Manual Muscle Test

MMT is a standardized set of assessments that measure muscle strength and function.

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Area of Assessment

Assessment Type

Cost

CDE Status

Please visit this website for more information about the instrument: Manual Muscle Testing- Using the Medical Research Council Muscle Grading Scale

Supplemental-Highly Recommended for Congenital Muscular Dystrophy (CMD), Myotonic Muscular Dystrophy (DM), Facioscapulohumeral Muscular Dystrophy (FSHD)

Supplemental: Cerebral Palsy (CP), Duchenne/Becker Muscular Dystrophy (DMD/BMD), Mitochondrial Disease (Mito) and Spinal Muscular Atrophy (SMA)

Diagnosis/Conditions

• Spinal Cord Injury

Populations

Key Descriptions

• Score range 0-5, minimum 0, maximum 5/5.
• There are three manual muscle tests grading systems:
  1) The Medical Research Council Scale
  2) Daniels and Worthingham
  3) Kendall and McCreary

Number of Items

Determined by the number of muscles being tested

Time to Administer

Less than 1 minutes

Required Training

Age Ranges

Instrument Reviewers

Initially reviewed by Wendy Romney PT, DPT, NCS, Cara Weisbach, PT, DPT, and the SCI EDGE task force of the Neurology Section of the APTA in 7/2012.

Reviewed in 2020 by Ali Baumgarten OTS, Jumai Hariran OTS, Kaily Nagel OTS, & Kristina Nguyen OTS

Body Part

ICF Domain

Measurement Domain

Professional Association Recommendation

Recommendations for use of the instrument from the Neurology Section of the American Physical Therapy Association’s Multiple Sclerosis Taskforce (MSEDGE), Parkinson’s Taskforce (PD EDGE), Spinal Cord Injury Taskforce (SCI EDGE), Stroke Taskforce (StrokEDGE), Traumatic Brain Injury Taskforce (TBI EDGE), and Vestibular Taskforce (Vestibular EDGE) are listed below. These recommendations were developed by a panel of research and clinical experts using a modified Delphi process.

Abbreviations:

LS / UR

Reasonable to use, but limited study in target group / Unable to Recommend

Recommendations for use based on acuity level of the patient:

Acute

Subacute

(CVA 2 to 6 months)

(SCI 3 to 6 months)

Chronic

(> 6 months)

SCI EDGE

Recommendations based on SCI AIS Classification:

AIS A/B

AIS C/D

SCI EDGE

Recommendations for entry-level physical therapy education and use in research:

Students should learn to administer this tool? (Y/N)

Students should be exposed to tool? (Y/N)

Appropriate for use in intervention research studies? (Y/N)

Is additional research warranted for this tool (Y/N)

SCI EDGE

Considerations

• MMT may not be sufficiently sensitive to measure strength in good and normal range. (Schwartz et al, 1992)
• Herbison et al (1996) and Schwartz et al (1992) found significant differences in strength change over time using myometry that were not detected with manual muscle testing with strength grades greater than 3.5.

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Spinal Injuries

Interrater/Intrarater Reliability

Spinal Cord Injury:

(Herbison et al, 1996, n = 88, C4-C8 AIS A-D, 0-2 years post injury, measured C5 elbow flexor strength)

• Excellent interrater reliability (ICC = 0.94)

Construct Validity

SCI:

(Schwartz et al, 1992, n = 122)

Correlation between MMT and Myometry: Time post SCI

Muscle

72 hours

1 week

1 month

3 months

6 months

12 months

L bicep

R bicep

L ECR

R ECR

** = Excellent correlation > 0.6

* = Adequate correlation 0.31-0.59

SCI:

(Noreau, Vachon, 1998, n = 38 level of injury C5-L3, AIS A-D)

Spearman Correlation Coefficients between MMT and Myometry

Muscles

Paraplegia at Admit (n = 23)

Paraplegia at Discharge (n = 23)

Tetraplegia at Admit (n = 15)

Tetraplegia at Discharge (n = 15)

