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Manual Muscle Testing (MMT)

Based on Dena Gardiner - The Principles of Exercise Therapy

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1. PRINCIPLES & AIMS OF MMT

Principles

1. Gravity as resistance - The effect of gravity on the tested limb segment is the primary baseline resistance. Testing positions are structured around whether gravity is eliminated (horizontal) or acts against the muscle (vertical/anti-gravity).
2. Standardized positioning - Each test has a defined starting position for the patient and the examiner. Consistency in positioning ensures reliability and comparability.
3. Stabilization - The proximal segment is stabilized by the therapist to prevent trick movements and substitution by accessory muscles.
4. Break test vs. active test - In the break test, the examiner applies force to overcome the patient's isometric hold. In active movement testing, the patient moves through range against examiner resistance.
5. Grading objectivity - Results are recorded on a standardized numerical scale (MRC 0-5 / Oxford scale), providing a common language across clinicians.
6. Comparison - The stronger (unaffected) side is tested first and used as a reference standard.

Aims

• To assess the degree of muscle weakness in neurological, musculoskeletal, or systemic conditions
• To establish a baseline before starting exercise therapy
• To monitor progress during rehabilitation and treatment
• To plan therapeutic exercise programs appropriate to the patient's current strength level
• To detect nerve or muscle injury and localize lesions
• To guide appropriate muscle re-education and progressed exercise prescription
• To document functional capacity for medicolegal or disability assessment purposes

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2. INDICATIONS & LIMITATIONS

Indications

Limitations

1. Volition-dependent - Results depend entirely on the patient's cooperation and effort; pain, fear, or poor comprehension give false-low scores.
2. Inter-rater variability - The amount of resistance applied at grades 4 and 5 is subjective; different examiners may grade the same patient differently.
3. Ceiling effect - The scale lacks sensitivity in the upper range (grades 4-5); a patient may show significant strength deficit compared to normal yet still score grade 4.
4. Upper motor neuron lesions - MMT is not reliable in spasticity (UMN lesions) because spastic muscles resist passive movement but may not generate voluntary power.
5. Pain inhibition - Active pathology (inflamed joints, acute tears) inhibits voluntary contraction, giving falsely low grades.
6. Not quantitative - Does not measure force in Newtons; dynamometry is needed for precise quantification.
7. Not suitable for all populations - Children, cognitively impaired, or uncooperative patients cannot be tested accurately.
8. Trick movements - Without proper stabilization, synergistic muscles may substitute, giving falsely high grades.

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3. THE GRADING SCALE (Dena Gardiner / MRC / Oxford Scale)

• 4+ = strong but not quite normal; 4- = barely overcomes moderate resistance
• 3+ = moves against gravity plus minimal resistance; 2+ = partial range in gravity-eliminated position

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4. TECHNIQUES OF MMT

A. General Testing Procedure

1. Explain the procedure to the patient - what you will do and what you need them to do
2. Ensure a comfortable, adequately supported position
3. Expose and inspect the muscle/limb being tested
4. Demonstrate the movement passively first (move the limb through range)
5. Ask the patient to perform the movement actively to assess movement quality
6. Test the unaffected side first to establish the patient's normal baseline

1. Position the patient in the test position appropriate to the grade being assessed
2. Stabilize the proximal segment firmly
3. Apply resistance at the distal end of the moving segment (lever arm principle)
4. Apply resistance in the opposite direction of the movement
5. For grades 1-2: observe and palpate; position in gravity-eliminated plane
6. For grades 3-5: place in anti-gravity position; gradually increase resistance
7. Do not allow substitution - watch for trick movements (e.g., trunk lean, shoulder shrug)
8. Record the grade immediately

• Document bilaterally for comparison
• Note any pain, fatigue, trick movements, or restricted ROM that affected the result

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B. GROUP MUSCLE TESTING

• Quick screening to identify functional weakness
• Used in mass/class settings (Dena Gardiner's "Mass Treatments" concept)
• Identifies which groups need individual testing follow-up

• The patient performs a functional movement (e.g., "lift your leg," "push your hand down")
• Resistance is applied to the group as a whole
• All synergists performing the movement are graded together
• Positional testing follows the same gravity/resistance principles

• Patient supine; therapist resists the hip flexor group at the thigh
• Grades 0-2: side-lying; grades 3-5: supine against gravity

• Initial screening
• Post-acute bed-side assessment
• Monitoring mass rehabilitation classes
• When specific muscle differentiation is not required

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C. INDIVIDUAL MUSCLE TESTING

• Precise localization of a nerve or muscle lesion
• Specific muscle re-education program planning
• Research or medicolegal documentation

• Position the limb so only the target muscle is in an advantageous line of pull
• Stabilize origins and eliminate all accessory muscles
• Movement direction must correspond to the specific fiber direction of the target muscle

• Dorsiflexor group: patient dorsiflexes foot against resistance (group)
• Tibialis anterior (individual): dorsiflexion + inversion; examiner resists specifically in plantar flexion + eversion direction

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5. MMT PROCEDURE - UPPER LIMB MUSCLES

Shoulder Region

Elbow & Forearm

Wrist & Hand

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6. MMT PROCEDURE - LOWER LIMB MUSCLES

Hip

Knee

Ankle & Foot

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7. MMT PROCEDURE - SPINE MUSCLES

Neck (Cervical)

Trunk (Thoraco-Lumbar)

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8. MMT PROCEDURE - FACIAL MUSCLES

• Grade 5 (Normal): Full symmetric movement
• Grade 4 (Good): Slight asymmetry, complete movement
• Grade 3 (Fair): Obvious weakness; incomplete movement
• Grade 2 (Poor): Barely perceptible movement
• Grade 1 (Trace): No movement but possible slight contraction
• Grade 0 (Zero): Complete flaccid paralysis (e.g., Bell's palsy)

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9. DOCUMENTATION TIPS

• Record grade bilaterally (e.g., Right 4/5, Left 5/5)
• Note any pain (P), fatigue (F), or substitution (S) that affected grading
• Repeat testing at consistent times and positions for serial comparisons
• Use a body chart or standard MMT form for clear documentation

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Key Reference

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