Strength Testing

[gcoe]

Hi all

I am interested to know what people in other countries are doing for strength testing in rehab, particularly with our neuro patients, and what your views are about what we should be doing for measuring strength.

Here in NZ we seem to be stuck with MMT using the Medical Research Council Scale (0-5). As a test it has so many limitations. It seems odd in the 21st century that we are using such an archaic system when there is so much technology available

It would be nice if we were using hand held dynamometers. A simple dynamometer would give so much more useful information, provide a chance for superior clinical reasoning and would provide a responsive test to monitor progress. However our public hospital system won't fork out the cost and there doesn't seem to be the will amongst physios to change.

We also have a company here that has developed a hand held dynamometer that will measure strength against range - ie you perform a concentric muscle test through full range and you get a readout curve of strength against gonimoetry. From the preliminary industrial and reliability tests it looks really promising, however it will probably cost a bit and I just don't see it getting adopted by physios here.

What do you think?

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[irishneurohead]

i understand your frustration but you need to remember that MMT is generally accepted not even in the PT field but with docs, nurses, OTs etc. I think its probably not going anywhere fast - but im happy enough with it as its a small part of a physiotherapists overall assessment and we need to focus more on functional abilities etc rather than always impairments.

[gcoe]

Hi irishneurohead

Thanks for your post. I was beginning to think no one is interested

Yes I totally agree we need to concentrate on functional outcomes and measuring things at the activity limitation and participation levels are where a lot of it is at. I would never not take a relevant functional measure in assessing a patient's status.

Having said that strength is such a huge issue at an impairment level in stroke. It is also a very important pillar for clinical reasoning when identifying and activity limitation. High quality data on strength could greatly improve our ability to answer WHY a person is unable to perform a given activity. There is good evidence for the importance of weakness in affecting function and as a lot of our interventions in stroke do involve strengthening - including many of our task-based interventions. I don't think we should trivialising it's importance. Just one example is in the markedly weak patient; here impairment measures may be the only measure that may be able to detect change following treatment whereas functional measures may be too blunt. Detectable improvements in strength may precede a a functional gain. MMT won't be able to do this.

As for the MMT being an "common language" between disciplines I think that is a good point to make. Then again I wouldn't think that would be the main reason for using it. If I wanted to communicate to other members of the team a patient's strength status I could quote a patients strength against norms so if you could say "this patient has 25% strength of triceps expected for his/her gender and age and 10% that of the other side" - I know that sonds a bit verbose but it could be contracted in note writing. I think this would be much more meaningful. As we are the experts on weakness in the team wouldn't the team usually want more detailed information than what they can provide?

Another problem I find with MMT (and this may be better handled in Ireland than here) every physio seems to do a different sort of MMT for a given muscle. Some do screening isometric manoeuvres and ignore the affect of gravity, some test in the inner range some test in the outer range some test through full range etc. Some do concentric resistance through full range, some through part of the range. Physios have abandoned the protocols in the book(s). Doctors are even worse at this than physios. So there is no standardisation anymore. Physios trained in the days when MMT was one of their main measurements would have a fit seeing what happens in practice today. All this failure to standardise means whatever adequate reliability there might be in the research (and on the whole there isn't much) is sacrificed in practice. If you don't have a reliable tool then you really don't have a measurement tool.

[neelpandey]

Nice posting good informations

[natty1905]

Hi

I too was confused about MMT. I have the book by Kendall which everyone seems to quote but other people contradict that, even my lecturers. I was going to do some kind of reliability test for Serratus Anterior MMT at undergraduate but came to the conclusion that the most importand functions of Serratus are multi-faceted and impossible to test. The manual muscle test that we were shown for Serratus has no relation to upward rotation whatsoever which is normally the faulty movement from what I have read!

[gcoe]

Hi Natty1905

When you were studying the SA did you go back and look at any research articles?

Kendall’s book is interesting and the latest one gives lots of detailed testing and examples of paralysis. However none of it is supported by research. I think there is quite a lot out there on the SA in the normal and in pathology. Robert Donatelli’s: Book Physical therapy of the Shoulder gives an excellent account of the Serratus anterior in scapular movement.

I understood that serratus anterior as a whole works in pure protraction of the scapular so is tested with a shoulder protraction test. What Kendall is getting at in their preferred test but don't really state, is that the lower fibres of SA that originate on the lower medial border and the inferior angle and run to the 3rd 4th and 5th ribs work as a force couple with upper trapezius and lower trapezius to rotate the scapular up during shoulder elevation. In this force coupling the lower border of of the scapular is pulled forward and upward, the upper trapezius pulls the lateral part of the acromion upwards in medially, and the lower trapezius pulls the medial part of the acromion downwards in inwards. Each muslce counters the unwanted action of the other two so you get a relatively pure upward rotation..

So clinically in:
1. frank paralysis of the long thoracic nerve the patient can’t protract the scapular at all and you get the classic winging of the scapular.

2. Whereas a common muscle imbalance problem where the scapular fails to get the proper scapula-humeral rhythm during shoulder elevation, you often get weakness of these lower fibres of SA along with weakness of the lower trapezius ending up with excessive upper trapezius activity and a failure to sufficiently upwardly rotate the scapular

[natty1905]

Yes I have been reading that in Movement Impairment Syndromes however I still struggle to understand the test. Is it merely a case of observing the scapular humeral rhythm from behind or is there some way to test the lower fibres of trapezius and lower digitations of serratus during upward rotation of the scapular. I am not just being lazy here but have read various authors and cant get to the bottom of it!

[gcoe]

Hi natty1905

I think it is both about observing the movement of the scapular first then testing the muscle. It sounds like you are reading good texts. Shirley Sahrmann gives an excellent description what to observe the scapula doing during shoulder flexion or abduction on pp 209-210 or her book. So that is the observation part. In Kendall's (5th edition) book the test with the shoulder flexed to 120-130 degrees then palpating the inferior part of the scapular. I test it by providing a resistance to protraction of the lateral border of the scapula just above the inferior angle.

Once you have clinically seen a patient with weak lower serratus anterior it is easy picture to remember. However to really get the idea you might need to go through it with an experienced clinician - It is a bit hard to explain in great detail in writing

If you are still finding it confusing try Donatelli’s book - slightly different presentation and testing but achieves the same result. I haven't got my copy on hand but as I remember it also has an excellent CD that goes with it as a visual guide.

[nikitatolstoy]

Hi natty1905

I think it is both about observing the movement of the scapular first then testing the muscle. It sounds like you are reading good texts. Shirley Sahrmann gives an excellent description what to observe the scapula doing during shoulder flexion or abduction on pp 209-210 or her book. So that is the observation part. In Kendall's (5th edition) book the test with the shoulder flexed to 120-130 degrees then palpating the inferior part of the scapular. I test it by providing a resistance to protraction of the lateral border of the scapula just above the inferior angle.

Once you have clinically seen a patient with weak lower serratus anterior it is easy picture to remember. However to really get the idea you might need to go through it with an experienced clinician - It is a bit hard to explain in great detail in writing

If you are still finding it confusing try Donatelli’s book - slightly different presentation and testing but achieves the same result. I haven't got my copy on hand but as I remember it also has an excellent CD that goes with it as a visual guide.

Very interesting post... Thanks for sharing...