of MMT is also the main test used in chiropractic, developed originally from the work of Kendall and Kendall [ 21 , 23 ]. In physical therapy the "break test" has the following operational definition [ 20 — 22 ]. The subject is instructed to contract the tested muscle maximally in the vector that "isolates" the muscle. The examiner resists this pressure until the examiner detects no increase in force against his hand. At this point an additional small force is exerted at a tangent to the arc created by the body part being tested.
The initial increase of force up to a maximum voluntary strength does not exceed 1 sec. For example in the seated test for the rectus femoris muscle, a seated subject is asked to flex his knee toward his chest 10 degrees; when that position is reached, the examiner applies resistance at the knee, trying to force the hip to "break" its hold and move the knee downward into extension. The ability of a muscle to lengthen but to generate enough force to overcome resistance is what is qualified by the examiner and termed "Strong" or "Weak.
The grading system is based on muscle performance in relation to the magnitude of manual resistance applied by the examiner. Scores are ranked from no contraction to a contraction that can be performed against gravity and can accept "maximal" resistance by the examiner, depending on the size of the muscle and the examiner's strength.
However, in the AK use of MMT the implication of grades is limited to an interpretation of 'better' or 'worse', 'stronger' or 'weaker,' and no assumption is made about the magnitude of difference between grades. MMT procedures are also commonly employed in clinical neurology as a means of subjectively evaluating muscle function. The examiner in the application of force to the subject's resistance evaluates the muscle groups being studied as subjectively "weak" or "strong" on a 5-point scale [ 24 ].
MMT is employed by physical therapists to determine the grades of strength in patients with pathological problems and neurologic or physical injuries strokes, post-polio syndromes, fractures, post-surgical disabilities, etc. The physical therapist's patients are often initially examined by a medical doctor who supervises the physical therapist's rehabilitation programs that may involve isometric, isokinetic, and isotonic muscle training regimes for the gradual rehabilitation of muscle function often involving instruments and machinery.
In the absence of a pathological neurological deficit pathological deficits were originally what physicians sought to find using MMT , [ 25 , 26 ] clinical inferences are made based upon the result of the MMT. This method of MMT is used in both chiropractic and physical therapy to determine a patient's progress during therapy [ 3 — 9 , 20 — 23 ]. MMT, when employed by AK chiropractors, is used to determine whether manipulable impairments to neurological function controlling muscle function exist.
For example, chiropractic management using MMT for a patient with carpal tunnel syndrome could involve assessment of the opponens policis and flexor digiti minimi muscles innervated by the median and radial nerves , and then adjustment as indicated to the carpal bones, the radius and ulna, attention to an inhibited on MMT pronator teres muscle, adjustment of the cervical or thoracic spines, and evaluation of cranial nerve XI through MMT of the sternocleidomastoid and upper trapezius muscles.
Any or all of these factors may require treatment in order to strengthen the inhibited opponens policis and flexor digiti minimi muscles that are evidence of the carpal tunnel syndrome. This "continuous nervous system" thinking and testing may allow the identification of contributing sites to a pain state.
The expectation in a chiropractic setting is that the proper therapy will immediately improve muscle strength upon MMT, taking the patient from "weak" to "strong. Chiropractic therapy may produce rapid responses for the innervation of muscles because the basic therapy required for chiropractic patients is decompression of the nervous system. It is purported that this can be done readily with chiropractic manipulative therapy CMT [ 27 — 30 ].
When performed by an examiner's hands MMT may not be just testing for actual muscle strength; rather it may also test for the nervous system's ability to adapt the muscle to the changing pressure of the examiner's test. A nervous system functioning optimally will immediately attempt to adapt a muscle's activity to meet the demands of the test. There appears to be a delay in the recruitment of muscle motor units when the nervous system is functioning inadequately [ 66 , 71 — 73 , 82 , 90 , ].
This delay varies with the severity of the nervous system's impairment, and influences the amount of weakness shown during the MMT. Determining the ideal operational definition of a MMT can be difficult given the large number of test variations that exist.
All of the tests described by Kendall, Wadsworth, Goodheart, Walther and others [ 3 , 20 — 23 ] involve multiple joint movements and handling techniques. This results in a large number of variables that are difficult to control. Because of the variability possible during a MMT, several studies examining MMT have used specialized instrumentation to provide support for the extremity tested and for standardization of joint position.
