Intrarater Reliability of Manual Muscle Testing and Hand-held Dynametric Muscle Testing

CAROLYN T. WADSWORTH, RUTH KRISHNAN, MARY SEAR, JEAN HARROLD, and DAVID H. NIELSEN Physical therapists require an accurate, reliable method for measuring muscle strength. They often use manual muscle testing or hand-held dynametric muscle testing (DMT), but few studies document the reliability of MMT or compare the reliability of the two types of testing. We designed this study to determine the intrarater reliability of MMT and DMT. A physical therapist performed manual and dynametric strength tests of the same five muscle groups on 11 patients and then repeated the tests two days later. The correlation coefficients were high and significantly different from zero for four muscle groups tested dynametrically and for two muscle groups tested manually. The test-retest reliability coefficients for two muscle groups tested manually could not be calculated because the values between subjects were identical. We concluded that both MMT and DMT are reliable testing methods, given the conditions described in this study. Both testing methods have specific applications and limitations, which we discuss. Key Words: Muscle contraction, Muscle performance, Physical therapy.

Muscle strength assessment is an integral aspect of physical examination. Knowledge of muscle strength, that is, the muscle's ability to produce tension, assists an examiner in making a differential diagnosis, measuring improvement or deterioration, determining functional impairment, and planning therapeutic measures. Physical therapists have contributed to the development of muscle strength assessment methodologies and routinely use them on a frequent basis. Not all methodologies, however, yield equally quantifiable results. The need for accurate, reliable strength measurements is undeniable, but the best method for

Mrs. Wadsworth is Lecturer, Physical Therapy Education, College of Medicine, The University of Iowa, 2600 Steindler Bldg, Iowa City, IA 52242 (USA). Ms. Krishnan is Staff Physical Therapist, Moline General Hospital, Moline, IL 61265. Ms. Sear is Instructor in Physical Therapy, University of Kansas, Kansas City, KS 66103. Ms. Harrold is Staff Physical Therapist, Marian Health Center, Sioux City, IA 51101. Ms. Krishnan, Ms. Sear, and Ms. Harrold were students in the physical therapy program, The University of Iowa, at the time this study was conducted. Dr. Nielsen is Associate Professor, Physical Therapy Education, College of Medicine, The University of Iowa. This article was submitted May 2, 1986; was with the authors for revision 15 weeks; and was accepted November 3, 1986. Potential Conflict of Interest; 4.

obtaining these measurements has not been ascertained. Manual muscle testing is the most widely used clinical method of strength assessment.1 Manual muscle testing is based on a system of grading movement against examiner or gravity resistance, first used by Lovett in 1912.2,3 Several aspects of this system have led to its being classified as a semiquantitative method of measurement. Some of the MMT grades rely largely on an examiner's judgment. For example, an examiner's subjective assessment of the amount of resistance applied is inherent in the grading criteria for strengths in the Good to Normal range.4-7 In contrast, the grading criteria for muscle strengths in the Poor to Fair range are more objective because an examiner uses gravity as a standard. Another subjective aspect of MMT is that an examiner must develop an internal basis for comparing test results, for example, being able to sense normative values for age, sex, or size of body parts. An examiner also relies on personal experience and skill to palpate muscles and tendons, detect substitution, and properly stabilize the patient for MMT. Use of the standardized MMT protocol, which specifies test positions and incorporates gravity as at least one objective measurement criterion, helps reduce the

potential for human error. Up to 40% of the body's muscles, however, are so small that the part of the grading system based on gravity resistance is inapplicable.3,6,7 Iddings et al, in one of the few published studies that address the reliability of MMT, found that MMT used in a clinical setting can be highly reliable despite differences in examiner training and testing techniques.8 Other researchers, who appraised MMT for standardization in the poliomyelitis vaccine trials, also found it to be reliable.9,10 In contrast, Beasley found that physical therapists using MMT were unable to identify up to 50% of loss of knee extensor muscle strength in patients with poliomyelitis.11 In this study, physical therapists assigned Normal grades to muscles that were able to produce up to only half the force on a cable tensiometer of agematched norms.11 Also, therapists using MMT did not distinguish muscle strength differences of 20% to 25% between patients' strong and weak sides.11 More studies are needed to substantiate one or the other contradictory conclusion of these studies. An alternative to MMT is a quantitative, instrumented system for assessing muscle strength. The Graham-Desaguliers force dynamometer, developed in London in 1763 to measure human PHYSICAL THERAPY