Elbow flexors

Elbow extensors

Shoulder flexors

Shoulder extensors

Shoulder abductors

Shoulder adductors

** = Excellent correlation > 0.6

* = Adequate correlation 0.31-0.59

Osteoarthritis

Standard Error of Measurement (SEM)

Osteoarthritis (OA):

(Youdas et al, 2010; n = 20 subjects with OA and 20 healthy subjects; mean age = 53.4(9.0) for subjects with OA and 50.4(7.2) for healthy subjects)

• SEM for right side MMT using handheld dynanometer (HHD) = 1%
• SEM for left side MMT using handheld dynanometer (HHD) = 2%

Minimal Detectable Change (MDC)

Osteoarthritis (OA):

(Youdas et al, 2010)

• MDC for right side MMT using handheld dynanometer (HHD) = 4%
• MDC for left side MMT using handheld dynanometer (HHD) = 4%

Test/Retest Reliability

Osteoarthritis (OA):

(Youdas et al, 2010)

• Excellent test-retest reliability for right side (ICC = 0.98)
• Excellent test-retest reliability for left side (ICC = 0.97)

Responsiveness

Osteoarthritis (OA):

(Youdas et al, 2010)

• Sensitivity = 0.35
• Specificity = 0.90
• Positive likelihood ratio = 3.5

Non-Specific Patient Population

Normative Data

Trapezius Muscle: (Cibulka et al., 2013; n = 11; mean age = 20-31 (23.8) years; mean height 173.9 cm, mean weight 76.2 kg, mean body mass index of 25.0 (SD = 2.2))

The mean and SD for normalized percentages of maximal voluntary isometric contraction (MVIC) for the new trapezius MMT.

The mean and SD’s torque for upper, middle, lower, and new trapezius muscles. These were measured with a Microfet 2 Dynamometer in kilograms.

Test/Retest Reliability

Trapezius Muscle: (Cibulka et al., 2013)

• Excellent test-retest reliability:
  • Upper trapezius testing: (ICC = 0.88 [95% CI: 0.62-0.97])
  • Middle trapezius testing: (ICC = 0.94 [95% CI: 0.78-0.98])
  • Lower trapezius testing: (ICC = 0.89 [95% CI: 0.560-0.97])
  • New trapezius testing: (ICC = 0.92 [95% CI: 0.70-0.98])

  Interrater/Intrarater Reliability

  ICU survivors and simulated patients:

  (Fan et al, 2010, n = 19, 26 muscle groups, 19 clinicians)

  • Adequate to Excellent overall interrater reliability of Upper extremity muscles (ICC = 0.62-1.00)
  • Adequate to Excellent overall interrater reliability of Lower Extremity muscles (ICC = 0.66-1.00)

  Musculoskeletal Conditions

  Standard Error of Measurement (SEM)

  Myositis (Pfister et al., 2018; n=46)

  • SEM using intrarater reliability was 1.8% (2.5)
  • SEM using interrater reliability was 2.2% (3.1)

  Minimally Clinically Important Difference (MCID)

  Myositis (Pfister et al., 2018; n=46)

  • MDC using intrarater reliability = 4.9% (6.9)
  • MDC using interrater reliability = 6.2% (8.6)

  Normative Data

  Myositis (Pfister et al., 2018; n=46)

  • Measurement 1 = 70+/-8
  • Measurement 2 = 71+/-7
  • Measurement 3 = 72+/-7

  Interrater/Intrarater Reliability

  Myositis (Pfister et al., 2018; n=46)

  • Excellent Intrarater reliability ICC (95%CI) = 0.94 (0.90-0.97)
  • Excellent Interrater reliability ICC (95%CI) = 0.91 (0.83-0.95)

  Inflammatory Myopathies: (Rider, L.G. et al., 2010; n=73 children, 45 adults; mean age=10.2 (5.6), 42 (17.2) years; using Kendall’s 0-10 point scale)

  • Excellent intrarater reliability for juvenile IIM: ICC range from 0.84-0.95
  • Adequate interrater reliability for juvenile IIM: ICC range from 0.68-0.76

  Internal Consistency

  Idiopathic Inflammatory Myopathies (IIM): (Rider, L.G. et al., 2010; n=73 children, 45 adults; mean age=10.2 (5.6), 42 (17.2) years; using Kendall’s 0-10 point scale)

