Strength Training ppt

1
Muscle Strength Testing

• University of the Philippines Manila
• COLLEGE OF ALLIED MEDICAL PROFESSIONS
• PT 142 Assessment in Physical Therapy
• Mitch B. Encabo, MPA, PTRP
• Edited for instruction by
• Aila Nica J. Bandong, PTRP

2
LEARNING OBJECTIVES

• At the end of the session the students should be
  able to
• Define muscle strength and their functional
  implications
• Discuss basic considerations in performing muscle
  strength testing
• Differentiate methods of doing muscle strength
  testing
• Discuss Daniels and Worthinghams manual muscle
  testing
• Discuss modified tests used in assessing muscle
  strength
• Instrumental muscle strength testing
• Functional muscle strength testing
• Discuss probable conditions that require
  modifications of the standard technique

3
MUSCLE STRENGTH TESTING

• Refers to the determination of the strength of a
  muscle or muscle group
• Does not reflect muscle function
• Test based on the
• Effective performance of movement
• Manual resistance
• Gravity

4
MUSCLE STRENGTH TESTING

• Purpose
• Diagnostic
• Examine the improvement or deterioration of a
  patients status over time
• Predictive or prognostic tool
• Determine the extent of strength loss
• Outcome measures in clinical research
• Determine the need for compensatory measures or
  assistive devices
• Helps in the formulation of the treatment plan
• Evaluates the effectiveness of treatment

5
MUSCLE STRENGTH vs ENDURANCE

• Muscle Strength
• Force production
• Voluntary exertion in one maximal effect
• Results in isotonic or isometric contractions
• Gross indicator of functional ability

• Muscle Endurance
• Repeated contractions
• Maintenance of isometric contraction

6
MUSCLE WEAKNESS

• Any reduction of the normal ability of the muscle
  to generate force
• Causes
• Muscle strain
• Pain, reflex inhibition
• PNI, Nerve root lesion, UMNL
• Tendon pathology, avulsion, rupture
• Prolonged disuse/immobilization
• Psychological overlay

7
(No Transcript)
8
Test Performance

• Muscle origin, insertion and action
• Function of participating muscles
• Patterns of substitution
• Ability to detect contractile activity
• Ability to palpate muscle or tendon
• Ability to detect atrophy
• Recognize abnormal position or movement

9
Test Performance

• Awareness of deviation from normal ROM , laxity
  or deformities
• Identify muscles with the same innervation
• Relationship of diagnosis to sequence and extent
  of test
• Ability to modify test procedures as necessary
• Effect of fatigue
• Effect of sensory loss and movement

10
Evaluation of Muscle Strength

• Detect substitution whenever weakness exist
• Accurate grading of muscle strength

11
BASIC CONSIDERATIONS

• Observation
• Palpation
• Positioning
• Stabilization
• Resistance
• Validity and reliability

12
Observation and Palpation

• Observe the size and contour of muscles
• Palpate contractile tissues

13
Positioning

• Patient comfort
• Depends partly on the effect of gravity
• Use position that offers the best fixation of the
  body as a whole
• Use antigravity positions as applicable
• Two jointed muscles

14
Stabilization

• Proximal attachment of muscles
• Used to isolate the desired action to a specific
  joint
• Stabilize the part proximal to the part being
  tested
• Stabilization of the proximal attachment of the
  muscle through
• Muscle tension
• Gravitational pull
• External pressure from
• manual stabilization

15
Resistance

• Force that acts in opposition to a contracting
  muscle
• Applied in the direction opposite the line of
  pull
• Must never be sudden or jerky
• Applied gradually, but not to slowly, to allow
  the patient to get set and hold
• Applied uniformly
• Long lever arm vs Short lever arm
• Break test vs Active resistance test

16
(No Transcript)
17
Validity and Reliability

• Inherent limitation
• Types of muscle contractions
• Rate of tension development
• Affected by
• Difference in testing methods
• Magnitude of resistance
• Force application, point of application, speed
• Factors
• Patient factors
• Therapist factors
• Environmental factors
• Others

