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Grading muscle strength is important for clinical purposes, as it helps determine the appropriate course of treatment for patients with musculoskeletal disorders. There are various methods to grade muscle strength, with the most common being the Medical Research Council (MRC) scale, also known as the Oxford scale. This scale has six grades, but some researchers have suggested modifications to improve its accuracy, such as the inclusion of intermediate grades. Other methods of assessing muscle strength include manual muscle testing, functional tests of muscle strength, and myometry, which uses a dynamometer to provide more objective values.
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What You'll Learn
Manual assessment using the Medical Research Council (MRC) scale
Manual muscle testing is often graded using the ordinal Medical Research Council (MRC) scale. The MRC scale is used to quantify and communicate the findings of manual muscle testing. The scale has six grades, although these are not clearly defined, particularly between grades 4 and 5. The span of muscle strength encompassed by each grade also varies widely.
The MRC scale is used to assess muscle strength and weakness. A minus grade on the scale denotes a loss of range, so a grade of 4, by definition, is full range, and therefore 4- is not graded. The MRC percentage is calculated on the 'whole' score, rather than the + and - grades.
When using the MRC scale, if you are uncertain what grade to give, you should choose the lower option. If the results do not give a true indication of the patient's ability, this should be noted, and the results should not be included in the database. If specific muscle groups are a problem, for example due to pain, this should also be noted, and the muscle group should not be included in any calculation of the MRC %.
To perform a manual muscle test, the patient should be asked to perform a movement in the antigravity position. If they are unable to, check their understanding and the range of motion (ROM) available. Based on the limiting factors, either instruct and demonstrate again, decide if ROM is affecting performance, or repeat the test using the antigravity position. Resistance is given through the full available range.
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Myometry: using a dynamometer to assess muscle strength
Myometry is a method of measuring muscle strength using a dynamometer, a device that assesses muscle function by measuring the force generated by muscles. This technique has been used since the late 1700s and has seen advancements in accuracy, portability, and automation over time. Modern muscle dynamometers like Strength By Numbers AxIT Push-IT and Pull-IT provide accurate, portable, and automated solutions for health and fitness professionals.
Hand-held dynamometry (HHD) is a specific type of myometry that is commonly used to assess muscle strength. HHD devices are set up or held by a therapist to obtain an objective measurement of force. Unlike traditional manual muscle testing, which involves a "break test," HHD typically uses a "'make test' format". In a "make test," the subject exerts a maximum isometric force while the dynamometer remains stationary. This assessment requires the subject to push as hard as they can for a duration of 3 to 5 seconds.
The "make test" is preferred over the "break test" because it provides more consistent and reproducible results. During a "break test," the assessor applies force to overcome the strength of the person being tested, resulting in an eccentric muscular contraction. This method introduces greater variability due to the assessor's strength, which can be mitigated in a "make test" by using external stabilization with a belt.
Myometry with a dynamometer is a valuable tool for health and fitness professionals, as well as physiotherapists, as it provides objective and quantitative data to support treatment decisions and track progress. It can be used to evaluate both maximum force and endurance, making it useful for diagnosing muscle weaknesses, imbalances, or impairments. Additionally, myometry helps guide tailored training and rehabilitation programs, optimizing patient care and promoting overall health and fitness.
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Functional tests: e.g. heel-and-toe walking, standing up
Functional tests are a way to assess muscle strength by evaluating a patient's ability to perform essential daily activities. They do not provide a grade or numeric quantity that can be tracked over time to gauge improvement. However, they can provide valuable information about whether the patient has sufficient strength to perform daily tasks.
Functional tests for muscle strength can include heel-and-toe walking and standing up from a seated position. Heel-and-toe walking, or walking on the tips of the toes, is a test of distal strength. It specifically works the tibialis anterior, located on the outer surface of the tibia or shin, and helps to strengthen and stabilize the ankle. Toe walking is common in young children who are learning to walk, but most children outgrow it by the age of two. In older children, persistent toe walking may be a sign of an underlying medical condition, such as autism-related conditions, or it may be due to tightened calf muscles and tendons.