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muscle strength while eliminating synergistic activity, was the earliest reported instrumented system.12 In 1798, Regnier in Paris invented an all-purpose portable dynamometer, which he used for the first recorded attempt to study muscle strength in individuals with diseases.12 Numerous devices have been designed since to provide objective, quantitative strength measurements. They register the peak force generated by a muscle through loading in tension or compression. Myometers, cable tensiometers, dynamometers, and grip meters all have been shown to be statistically reliable instruments for testing muscle strength under various conditions.4,5,13-19 For example, Mathiowetz et al, who studied grip and pinch strength using handheld grip dynamometers and pinch gauges, found interrater correlation coefficients to be .97 or above and testretest reliability coefficients .80 or above; they emphasize that raters must follow standardized test procedures to obtain these results.18 In a comparison of a cable tensiometer, a Wakim-Porter strain gauge, a spring scale, and a Neuman myometer, Clarke found the tensiometer to be the most precise instrument with a test-retest interrater correlation coefficient greater than .90.13 In the sparse literature comparing the results obtained through MMT and muscle testing with a hand-held forcemeasuring device, one study measured the hip flexor and abductor muscle strength of 128 patients with unilateral lower extremity pathological conditions. An examiner using a hand-held device was able to detect consistently unilateral weakness as identified by another examiner using MMT.1 A similar study compared the data obtained from bilaterally testing hip flexors and abductors with a hand-held device to the same tester's subjective identification of the stronger limb. The tester's subjective assessment was correct in 82% of the cases, but he was unable to identify the stronger limb when the mean strength difference between limbs was less than 8.8% in abduction and less than 6.4% in flexion.20 Few, if any, studies have determined the intrarater reliability of both MMT and hand-held dynametric muscle testing (DMT) to compare the two modes of testing. Most physical therapists assess muscle strength using one or both methods. A reliability study would facilitate their choice of method and confidence in their results. Recognizing the Volume 67 / Number 9, September 1987

need to identify a reliable, clinically acceptable method of muscle strength assessment, we designed our study to determine the intrarater reliability of MMT and DMT, including subjective between-method comparisons of reliability. We also examined the advantages, disadvantages, and clinical utility of these two methods. We expected both methods to be reliable because of their widespread clinical acceptance; however, we hoped this investigation would provide more information regarding the discriminating capabilities of each. METHOD Subjects The human subjects committees of The University of Iowa and St. Luke's Hospital, Cedar Rapids, Iowa, approved this study before subject screening. Criteria for subject selection included a minimum of Fair strength (able to assume and hold test positions against gravity) in the muscle groups to be tested, no spasticity, and the ability to isolate movements on command. We selected 13 subjects who met the criteria and consented to participate in the study from inpatients receiving physical therapy at St. Luke's Hospital. We performed initial tests on all 13 subjects, but because of circumstances unrelated to their disorders, two subjects could not participate in the retest session. The subjects had various chronic orthopedic and neuromuscular diagnoses, producing muscle strength deficiencies that essentially were stable. Their mean age was 70 years, with a range of 21 to 96 years. Procedure We used a test-retest design in which one rater performed duplicate tests (MMT and DMT) offivemuscle groups on the same patients, then repeated the tests two days later. We randomized the type of testing and the order of the muscle groups. A physical therapist with eight years of clinical experience served as the rater. She performed all tests on the patients' involved (potentially weakened) limbs. We examined five muscle groups, selected for their ease of measurement, that is, muscle groups with testing positions that could be assumed readily by the patients and reproduced accurately and maintained by the therapist. These muscle groups and their standardized testing positions are the following2,3:

RESEARCH 1. Wrist extensorstested with the subject seated in a chair with his forearm supported on an adjacent bed, but with his hand unsupported. The subject's elbow was flexed to 90 degrees, his forearm was pronated, his wrist was extended to 30 degrees, and his fingers were relaxed. The rater stabilized the subject's forearm on the bed and resisted movement through contact over the dorsum of the subject's hand. 2. Shoulder abductorstested with the subject seated in a chair with his shoulder abducted to 90 degrees, in zero degrees of rotation, and with his elbow extended. The rater stabilized the subject's shoulder girdle with one hand just proximal to the glenohumeral joint and resisted movement through contact over the distal end of the humerus. 3. Hip flexorstested with the subject seated in a chair with his back supported and his pelvis stabilized by the chair; the subject's arms were across his chest, and his hip was flexed to 135 degrees. The rater resisted movement through contact over the distal end of the femur. 4. Elbow extensorstested with the subject lying supine on a bed with his shoulder flexed to 90 degrees, in zero degrees of rotation, and his elbow flexed to 45 degrees. The rater stabilized the subject's upper arm and resisted movement through contact over the distal end of the ulna. 5. Kneeflexorstestedwith the subject lying prone on a bed with his hip in a neutral position and his pelvis stabilized by the bed; the subject's knee was flexed to 75 degrees. The rater stabilized the subject's thigh against the bed and resisted movement through contact over the distal end of his tibia. The testing position needed to be modified for two subjects who could not tolerate or assume the standard positions. One subject was positioned prone to test the elbow extensors, and the other was positioned side lying to test the knee flexors. These modifications did not appear to hinder the rater. We used the following protocol throughout testing. An investigator screened a subject's chart for pertinent information and identified the side of the involved limbs that were to be tested. Just before testing, one investigator, serving as a subject liaison, met with the subject to explain the procedure and answer questions. She requested that the 1343

subject not converse with the rater in an attempt to eliminate bias regarding the subject's status. She then prepared the subject for testing. The rater entered the room and began testing. Another investigator, serving as a recorder, directed the rater according to the preestablished, randomized mode and order of testing. She told the rater which side to test, which mode of testing to administer first, and the order in which to test the muscle groups. She also recorded all results, verbalized by the rater, and computed the torque measurements obtained with the dynamometer. The rater performed MMT using the positions previously described. She used a "break test," in which a subject actively holds a body part in a prescribed position, while an examiner attempts to "break" the hold by a manual counterforce (Fig. 1). The rater consistently commanded the subject to "hold, hold, don't let me move you" during the contraction, which lasted about five seconds. The rater used the MMT grading system, described by Daniels and Worthingham2 and Kendall and McCreary.3 We assigned ordinal values to the respective descriptive classification levels for the purpose of statistical analysis as follows: 11 = Normal: The ability to move the body part into the test position and hold against gravity and maximum resistance. 10 = Good: The ability to move the body part into the test position and hold against gravity and moderate resistance. 9 = Good minus: The ability to move the body part into the test position and hold against gravity and some resistance. 8 = Fair plus: The ability to move the body part into the test position and hold against gravity and minimum resistance. 7 = Fair: The ability to move the body part into the test position and hold against gravity. 6 = Fair minus: The ability to move the body part more than half way to completion of the test position against gravity. 5 = Poor plus: The ability to move the body part less than half way to completion of the test position against gravity. 4 = Poor: The ability to move the body part into the test position with gravity lessened.
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Fig. 1. Testing kneeflexormuscles using manual muscle testing.

3 = Poor minus: The ability to move the body part more than half way to completion of the test position with gravity lessened. 2 = Trace plus: The ability to move the body part less than half way to completion of the test position with gravity lessened. 1 = Trace: The ability to initiate a feeble contraction or flicker of muscle or tendon movement that is visible or palpable, but does not move the body part. 0 = Zero: No ability to contract the muscle. The rater used a calibrated 25-kg Chatillon* hand-held dynamometer for DMT (Fig. 2). She chose a cuff of appropriate size to fit a subject's limb. She held the dynamometer perpendicular to the limb at the specified contact points. She tested the subjects in the positions previously described for MMT. She used a "make test," in which a subject exerts maximum force against the stationary dynamometer (Fig. 3). She used the verbal command "Push, push. Is that all you've got?" during the contraction, which lasted about five seconds. The rater performed three trials and then
* John Chatillon & Sons, 83-30 Kew Gardens Rd, Kew Gardens, NY 11415.