  • Excellent internal consistency for total MMT for juvenile IIM (Cronbach’s alpha = 0.97) and adult IIM (Cronbach’s alpha = 0.93)
  • Excellent internal consistency for proximal MMT for juvenile IIM (Cronbach’s alpha = 0.96) and adult IIM (Cronbach’s alpha = 0.93)
  • Excellent internal consistency for MMT6 subset #118 for juvenile IIM (Cronbach’s alpha = 0.85)
  • Adequate internal consistency for MMT6 subset #118 for adult IIM (Cronbach’s alpha = 0.78)
  • Adequate to excellent internal consistency for MMT8 subsets (Cronbach’s alpha = 0.78-0.91)

  Description of muscle groups and their percentage MMT score values in juvenile and adult patients with IIM*

  MMT score

  Muscle groups included in score

  Juvenile IIM (n = 73)

  Adult IIM (n = 45)

  Neck flexors, neck extensors, trapezius, deltoid, biceps, iliopsoas, gluteus maximus, gluteus medius, quadriceps, wrist flexors, wrist extensors, ankle dorsiflexors, ankle plantar flexor

  Trapezius, deltoid, biceps, iliopsoas, gluteus maximus, gluteus medius, quadriceps

  MMT6 subset #118§

  Neck extensors, trapezius, gluteus maximus, iliopsoas, wrist extensors, ankle dorsiflexors

  Neck flexors, trapezius, deltoid, gluteus maximus, iliopsoas, quadriceps, wrist flexors, ankle dorsiflexors

  Neck flexors, deltoid, biceps, gluteus maximus, gluteus medius, quadriceps, wrist flexors, ankle dorsiflexors

  Neck flexors, deltoid, biceps, gluteus maximus, gluteus medius, quadriceps, wrist extensors, ankle dorsiflexors

  Neck extensors, trapezius, deltoid, gluteus maximus, iliopsoas, quadriceps, wrist extensors, ankle dorsiflexors

  Neck extensors, deltoid, biceps, gluteus maximus, iliopsoas, quadriceps, wrist flexors, ankle dorsiflexors

  Neck extensors, deltoid, biceps, gluteus maximus, iliopsoas, quadriceps, wrist extensors, ankle dorsiflexors

  Neck extensors, deltoid, biceps, gluteus medius, iliopsoas, quadriceps, wrist extensors, ankle dorsiflexors

  • * Values are the median (25th, 75th percentiles). Scores are expressed as a percentage of the maximum potential score. MMT = manual muscle testing score; IIM = idiopathic inflammatory myopathies; MMT6 = 6 muscle group MMT.
  • † Proximal and distal muscle groups tested bilaterally; maximum potential score = 240.
  • ‡ Muscle groups tested bilaterally; maximum potential score = 140.
  • § Muscle groups tested unilaterally on the right side; maximum potential score = 60.
  • ¶ Muscle groups tested unilaterally on the right side; maximum potential score = 80.

  Construct Validity

  Myositis (Pfister et al., 2018; n=50; mean age=56 (14.0) years; time since diagnosis=36 (18) months)

  • Excellent convergent validity between MMT with averaged force of hand-held dynameter of shoulder abduction (r = 0.85), neck flexion (r = 0.62), and hip abduction (r = 0.61)
  • Adequate convergent validity between MMT with averaged force of hand-held dynameter of elbow flexion (r = 0.55)
  • Poor convergent validity between MMT with averaged force of hand-held dynameter of wrist extension (r = .27), knee extension (r = 0.28), ankle extension (r = 0.24), and hip extension (r = 0.28)
  • Excellent convergent validity between MMT with normalized force of hand-held dynameter of shoulder abduction (r = 0.75) and hip abduction (r = 0.65)
  • Adequate convergent validity between MMT with normalized force of hand-held dynameter of elbow flexion (r = 0.54), neck flexion (r = 0.57), and hip extension (r = 0.38)
  • Poor convergent validity between MMT with normalized force of hand-held dynameter of wrist extension (r = 0.19), knee extension (r = 0.27), and ankle extension (r = 0.09)

