Report Viewer

NINDS CDE Notice of Copyright
Manual Muscle Testing-Using the Medical Research Council Muscle Grading Scale
Availability
Please visit this website for more information about the instrument: Manual Muscle Testing-Using the Medical Research Council Muscle Grading Scale
Classification
Core: Amyotrophic Lateral Sclerosis (ALS) and Neuromuscular Disease (NMD)
 
Supplemental-Highly Recommended: 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)
Short Description of Instrument
The Manual Muscle Test (MMT), first described in a peer-reviewed publication in 1915, is a scored neurologic examination derived from the Medical Research Council Scale. (Brooke et al, 21983; Medical Research Council, 1976) The MMT is a commonly used method to document impairments in muscle strength. (Cuthbert et al, 2007).
 
Administration Time: 15-30 minutes; Administrative time is dependent on the muscle (s) selected, the age and cooperation of the participant.
 
The Medical Research Council Manual Muscle Testing Scale is strongly recommended for use with Manual Muscle Testing. (Medical Research Council, 1976)
Comments/Special Instructions
In the clinical setting, manual muscle testing (MMT) is commonly used to estimate strength. It has the advantages of being quick, convenient and requiring no equipment. (Meldrum et al., 2003)
 
"Manual muscle testing is both a science and an art. To achieve accurate results, muscle tests must be performed according to a precise testing protocol. The following factors must be carefully considered when testing muscles in clinical and research settings:
• Proper positioning so the test muscle is the prime mover
• Adequate stabilization of regional anatomy
• Observation of the manner in which the patient or subject assumes and maintains the test position
• Observation of the manner in which the patient or subject performs the test
• Consistent timing, pressure, and position
• Avoidance of preconceived impressions regarding the test outcome
• Nonpainful contacts - nonpainful execution of the test
• Contraindications due to age, debilitative disease, acute pain, and local pathology or inflammation" (Cuthbert et al., 2007)
Scoring and Psychometric Properties
Scoring: Most of the time patients are graded on the Modified MRC scale which is included in the form.
Each muscle is observed separately and the power of the muscle in relation to a single joint is recorded on a scale of 0 to 5.
0 = No contraction
1 = Flicker or trace of contraction
2 = Active movement, with gravity eliminated
3 = Active movement against gravity
4 = Active movement against gravity and resistance
5 = Normal power
Grades 4-, 4 and 4+ may be used to indicate movement against slight, moderate and strong reisistance, respectively. (Medical Research Office, 2016)
 
"MMT is a scored neurologic examination derived from the Medical Research Council scale. The scale is numerical, with scores between 0 and 10, and is based on the examination of 34 muscles: neck flexors and extensors; shoulder abductors and external rotators; elbow flexors and extensors; wrist extensors and flexors; abductor pollicis brevis; flexor digiti minimi; hip flexors, extensors, and abductors; knee extensors and flexors; ankle dorsiflexors; plantar flexors; and extensor hallucis longus. Each muscle is scored from 0 to 5, with 0 representing paralysis and 5 normal strength. Modifications to this scale add either a minus or a plus to the score. For example, 4- represents a muscle that is slightly weaker than one with a score of 4, and 4+ is applied to a muscle that is slightly stronger than one with a score of 4. Each muscle strength score is then converted to a 10-point scale. The final MMT score is the mean of the scores of all 34 muscles." (Great Lakes ALS Study Group, 2003)
 
Psychometric Properties: See Bohannon, 2005 and Cuthbert et al., 2007 for reliability/validity data.
Psychometric data from the Shirley Ryan Ability Lab (2020).
Excellent interrater reliability (Intraclass Correlation Coefficient (ICC) = 0.94) and good correlations with myometry in spinal cord injury.
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)
Myositis: inter-rater = 2.2%, intra-rater = 1.8%
Excellent intrarater reliability for juvenile Idiopathic Inflammatory Myopathies (IIM): ICC range from 0.84-0.95
Some ceiling effects inmost muscles.
Rationale/Justification
Strengths: The MMT is commonly used clinically to evaluate muscle strength due to ease of performance and lack of cost. (Karagiannopoulos et al., 2022;Kendall et al., 2005 ) The MMT requires no special equipment, can be performed in virtually any clinical office (or the patient's home), consumes less examiner time to preform. (Great Lakes ALS Study Group, 2003) Reliable inexpensive and quick (Andre et al, 1986)
 