Fig. 2. Hand-held dynamometer and tape measure used in dynametric muscle testing.

measured the distance from the center of the dynamometer pad to the joint axis. The recorder documented each force measurement and calculated the torques as the products of the distance and the forces. The subject liaison investigator remained with the subject to answer any questions after testing. The same procedure was followed during the retest, which was conducted two days later. Data Analysis A simple computer procedure was used to rank the MMT ordinal data in ascending order (from lowest to highest) before the statistical analysis. The statistical analysis involved computing bePHYSICAL THERAPY

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ferences during DMT for the other muscle groups. DISCUSSION As reflected by the between-test correlation coefficients and lack of significant mean differences, MMT for shoulder abduction, hip flexion, and knee flexion demonstrated good intrarater reliability in this study. These results complement the findings of Iddings et al8 and Lilienfeld et al,10 which showed that MMT had high interrater reliability. These results, therefore, suggest that MMT is a consistent evaluation tool. Our results, however, also reflect that MMT is less discriminating than DMT in identifying small differences in muscle strength. Because we adhered to the MMT grading system with inherently few increments, MMT was less sensitive than DMT to variability in strength of muscles in the Fair to Normal range. Beasley also identified this limitation of MMT.11 Thus, physical therapists can use MMT with confidence in its reliability, but may not be able to detect muscle strength increments as discretely as with instrumented systems. Dynametric muscle testing also demonstrated high intrarater correlation coefficients. In contrast to the almost identical test-retest mean MMT values, the retest mean DMT values were higher for all five muscle groups, with two tests being statistically significant. We attributed the observed increases to a learning effect, which could be minimized by familiarizing subjects with the dynamometer during a practice session. (Perhaps further study is indicated to determine the amount of practice needed before stabilizing of values.) Our results, thus, support physical therapists' use of a hand-held dynamometer as a reliable muscle strength testing tool. Manual muscle testing and DMT were comparably reliable, given the conditions described in this study, but each method has specific applications and limitations. Manual muscle testing is clinically versatile and inexpensive to administer, requiring only an appropriate supportive base for a subject. This system is devised to measure the entire range of muscle strength from Zero to Normal, but is limited to only 12 ordinal values that produce an inherent limitation in measurement resolution. Using this system, a tester can grade only clinically detectable weakness and thus may not be able to discriminate accurately small variations of strength, particularly 1345

Fig. 3. Testing knee flexor muscles using dynametric muscle testing. TABLE Test-Retest Reliability Coefficients Manual Muscle Testing Dynametric Muscle Testing (r) .88b .69 .72* .90* .75*

Muscle Groups

(r)
Wrist extensors Shoulder abductors Hip flexors Elbow extensors Knee flexors
a
a

.98 .74b
a

.63

Ellipsis indicates that reliability coefficient could not be calculated for this muscle test because the MMT grade was essentially the same for all subjects for the test-retest data. With the exception of one subject who had an MMT grade of 10 on one test and a grade of 11 on the other test, all subjects demonstrated the grade of 11 for both tests. * Statistically significant from zero (p < .05).

tween-test Pearson product-moment reliability coefficients and between-test Student's paired t tests on the DMT and ranks of the MMT data. Pearson product-moment correlation analysis and Student's t tests on the ranks of the ordinal data are equivalent to Spearman's rank order correlation analysis and the Wilcoxon matched-pairs signedranked test, respectively.21 RESULTS As shown in the Table, the test-retest reliability coefficients for the MMT ranged from .63 to .98 and were statistically significant (p < .05) for the shoulder abductor and hip flexor muscles. The correlation coefficients could not be calculated for the wrist extensor and
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elbow extensor muscles because, with the exception of one subject, the subjects demonstrated a grade of 11 on both the test and retest, invalidating this statistical technique. The test-retest reliability coefficients for the DMT ranged from .69 to .90. With the exception of the shoulder abductor muscles, the test-retest reliability coefficients for all muscle groups during DMT were statistically significant (p < .05). The paired t test revealed that no significant test-retest mean differences occurred during MMT for all muscle groups (p > .05) (Fig. 4). The paired t test, however, did demonstrate significant test-retest mean differences during DMT for the wrist extensor and elbow extensor muscles (p < .05) (Fig. 5). We found no significant test-retest mean dif-