  Idiopathic Inflammatory Myopathies (IIM): (Rider, L.G. et al., 2010; n=73 children, 45 adults; mean age=10.2 (5.6), 42 (17.2) years; using Kendall’s 0-10 point scale)

  • Excellent correlation between Total and Proximal MMT scores in juvenile IIM with distal and axial MMT scores (rs =0.73–0.88, P< 0.000)
  • Adequateto excellent correlation between Total and Proximal MMT scores in adult PM/DM with distal and axial MMT scores (rs= 0.40 – 0.74, P 0.008).
  • Adequate correlation Total and Proximal MMT scores in adult PM/DM correlated with lactate dehydrogenase (rs = -0.45 to -0.50, P = 0.007–0.016).
  • Adequate correlation with creatine kinase (CK), aldolase, and aspartate aminotransferase (rs = -0.30 to -0.38, P = 0.012–0.055).
  • Adequate correlation between Prednisone dose with Total, Proximal, and best MMT subset scores in juvenile IIM (rs = -0.33 to -0.39, P ≥ 0.005)
  • Poor correlation between Prednisone dose with Total, Proximal, and best MMT subset scores in adult PM/DM (rs = -0.11 to -0.22, P > 0.18)
  • Adequate correlation between total MMT and Physician Global Activity for juvenile IIM (rs = -0.54) and adult IIM (rs = -0.33)
  • Excellent correlation between total MMT with Childhood Health Assessment Questionnaire (rs = -0.62), Childhood Myositis Assessment Scale (rs = 0.70), and Convery activities of daily living (rs = 0.63)
  • Adequate correlation between total MMT with MRI STIR + T1-weighted average for juvenile IIM (rs = -0.48) and adult IIM (rs = -0.43)
  • Poor to adequate correlation between total MMT and creatine kinase in juvenile IIM (rs = -0.16) and in adult IIM (rs = -0.34)

  Convergent construct validity (r_s) of MMT scores with measures of myositis activity and damage*

  MMT score

  Total MMT

  Proximal MMT

  Physician Global Activity

  C‐HAQ

  ADL

  CMAS

  MRI STIR + T1‐weighted average

  Creatine kinase

  Juvenile IIM (n = 73)

  Adult IIM (n = 45)

  Juvenile IIM (n = 73)

  Adult IIM (n = 45)

  Juvenile IIM (n = 73)

  Adult IIM (n = 44)†

  Juvenile IIM (n = 58)

  Adult IIM (n = 45)

  Juvenile IIM (n = 69)

  Juvenile IIM (n = 31)†

  Adult IIM (n = 45)†

  Juvenile IIM (n = 73)‡

  Adult IIM (n = 45)†

  MMT6 subset #118

  Content Validity

  Idiopathic Inflammatory Myopathies (IIM): (Rider, L.G. et al., 2010; n=73 children, 45 adults; mean age=10.2 (5.6), 42 (17.2) years; using Kendall’s 0-10 point scale)

  Content validity of the MMT was determined by a panel of expert pediatric and adult PTs, and Rheumatologists experienced in evaluating myositis. Each expert ranked items quantitatively and qualitatively and recorded whether a particular muscle group could not be tested accurately. From the results of this panel, concluded that the instrument has strong content validity (Rider, L.G. et al., 2010).

  Face Validity

  Idiopathic Inflammatory Myopathies (IIM): (Rider, L.G. et al., 2010; n=73 children, 45 adults; mean age=10.2 (5.6), 42 (17.2) years; using Kendall’s 0-10 point scale)

  Rider, L.G. (2010) states that, “The top-rated 8 muscle group subsets also had acceptable face validity, included frequently involved muscle groups, and were felt to be easier to test, even in patients with joint contractures or calcinosis. However, they require prospective validation, including in therapeutic trials, to further define their performance characteristics in other populations (p. 471).”