18
Validity and Reliability

• Patient Factors
• Age
• Gender
• Pain
• Fatigue
• Lower motor
• neuron disease
• Spasticity

• Therapist factors
• Experience
• Manner and content
• of instructions
• Interaction

• Environmental factors
• Temperature
• Distractions
• Other factors
• Muscle factors
• Psychological factors
• Methodological factors

19
METHODS
20
METHODSOFMMT
What is being tested?
Resistance
Type of Contraction
Method of Grading
21
Daniels and Worthingham MMT

• Criteria used in assigning a muscle grade
• Factors considered include the following

• Subjective Factors
• Examiners impression of the amount of resistance
  to give before the actual examination
• Amount of resistance that the patient tolerates
  during the actual test

• Objective Factors
• Ability of the patient to move the body part
  against gravity
• Ability of the patient to complete full range of
  motion
• Ability of the patient to hold the position once
  at the end of the range of motion

• Other Factors
• Amount of manual resistance applied
• Ability of the muscle to move the part through
  the full ROM
• Effect of gravity
• Evidence of contraction

22
Daniels and Worthingham MMT GRADING

• Normal ( N or 5 )
• Full range against maximum resistance and gravity
• Good ( G or 4 )
• Full range against moderate resistance and
  gravity
• Gives or yields at the end of the range
  given maximum resistance
• Functional threshold for the lower extremity
• Fair Plus ( F or 3 )
• Full range against mild resistance and gravity
• Gives or yields to some extent at the end of
  its range given moderate or maximum resistance
• For users of orthosis
• Fair ( F or 3 )
• Full range against gravity
• Gives at the end of the range against mild
  resistance
• Functional threshold for the upper extremities

23
Daniels and Worthingham MMT GRADING

• Poor ( P or 2 )
• Full range, gravity eliminated
• Poor Minus ( P- OR 2 - )
• Partial range gravity eliminated
• Trace ( T or 1 )
• Visible or palpable contraction
• No movement of the body part
• Zero (0)
• No visible or palpable contraction

24
How to Document???

• All muscles of the trunk and extremities are
  grossly graded 5/5 EXCEPT
• Shoulder abductors 3/5
• Knee flexors 3/5
• Significance Muscle weakness 2 to deconditioning

25
How to Document???

• BREAK TEST
• All the muscles of the wrist and hand are grossly
• graded 5/5 EXCEPT
• wrist flexors 4/5
• radial deviators 4/5 ( 10 deg )
• Significance Muscle weakness 2 to pain brought
  about by reflex inhibition

26
How to Document???

• RANGE TEST
• All of the muscles of the lower limb are grossly
  graded as 5/5 EXCEPT for
• hip extensors 4/5 (0-90 degrees)
• hip adductors 4/5 (0-20 degrees)
• Significance Muscle weakness due to prolonged
  immobilization, range test was used 2 to
  contractures of the hip flexors and
  adductors

27
Daniels and Worthingham MMTLIMITATIONS

• Presence of UMNL/ Spasticity
• Presence of joint instability due to chronic
  flaccidity
• Presence of severe contractures

28
Daniels and Worthingham MMTAREAS/CONDITIONS
THAT REQUIRE MODIFICATIONS

• Hands and toes
• Face
• Neck
• Weight bearing muscles
• Children

29
Hands and Toes

• Weight is minimal so effect of gravity is
  unimportant and need not be considered
• Tested in either gravity eliminated or
  gravity-assisted position
• Grading
• 5 Full range with max resistance
• 4 Full range with mod resistance
• 3 Full ROM (whether gravity eliminated or
  assisted)
• 2 Partial ROM (whether gravity eliminated or
  assisted)
• 1 Palpable or observable flicker of muscle
  contraction

30
Face

• Not always practical or possible to palpate
  muscle, apply resistance, or position the patient
  