in the Good to Normal range. Deviation from standardized testing procedures and the subjectivity of the grading system are potential sources of error. Muscle testing with a hand-held dynamometer provides a more objective means of muscle strength measurement than MMT with a continuous range of torque values. Use of an instrument, however, adds to the cost and complexity of testing. This method is most useful for measuring muscle strength greater than Fair, although some clinicians use it in gravity-eliminated positions.22 It is inapplicable for measuring muscle strength less than Poor. Use of a handheld dynamometer also is limited in the upper muscle strength ranges where an examiner may have difficulty stabilizing the instrument and resisting the subject. An examiner's own strength may affect his ability to use a dynamometer appropriately with stronger subjects. Recommendations for further studies include recognizing the numerous variables that can affect the reliability of both manual and dynametric methods. Maximal muscle contraction is limited ultimately by structural properties, neural activation, and feedback mechanisms.23,24 Numerous external factors also affect a subject's ability to exert a maximal contraction, such as pain, motivation, cooperation, limb and body position, physical condition, feedback of results, instructions, competition, fear, and incentives.7,17,18,23,25 McGarvey et al even found a statistically significant change in isometric strength with time of day, ranging from 3.97% to 7.22% for different muscle groups.17 An examiner's technique, which varies according to training, experience, strength, and standards, also may influence the results of muscle strength measurements.5-8,25 Other factors that must be considered during muscle strength testing include the type and velocity of contraction, warm-up activity, and adequate stabilization.24 Kroll proposed that the timing of trials may introduce experimental error; inadequate recuperation time between trials may cause energy depletion with apparent strength decrease, whereas successive daily sessions may produce a training or learning effect with apparent strength increase.14-16 Body position and joint angles have been shown to be major variables in muscle strength assessment, thus advancing the use of standardized test positions.5,26 This study was based on a relatively small sample. The criterion that all sub1346

Test Retest

Fig. 4. Manual muscle testing: test-retest mean grades and standard errors (N = 11). Although grades 1 through 11 were possible, because of criteria for subject selection, only grades 9 through 11 were present in subjects. None of the test-retest mean differences were statistically significant (p > .05).

Test Retest

Fig. 5. Dynametric muscle testing: test-retest mean torques and standard errors (N = 11). Note: Asterisks indicate statistically significant test-retest mean differences (p < .05).

jects must have at least a Fair grade for all muscle groups tested placed a limitation on the range of strength of the subjects. This limitation decreased the variance and made assessment of reliability more difficult. We propose extending this investigation to include more subjects and expanding the criteria for subject selection to allow a greater variance in strength. The potential for rater bias carrying over from the initial test to the retest exists in a study such as ours. We attempted to minimize this bias by separating the test and retest sessions by two

days. We also minimized rater contact with the subjects by having different persons screen the subjects and record the test values.
CONCLUSIONS

This study explored two common methods of assessing muscle strength, MMT and DMT. Given the restrictions described in this study, we consider both methods of strength testing to be reliable for the muscle groups we tested. We also identified limitations of each method, noting that particularly in stronger subjects the dynamometer becomes more
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difficult to stabilize and MMT becomes less discriminating. With confidence in both methods, we recommend allowing the subject's physical condition and the clinical or laboratory setting's test objectives to determine the test of choice. Our results support the reliability of testing methods that physical therapists commonly use and thus contribute to the significance of the MMT and DMT methods. Acknowledgments. We thank the rater, Phyllis Griffin, LPT, and John Wadsworth, MA, LPT, Director of Physical Therapy, both of Saint Luke's Hospital, Cedar Rapids, IA, for their assistance in the completion of this study.
REFERENCES
1. Marino M, Nicholas JA, Gleim GW, et al: The efficacy of manual assessment of muscle strength using a new device. Am J Sports Med 10:360-364,1982 2. Daniels L, Worthingham C: Muscle Testing: Techniques of Manual Examination, ed 4. Philadelphia, PA, W B Saunders Co, 1980 3. Kendall FP, McCreary EK: Muscles: Testing and Function, ed 3. Baltimore, MD, Williams & Wilkins, 1983 4. Borden R, Colachis SC: Quantitative measurement of the Good and Normal ranges in muscle testing. Phys Ther 48:839-843, 1968

