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Checking muscle tone is an important part of several movement disorder assessments, such as Parkinson's disease and dystonia. The most universally accepted clinical tool for measuring muscle tone is the Modified Ashworth Scale, which grades muscle spasticity from 1 (slight increase in muscle tone) to 3 (considerable increase in muscle tone). Other methods of measuring muscle tone include the Cutaneous Muscle Reflex test, which involves pinching the skin of the neck or trunk to stimulate cutaneous muscles, and the Patellar Reflex test, which involves striking the patellar ligament with a blunt instrument to elicit a response. Muscle strength is also important and can be graded according to the Medical Research Council (MRC) scale, with zero being no contraction and five representing normal strength. Coordination is another factor that is evaluated by observing a patient's gait and station, as well as their ability to perform rapid alternating movements and point-to-point movements.
| Characteristics | Values |
|---|---|
| Clinical Tool | Modified Ashworth Scale |
| Grading | 0–4, with 0 being no resistance and 4 being a limb rigid in flexion or extension |
| Grading (Modified) | 0–4+, with 1+ being a slight increase in muscle tone, with a catch and release or minimal resistance at the end of the range of motion |
| Grading (Muscle Strength) | 0–5, with 0 being no contraction and 5 being normal strength |
| Coordination Test | Finger-nose, heel-shin, and rapid alternating movements |
| Coordination Evaluation | Gait and station, rapid alternating movements, and point-to-point movements |
| Limb Manipulation | Passive limb manipulation in the awake state with muscles fully relaxed |
| Cutaneous Muscle Reflexes | Pinching the skin of the neck and trunk |
| Patellar Reflex | Hold the pelvic limb in partial flexion and lightly strike the patellar ligament with a hammer; the response is graded from 2 (normal) to 0 (absent) |
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What You'll Learn
Grading scales for muscle power and reflexes
Grading muscle power is considered more useful than grading reflexes, which can be marked as "absent", "present", "brisk", or "hyperactive". However, deep tendon reflexes can be graded as follows: 1+ and 3+ responses may be normal or abnormal depending on the patient's reflex history, other reflexes, and associated findings such as muscle tone, muscle strength, or other evidence of disease. Asymmetry of reflexes suggests abnormality.
Muscle strength testing is an important component of the physical exam that can reveal information about neurologic deficits. It is used to evaluate weakness and can be effective in differentiating true weakness from imbalance or poor endurance. It is also known as motor testing, muscle strength grading, or manual muscle testing. The most commonly accepted method of evaluating muscle strength is the Medical Research Council Manual Muscle Testing scale (MRC scale). This method involves testing key muscles from the upper and lower extremities against the examiner’s resistance and grading the patient’s strength on a 0 to 5 scale. Commonly tested muscles include the shoulder abductors, elbow flexors, elbow extensors, wrist extensors, finger flexors, hand intrinsics, hip flexors, knee extensors, dorsiflexors, great toe extensor, and plantar flexors.
Dynamometry provides a more precise measurement of the force that a muscle can exert and can allow for differences in strength to be tracked over time. Hand-grip dynamometry is a popular example, in which the patient squeezes a handle that records the force being applied. Limitations of dynamometry include the need for costly or specialized equipment, limited muscle groups that can be tested, and limited availability of testing equipment to clinicians across specialties or settings.
The Oxford Scale is another commonly accepted scale that does not require special equipment and demonstrates reasonable interrater reliability. More precise methods of measurement, such as hand-grip dynamometry, are less subjective and provide a quantifiable measurement that can be tracked over time.
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The Modified Ashworth Scale
The MAS is performed by extending the patient's limb first from a position of maximal possible flexion to maximal possible extension (the point at which the first soft resistance is met). The scale is then assessed while moving from extension to flexion. The MAS assigns a grade of spasticity from a 0-4 ordinal scale, with a higher score indicating greater resistance and more pronounced spasticity. A score of 1 on the MAS indicates a slight increase in muscle tone, with a catch and release or minimal resistance at the end of the range of motion when the affected part is moved in flexion or extension. A score of 3 indicates a considerable increase in muscle tone, with passive movement becoming difficult.
The MAS has been applied in clinical practice and research as a measure of spasticity in various patient groups, including stroke, multiple sclerosis, spinal cord injury, cerebral palsy, traumatic brain injury, paediatric hypertonia, and central nervous system lesions. It is widely used due to its simplicity, speed, and ease of use. However, the MAS has also faced criticism for its poor inter and intra-rater reliability, with studies finding only moderate to good intra-rater reliability and poor to moderate inter-rater reliability. The MAS may also be limited in its ability to differentiate between the various factors contributing to resistance to passive stretch.
Despite the criticisms, the MAS remains the most widely accepted tool for measuring muscle tone and spasticity. It is used to evaluate the efficacy of pharmacologic and rehabilitation interventions for the treatment and management of spasticity among patients with SCI. The MAS is also the gold standard for the measurement of new assessment tools, with its validity and reliability being extensively studied to ensure its accuracy and consistency when used by different assessors and across multiple testing occasions.
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Cutaneous muscle reflexes
Cutaneous reflexes play a crucial role in providing smooth gait alterations when encountering or anticipating obstacles and challenging terrain. For instance, cutaneous stimulation of the superficial fibular nerve (SF) occurs when the top of the foot comes in contact with an obstacle. The reflexive response is to pull the leg up and over the obstacle, while also preparing for a potential stumble or fall. This response is achieved through increased biceps femoris activity, which flexes the knee and facilitates the leg movement.