• Grading
• N/F (N)or light impairment
• Completes test movement with ease and
  control
• WF Moderate impairment that affects the degree
  of active motion
• Performs test with difficulty
• NF Severe impairment
• Minimal muscle contraction
• 0 Absent

31
Neck

• Using gravity eliminated position when testing
  for neck flexion and extension is impractical
• A muscle grade of 2 is assigned when the patient
  can complete partial ROM while in a gravity
  resisted position

Weight Bearing Muscles

• To be resisted maximally, some muscles require
  the assistance of body weight
• For gastrocnemius and soleus only

32
Children

• May not cooperate with standard MMT procedures
• 2-5 y/o can initiate test position, but they
  cannot sustain it because they dont understand
  the concept of exerting counterforce vs examiners
  resistance
• Needs to be modified for 4-6 y/o

33
Daniels and WorthinghamMODIFIED TESTS

• Combined tests for the extremities
• Quickie tests
• Squatting
• Walking on heels and toes
• Break test
• Movement cannot be totally prevented but can be
  minimized by telling the patient dont let me
  move you
• Evaluation of functional activities
• Donning and doffing
• Gripping the examiners hand

34
Daniels and WorthinghamCONSIDERATIONS

• Always start the test at grade 3
• In case a movement needs to be tested in the
  non-standard position , indicate the position
  used
• When in doubt about the grade assigned to a
  muscle group place a (?) beside the grade
• Note special cases ( MMT of fingers or toes, UMNL
  )
• Freedom from discomfort or pain
• Quiet non-distracting well ventilated environment
• Adequately firm and wide plinth with adjustable
  height
• Minimal position changes
• Presence of all materials needed for the test

35
Instrumented Muscle Testing

• Advantage increases the level of accuracy and
  reliability of strength testing
• Instruments/ devices
• Cable tensiometer
• Strain gauge
• Hand-held dynamometer
• Modified sphygmomanometer
• Grip strength dynamometer
• Pinch meter

36
Cable Tensiometer
37
Strain Gauge
38
Hand-held Dynamometer
39
Modified Sphygmomanometer
40
Pinch Meter
41
Instrumented Muscle Testing LIMITATIONS

• Measures isometric strength only
• Not useful for testing trunk strength

Instrumented Muscle Testing CONSIDERATIONS

• Reliability is reasonable
• Important to standardize strength
• Instruments are not interchangeable

42
Dynamic Muscle Testing

• Makes more sense since muscles function
  dynamically
• Machine use Isokinetic machines

43
Isokinetic Testing Machine LIMITATIONS

• Validity has not yet been established
• Movement occurring at constant speed is
  artificial
• Positions and movement constraints are not
  realistic

44
Functional Muscle Testing

• Utilized in cases when muscle strength cannot be
  tested by MMT
• Presence of spasticity and flaccidity
• Patients with poor comprehension
• Patients who are unable to follow instructions
• Observations and description of certain movements
  or activities of the patient

45
REFERENCES

• Clarkson Gilewich(1989), Musculoskeletal
  Assessment. Joint Range of Motion and Manual
  Muscle Strength Williams Wilkins.
• Erickson and McPhee(1993) Clinical Evaluation. In
  Delisa Rehabilitation Principles and Practice
  (2nd ed). Philadelphia JB Lippincott Company.
• Harms - Ringdahl(1993)International Perspectives
  in Physical Therapy.Muscle Strength. New York
  Churchill Livingstone.
• Hislop and Montgomery(2002) Daniels and
  Worthinghams Muscle Testing Techniques of
  Manual Examination(7th ed) PhiladelphiaWB
  Saunders Company.
• Kendall,McCreary, Provance Muscle Testing and
  Function (4th ed)Baltimore Williams and Wilkins,
  1993.
• Magee(1997) Orthopedic Physical Assessment(3rd
  ed) Philadelphia WB Saunders Company.
• Tobis and Hong (1990) Muscle Testing in Kottke
  and Lehmann Krusens Handbook of Physical
  Medicine and Rehabilitation (4th Ed)
  PhiladelphiaWB Saunders Company