  Floor/Ceiling Effects

  Myositis (Pfister et al., 2018; n=50; mean age=56 (14.0) years; time since diagnosis=36 (18) months)

  • Adequate ceiling effects of
  • Poor ceiling effects of 22-82% for various muscle groups

  Responsiveness

  Idiopathic Inflammatory Myopathies (IIM): (Rider, L.G. et al., 2010; n=73 children, 45 adults; mean age=10.2 (5.6), 42 (17.2) years; using Kendall’s 0-10 point scale)

  Standardized response means for Total MMT was 0.56 in juvenile IIM and 0.75 in patients with adult PM/DM. Using relative efficiencies, the Proximal MMT score was slightly less responsive relative to the Total MMT score in juvenile IIM, but slightly more responsive in adults with PM/DM (Rider, L.G. et al., 2010).

  • Relative efficiency of MMT subgroups were found (>0.90)

  Pediatric Disorders

  Standard Error of Measurement (SEM)

  Children with Spina Bifida (Mahoney et al., 2009; n=20; mean age = 9 years and 10 months)

  Muscle Group

  SEM

  Minimal Detectable Change (MDC)

  Children with Spina Bifida (Mahoney et al., 2009; n=20; mean age = 9 years and 10 months)

  The 90% confidence level was chosen. Therefore, the MDC represents the change needed to be 90% confident that actual change occurred.

  Muscle Group

  MDC 90%

  Interrater/Intrarater Reliability

  Children with Spina Bifida (Mahoney et al., 2009)

  • Excellent interrater reliability for hip abductors: ICC = 0.75
  • Adequate interrater reliability for knee extensors: ICC = 0.40
  • Poor interrater reliability for hip flexors: ICC = 0.37

  Bibliography

  Cibulka, M. T., Weissenborn, D., Donham, M., Rammacher, H., Cuppy, P., & Ross, S. A. (2013). A new manual muscle test for assessing the entire trapezius muscle. Physiotherapy Theory & Practice, 29(3), 242–248. https://doi.org/10.3109/09593985.2012.718856

  Pfister, P. B., de Bruin, E. D., Sterkele, I., Maurer, B., de Bie, R. A., & Knols, R. H. (2018). Manual muscle testing and hand-held dynamometry in people with inflammatory myopathy: An intra- and interrater reliability and validity study. PLOS ONE. Retrieved from https://www.ncbi.nlm.nih.gov/pubmed/29596450

  Fan, E., Ciesla, N. D., et al. (2010). "Inter-rater reliability of manual muscle strength testing in ICU survivors and simulated patients." Intensive Care Medicine 36(6): 1038-1043. Find it on PubMed

  Herbison, G. J., Isaac, Z., et al. (1996). "Strength post-spinal cord injury: myometer vs manual muscle test." Spinal Cord 34(9): 543-548. Find it on PubMed

  Mahoney, K., Hunt, K., Daley, D., Sims, S., & Adams, R. (2009). Inter-tester reliability and precision of manual muscle testing and hand-held dynamometry in lower limb muscles of children with spina bifida. Physical & Occupational Therapy in Pediatrics, 29(1),44-59. http://dx.doi.org/10.1080/01942630802574858

  Noreau, L. and Vachon, J. (1998). "Comparison of three methods to assess muscular strength in individuals with spinal cord injury." Spinal Cord 36(10): 716-723. Find it on PubMed

  Rider, L.G., Koziol, D., Giannini, E.H., Jain, M., Smith, M., Whitney-Mahoney, K., Feldman, B., Wright, S., Lindsley, C., Pachman, L., Villalba, M., Lovell, D., Bowyer, S., Plotz, P., Miller, F., & Hicks, J. (2010). Validation of manual muscle testing and a subset of eight muscles for adult and juvenile idiopathic inflammatory myopathies. Arthritis Care Res, 62, 465-472. doi: 10.1002/acr.20035

  Schwartz, S., Cohen, M. E., et al. (1992). "Relationship between two measures of upper extremity strength: manual muscle test compared to hand-held myometry." Archives of Physical Medicine and Rehabilitation 73(11): 1063-1068. Find it on PubMed

  Youdas, J. W., Madson, T. J., et al. (2010). "Usefulness of the Trendelenburg test for identification of patients with hip joint osteoarthritis." Physiother Theory Pract 26(3): 184-194. Find it on PubMed

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