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. 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.
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. 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. 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.
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. 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 other hand stabilizes the shoulder above the shoulder joint. The examiner states " Hold it, don't let me push it down. 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. 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. Shoulder MMT can be performed with central venous catheters e.
Figure 2. 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.
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.
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.
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. 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 other hand supports the patient's forearm. Don't let me push it down " and scores Grades 3, 4 or 5. 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.
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.
This test is not performed if there is an ipsilateral radial arterial catheter in place. 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 other hand provides stability at the side of the hip.
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. If weaker than Grade 2, the patient is supine. The examiner asks, " May I touch your leg here? 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. 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. This test can be performed in patients with intact and well secured femoral intravascular catheters. 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. 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. 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.
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.
Plantarflexion Gastrocnemius and Soleus in standing position. Patient stands on test limb with knee extended. Patient may place one or two fingers on a table or other external surface to assist with balance.
Therapist should stand or sit with a lateral view of test limb. Patient actively raises heel from floor 20 consecutive times without rest or fatigue through a full range of plantarflexion. Plantarflexion Soleus only in standing position.
Patient stands on test limb with knee slightly flexed. One or two fingers may be used to assist with balance. Therapist stands or sits with a lateral view of test limb. Patient actively raises heel from floor 20 consecutive times without rest or great fatigue through full range of plantarflexion. Patient is short sitting with ankle plantarflexed. Therapist sits on stool in front of patient and uses one hand to stabilize the leg just above the malleoli.
The other hand is used for resistance by placing it on the dorsal aspect of the foot. Patient actively dorsiflexes against resistance. The patient is short sitting with ankle in slight plantar flexion. Therapist sits in front or on side of test limb and uses one hand to stabilize the ankle just above the malleoli.
The other hand provides resistance by contouring over the dorsum and medial side of the foot at the level of the metatarsal heads. Resistance is directed toward eversion and slight dorsiflexion while patient actively inverts foot. Inversion with dorsiflexion.
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