5. Clarke HH, Elkins EC, Wakim KG: Relationship between body position and the application of muscle power to movements of the joints. Arch Phys Med 31:81-89, 1950 6. Hosking GP, Bhat US, Dubowitz V, et al: Measurements of muscle strength and performance in children with normal and diseased muscle. Arch Dis Child 51:957-963, 1976 7. Wakim KG, Gersten JW, Elkins EC, et al: Objective recording of muscle strength. Arch Phys Med 31:90-99, 1950 8. Iddings DM, Smith LK, Spencer WA: Muscle testing: Part 2. Reliability in clinical use. Phys Ther Rev 41:249-256, 1961 9. Gonnella C, Harmon G, Jacobs M: The role of the physical therapist in the gamma globulin poliomyelitis prevention study. Phys Ther Rev 33:337-345, 1953 10. Lilienfeld AM, Jacobs M, Willis M: A study of the reproducibility of muscle testing and certain other aspects of muscle scoring. Phys Ther Rev 34:279-289, 1954 11. Beasley WC: Influence of method on estimates of normal knee extensor force among normal and postpolio children. Phys Ther Rev 36:2141,1956 12. Peam J: Two early dynamometers: An historical account of the earliest measurements to study human muscular strength. J Neurosci 37:127-134, 1978 13. Clarke H: Muscular Strength and Endurance in Man. Englewood Cliffs, NJ, Prentice-Hall Inc. 1966, pp 10-16 14. Kroll W: Reliability variations of strength in testretest situations. Research Quarterly 34:5055, 1963 15. Kroll W: A reliable method of assessing isometric strength. Research Quarterly 34:350355, 1963

16. Kroll W: Reliability of a selected measure of human strength. Research Quarterly 33:410417, 1962 17. McGarvey SR, Morrey BF, Askew U , et al: Reliability of isometric strength testing: Temporal factors and strength variation. Clin Orthop 185:301-306, 1984 18. Mathiowetz V, Weber K, Volland G, et al: Reliability and validity of grip and pinch strength evaluations. J Hand Surg [Am] 9:222-226, 1984 19. Wiles CM, Kami Y: The measurement of muscle strength in patients with peripheral neuromuscular disorders. J Neurol Neurosurg Psychiatry 46:1006-1013, 1983 20. Saraniti AJ, Gleim GW, Melvin M, et al: The relationship between subjective and objective measures of strength. Journal of Orthopaedic and Sports Physical Therapy 2:15-19, 1980 21. Conover WJ, Iman RL: Rank transformations as a bridge between parametric and nonparametric statistics. The American Statistician 35(3):124-132, 1981 22. Darcus HD: A strain-gauge dynamometer for measuring the strength of muscle contraction and for re-educating muscles. Annals of Physical Medicine 1:163-176, 1952 23. Kroemer KHE, Marras WS: Towards an objective assessment of the "maximal voluntary contraction" in routine muscle strength measurements. Eur J Appl Physiol 45:1-9, 1980 24. Smidt GL, Rogers MW: Factors contributing to the regulation and clinical assessment of muscular strength. Phys Ther 62:1283-1290, 1982 25. Edwards RHT, McDonnell M: Hand-held dynamometer for evaluating voluntary-muscle function. Lancet 2:757-758, 1974 26. Elkins EC, Leden UM, Wakim KG: Objective recording of the strength of normal muscles. Arch Phys Med 32:639-647, 1951

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