Toe walking can be treated with exercises such as toe raises, which work the muscles in the lower leg and help to strengthen and stabilize the ankle. Toe raises involve lifting the toes while keeping the heels on the ground and can be done while seated or standing. Heel raises, which are similar to toe raises but involve lifting the toes while keeping the ball of the foot on the ground, are also a common exercise for treating plantar fasciitis.
Standing up from a seated position is another functional test of muscle strength. This test can provide information about the patient's overall strength and balance. It can also be used to evaluate specific muscle groups, such as the quadriceps and pelvic girdle. For example, pushing with the arms to get out of a chair may indicate quadriceps weakness, while rising from a supine position by turning prone and using the hands to push erect may suggest pelvic girdle weakness.
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Using a modified MRC scale with an intermediate grade
The ordinal Medical Research Council (MRC) scale is often used to grade muscle strength. It is a 6-point scale (or an expanded 16-point version) that can be used to quickly, safely, and simply assess muscle strength without the need for specialist equipment. However, the MRC scale has some weaknesses, including poorly defined limits between grades 4 and 5 and large differences in the span of muscle strength covered by each grade.
To address these issues, a modified MRC scale with an intermediate grade has been proposed. This modified scale includes an additional grade, '4+', to provide more
The use of a modified MRC scale with an intermediate grade can improve the accuracy and sensitivity of muscle strength assessments. This is particularly important in clinical contexts, where the appropriate course of treatment for a patient may depend on the specific degree of muscle strength or weakness. For example, in conditions such as lumbar radiculopathy, the treatment recommended for a patient may be largely determined by the extent of muscle weakness present.
However, research on the effectiveness of the modified MRC scale has yielded mixed results. One study found that the introduction of a '4+' grade did not significantly improve agreement or variability of ratings among clinicians using the scale. In this study, chiropractors in Northern Europe were presented with clinical cases suggesting muscle weakness between grades 4 and 5 and were instructed to grade muscle strength using either the standard or modified MRC scale. The results indicated that the modified scale did not necessarily lead to greater consistency in grading muscle strength.
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The importance of accurate and sensitive muscle strength assessment
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. The clinical importance of accurate and sensitive muscle strength assessment is clear. In some musculoskeletal disorders, such as lumbar radiculopathy, the appropriate clinical course of action for a patient may be largely dictated by the degree of muscle paresis.
The Medical Research Council (MRC) scale is the most commonly used grading scale for muscle strength testing. It is quick to complete, does not require special equipment, and demonstrates reasonable inter-rater reliability. However, it has some weaknesses, including poorly defined limits between grades and very large differences in the span of muscle strength encompassed by each grade. The introduction of a '4+' grade has been suggested to improve agreement between clinicians, but this has not been supported by studies.
Functional assessment of muscle strength focuses on how independently patients can perform their activities of daily living and whether strength is a limiting factor. It is important to choose the appropriate assessment tool based on the purpose of the assessment, patient characteristics, and the setting. For example, in patients with upper extremity impairment, grip strength measures may not accurately reflect muscle strength and may lead to underestimations. In such cases, a pneumatic dynamometer or Martin vigorimeter may be more suitable alternatives.
Proper technique is crucial during muscle strength testing to ensure valid results. This includes ensuring patient comfort, respecting pain, and considering any contraindications, such as situations where active range of motion or resistance work could disrupt the healing process or worsen the condition. The coordinated contraction of agonist, antagonist, and synergist muscles is also important for generating movement around limb joints.
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Frequently asked questions
The ordinal Medical Research Council (MRC) scale is often used to grade muscle strength.
The MRC scale has poorly defined limits between grades 4 and 5 and very large differences in the span of muscle strength encompassed by each of the six grades.
The modified MRC scale includes an intermediate grade '4+' to improve agreement between clinicians.
The introduction of a '4+' grade did not improve agreement or variability of ratings.
Functional tests of muscle strength include heel- and toe walking and standing up from a seated position.