Weaknesses: MMT for strength assessment has been criticized for lacking sensitivity to detect small meaningful changes and low reliability in quantifying muscle force production. (Bohannon, 2005;Karagiannopoulos, 2022) As demonstrated by Beasley, 1961, the MMT grades can be grossly disportionate and therefore poor indicators of strength loss. (Andre et al, 1986)
"In the clinical setting, manual muscle testing (MMT) is commonly used to estimate strength. It has the advantages of being quick, convenient and requiring no equipment. However it is widely acknowledged that MMT has a subjective element, provides only ordinal data, and lacks sensitivity." (Louwerse et al.,1990; Meldrum et al., 2003)
References
Key References:
Medical Research Office. (2016) Aids to the examination of the peripheral nervous system. Accessed 26 June 2023 from: https://www.ukri.org/publications/aids-to-the-examination-of-the-peripheral-nervous-system/.
 
Medical Research Council. Aids to the examination of the peripheral nervous system. London: Her Majesty's Stationery Office, 1976;14.
 
Additional References:
Andres PL, Skerry LM, Munsat TL, Thornell BJ, Szymonifka J, Schoenfeld DA, Cudkowicz ME. Validation of a new strength measurement device for amyotrophic lateral sclerosis clinical trials. Muscle Nerve. 2012 Jan;45(1):81-5.
 
Andres PL, English R, Mendoza M, Florence J, Malkus E, Schierbecker J, Siener C, Malspeis S, Schoenfeld DA, Munsat TL, Cudkowicz ME. Developing normalized strength scores for neuromuscular research. Muscle Nerve. 2013 Feb;47(2):177-82.
 
Beasley WC. Quantitative muscle testing: principles and applications to research and clinical services. Arch Phys Med Rehabil. 1961 Jun;42:398-425.
 
Bohannon RW. Manual muscle testing: does it meet the standards of an adequate screening test? Clin Rehabil. 2005 Sep;19(6):662-7.
 
Brooke MH, Fenichel GM, Griggs RC, et al. Clinical investigation in Duchenne dystrophy: 2. Determination of the "power" of therapeutic trials based on the natural history. Muscle Nerve 1983;6:91-103.
Cuthbert SC, Goodheart GJ. On the reliability and validity of manual muscle testing: a literature review. J Chiropr Med. 2007;15(1):1-23.
 
Florence JM, Pandya S, King WM, Robison JD, Baty J, Miller JP, Schierbecker J, Signore LC. Intrarater reliability of manual muscle test (Medical Research Council scale) grades in Duchenne's muscular dystrophy. Phys Ther. 1992 Feb;72(2):115-22; discussion 122-6.
 
Great Lakes ALS Study Group. A comparison of muscle strength testing techniques in amyotrophic lateral sclerosis. Neurology. 2003 Dec 9;61(11):1503-7.
 
Karagiannopoulos C, Griech S, Leggin B. Reliability and Validity of the ActivForce Digital Dynamometer in Assessing Shoulder Muscle Force across Different User Experience Levels. Int J Sports Phys Ther. 2022 Jun 1;17(4):669-676.
 
Kendall FP, McCreary EK, Provance PG, Rodgers MM, Romani WA. Muscles: Testing and Function, with Posture and Pain. 5th ed. Lippincott Williams & Wilkins; 2005.
 
Louwerse ES, Vianney de Jong JMB, Kuether G. Critique of assessment methodology in amyotrophic lateral sclerosis. In: Clifford Rose, ed. Amyotrophic lateral sclerosis. Demos Publications: New York; 1990. 18, p151-179.
 
Shirley Ryan Ability Lab. (2020) Manual Muscle Test. Accessed 13 July 2023 from: https://www.sralab.org/rehabilitation-measures/manual-muscle-test.
 
Meldrum D, Cahalane E, Keogan F, Hardiman O. Maximum voluntary isometric contraction: investigation of reliability and learning effect. Amyotroph Lateral Scler Other Motor Neuron Disord. 2003 Apr;4(1):36-44.
 
Munsat TL. Development of measurement techniques. Neurology. 1996 Oct;47(4 Suppl 2):S83-5.
 
Personius KE, Pandya S, King WM, Tawil R, McDermott MP. Facioscapulohumeral dystrophy natural history study: standardization of testing procedures and reliability of measurements. The FSH DY Group. Phys Ther. 1994 Mar;74(3):253-63.
 
Document last updated October 2024