The magnitude of cutaneous reflexes in leg muscles can be influenced by multiple factors, including movement and gait phase. These reflexes can be either excitatory or inhibitory to the normal cutaneous reflex pattern. For example, during the stance phase, high-intensity stimulation of the superficial radial nerve indicates a potential obstacle that could damage the foot. In such cases, the reflex aims to remove the foot completely away from the stimulus. This is achieved by decreased activity of the gastrocnemius muscle, allowing for a more complete dorsiflexion and inversion by the tibialis anterior, which pulls the foot up and inward.
Cutaneous reflexes have also been studied in the context of small muscles of the hand. Electrical and mechanical stimulation of the skin can evoke both excitatory and inhibitory effects in the same muscle. The earliest excitatory and inhibitory responses are believed to be mediated by group III and group II afferent nerve fibres, respectively. Additionally, cutaneous reflex responses have been recorded in the first dorsal interosseous and extensor digitorum brevis muscles following electrical stimulation of the digital nerves of the index finger and second toe. These responses can vary in terms of latency and amplitude, and they are influenced by factors such as central nervous lesions or damage to the motor cortex.
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Motor and sensory systems
To check an individual's muscle tone, a motor exam is performed to evaluate muscles for wasting, fasciculations, and abnormalities in tone. This includes testing reflexes like biceps, triceps, knee, and ankle jerks. The examiner will also test the patient's strength by asking them to contract their muscles against resistance, such as by lifting an arm while the examiner pushes down on it. This is done to assess for lateral differences in strength, which could indicate a deficit in one corticospinal tract. An overall loss of strength could point to a global problem with the motor system.
The sensory system is also crucial in this context, as it processes and transmits sensory information from peripheral receptors to the sensory cortex. Different sensory modalities like pain, temperature, vibration, and proprioception are carried by various nerve fiber types and pathways in the body. Testing these sensory modalities helps localize lesions to different parts of the central or peripheral nervous system.
Reflex testing is particularly valuable in both diagnosis and the location of problems. There are two types of reflexes: muscle stretch reflexes and cutaneous reflexes. Muscle stretch reflexes are essential for normal neuromotor activity and play a role in a child's gait patterns. Podiatrists commonly test tendon taps, ensuring they are brisk, with the relevant tendon on a slight stretch, and the patient relaxed.
Additionally, specific scales, such as the modified Ashworth scale and the Beighton scale, are useful clinical scoring systems for assessing and rating muscle tone and hypermobility. These scales provide a standardized approach to evaluating muscle tone and joint mobility, aiding in the diagnosis and management of various conditions.
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Muscle strength
Manual Muscle Testing (MMT)
MMT is a low-tech method that involves a clinician subjectively interpreting a patient's muscle strength. This can be useful for degenerative diseases that progress quickly, as it allows for frequent monitoring of a patient's strength and can provide meaningful data on the progression of conditions. The therapist will attempt to move the patient's limb against the force of gravity while stabilising the patient's joint and shoulder. The patient's muscle strength is then graded on a scale, such as the Oxford Scale or the Medical Research Council Scale, which use a similar 0-5 grading system.
Dynamometry
Dynamometry uses a range of equipment to provide a more objective assessment of a patient's strength. This method is often preferred over MMT as it provides a numerical value for strength that is considered reliable and valid. One example of a dynamometry test is the "make test", where constant resistance is held against the patient's fully contracted muscle to determine their isometric strength. Another is the "break test", where the therapist applies increasing resistance to the patient's fully contracted muscle to test both isometric and eccentric strength.
Pulmonary Function Muscle Strength Test
This test assesses the strength of the respiratory muscles used for breathing, deep breathing during exercise, and coughing. It is particularly important for patients with diseases involving muscle weakness, such as muscular dystrophy. The test typically involves three separate assessments: normal resting breathing, deep inhalation, and forceful exhalation. For the latter two, the patient may use a mouthpiece to blow out as hard as they can, measuring the strength of their expiratory muscles and their ability to move air in and out of the lungs.
Armed Forces Entrance Physical Qualifications
For those interested in a more general measurement of functional strength, the armed forces' entrance physical qualifications can provide a good benchmark. Organisations like the Navy Seals, Green Berets, and Rangers have publicly available fitness requirements and testing procedures that include percentiles.
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Frequently asked questions
Checking muscle tone usually involves a medical professional and is often part of a full motor examination. They will test your reflexes and muscle strength, which is graded from 0-5. They may also test your coordination and sensation.
The most universally accepted clinical tool used to measure the increase of muscle tone is the Modified Ashworth Scale. This scale grades muscle spasticity from 1-4, with 1 being a slight increase in muscle tone and 4 being a limb rigid in flexion or extension.
The Modified Ashworth Scale is used to test spasticity, which is a velocity-dependent increase in muscle stretch reflexes associated with increased muscle tone. Spasticity can be caused by upper motor neuron syndrome, brain injury, stroke, cerebral palsy, multiple sclerosis, trauma, and spinal cord injury.
Yes, there are other methods such as the Modified Tardieu Scale, Wartenberg Pendulum Test, Clinical Gait Analysis, and the Visual Analog Scale. However, all methods for checking muscle tone have their limitations.