Throughout its history manual muscle testing has been performed by practitioners' hands, isokinetic machines, and other handheld devices. However, isokinetic machines and dynamometers for more objective testing of muscles are still too expensive or cumbersome for clinical use, but this equipment is useful for research purposes [ 20 — 23 ]. Kendall et al [ 21 ] state:. One hand of the examiner positions and stabilizes the part adjacent to the tested part.
The other hand determines the pain-free range of motion and guides the tested part into precise test position, giving the appropriate amount of pressure to determine the strength. All the while this instrument we call the hand is hooked up to the most marvelous computer ever created. It is the examiner's very own personal computer and it can store valuable and useful information of the basis of which judgments about evaluation and treatment can be made.
Such information contains objective data that is obtained without sacrificing the art and science of manual muscle testing to the demand for objectivity. According to Walther [ 23 ]:. Regardless of the methods or equipment one uses to standardize MMT in a clinical or research setting, it is most important that the test protocol be highly reproducible by the original examiner and by others.
One way researchers determine if a clinical test is consistent and repeatable over several trials is to analyze its reliability. The reliability of a diagnostic method is the consistency of that measurement when repeated.
Depending on the type of measurement that is performed, different types of reliability coefficients can be calculated.
In all coefficients, the closer the value is to 1, the higher the reliability. For instance, calculating Cohen's kappa coefficient allows the researcher to determine how much agreement existed between two or more doctors performing MMT on patients with low back pain. A value greater than. The advantage of the kappa coefficient is that it is a measure of chance corrected concordance, meaning that it corrects the observed agreement for agreement that might occur by chance alone.
There are difficulties with the interpretation of kappa and correlation coefficients that have been described by Feinstein and Brennan [ 32 , 33 ]. To examine the reliability coefficients calculated by the authors of MMT studies, see Table 1.
This review of the literature shows the importance of clinical experience and expertise, and this factor has been highlighted in many papers discussing the reliability of the MMT [ 20 — 23 , 34 — 36 ].
The skills of the examiners conducting studies on MMT and their skills in interpreting the derived information will affect the usefulness of MMT data. The examiner is obliged to follow a standardized protocol that specifies patient position, the precise alignment of the muscle being tested, the direction of the resisting force applied to the patient, and the verbal instruction or demonstration to the patient. All of these precautions have proven necessary to reliably study the validity of the MMT in the diagnosis of patients with symptomatology.
There was significant improvement in the degree of consistency of a given examiner's scores as noted by Florence et al [ 34 ] when the examiner had more clinical experience and training in MMT. Mendell and Florence [ 35 ], Caruso and Leisman , [ 36 ] and many other researchers of MMT have discussed the importance of considering the examiner's training on the outcomes of studies that assess strength via MMT [ 20 — 23 ].
Interexaminer reliability of the MMT has been reported by Lilienfeld et al [ 37 ], Blair [ 38 ], Iddings et al [ 39 ], Silver et al [ 40 ], Florence et al [ 34 ], Frese et al [ 41 ], Barr et al [ 42 ] and Perry et al [ 43 ].
Test-retest reliability has been examined by Iddings et al , [ 39 ] Jacobs [ 44 ], Florence et al [ 34 ], Wadsworth et al [ 45 ], Mendell and Florence [ 35 ], Hsieh and Phillips [ 46 ], Barr et al [ 42 ], Florence et al [ 47 ], Lawson and Calderon [ 48 ], Caruso and Leisman [ 36 ], and Perry et al [ 43 ]. The results of these studies indicate that in order to be confident that a true change in strength has occurred; MMT scores must change more than one full grade.
In clinical research studies on chiropractic treatment, the change from an "inhibited" or "weak" muscle to a "facilitated" or "strong" muscle is a change in at least one full grade, and is a common result of successful treatment. Number of Subjects: Materials and Methods: A systematic review of the literature was conducted, resulting in the identification of 9 articles that were relevant to the purpose of this study.
These 9 articles were critically appraised via the Downs and Black scale as modified by Kennelly, which utilizes a series of questions to determine the level and quality of each article. Results: Analysis of the nine identified studies provide multiple results of interest.
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