Functional Muscle Examination and Gait Analysis"

Functional Muscle Examination and Gait Analysis" Betty R. Landen, Captain, AMSC, and Amelia D. Amizich, Major, AMSC The concept of manual muscle testing was developed early in the twentieth century by Dr. Robert Lovett and Wilhalmine Wright. At that time, the incidence of poliomyelitis was increasing steadily. Dr. Lovett realized that some method of evaluating the extent of disability was important. Since then, efforts of physical therapists and some physicians have resulted in a voluntary muscle test which is universally accepted. 4 Resistance to movement, either by gravity or manual resistance has constituted the basis of manual muscle tests. These were designed to evaluate the type of muscle imbalance noted in patients with poliomyelitis. Changes in medical care have created a need for different types of evaluation. While Salk and others were developing a vaccine to prevent poliomyelitis, scientists also were developing drugs, improved surgical techniques, and other methods of prolonging life. Simultaneously, man was discovering mechanical tools which can injure him, such as the automobile. Presently, much of the physical therapist's time is given to treatment of congenital, traumatic, geriatric, and other neurological disorders. Spasticity, poor co-ordination, and other reflex responses of neuromuscular deficiencies, present problems which are not seen in poliomyelitis. Specific methods of muscle re-education which were effective for treating muscle weakness in lower motor neuron disease have been supplemented by new techniques more applicable to motor dysfunction in upper motor neuron lesions. These changes in the type of involvement and treatment procedures suggest the need for more realistic attitudes in the evaluation of cerebral vascular accidents, multiple sclerosis, brain tumors, Parkinson's disease, amyotrophic lateral sclerosis, spinal cord injuries, and other central nervous system disorders. 3,12 In examining a patient who has involvement of the central nervous system, muscles or groups of muscles which appear to be functional when tested in the accepted voluntary muscle test posi- * Physical Therapy Department, Letterman General Hospital. San Francisco, California. tions often are useless when the patient's position is changed. Conversely, many muscles which appear severely involved when the patient is prone or supine may prove to be highly useful in the erect position. There are several reasons for these responses, such as impairment in tactile or proprioceptive sensation, or the presence of hyperactive reflexes such as the labyrinthine, tonic neck, or stretch responses. 9,13 For example, a hemiplegic patient in the supine position may be able to extend his elbow against gravity, aided by the stimulus provided by the resistance of gravity and the labyrinthine response. The labyrinthine response reinforces extension when the head is positioned face-up in space. The same patient may be unable to extend the elbow, in a sitting position when the head is erect, ruling out the labyrinthine response and the force of gravity. The same patient may be unable to flex his hip against gravity in the sitting position, but may be able to flex it when walking because when motion is started from an extended position a stretch response in the flexor group is elicited. Another phenomenon often seen in upper motor neuron involvement is the ability of the patient to perform movements as part of a "relatively normal" pattern of motion when he is unable to contract one muscle specifically or move only one joint through a given range. For example, the patient may be able to make a fist or grasp a medium-sized object when he is unable to isolate the action of the flexor digitorum profundus. How do we grade this on a voluntary manual muscle test? Spasticity, tremor, rigidity, and poor co-ordination are often seen in these patients, with or without significant paresis. Frequently, patients have difficulty in performing fine movements or in performing antagonistic movements rapidly. We may test the muscles of the forearm and hand grossly or specifically and find them all to be functional or better in strength, but on further examination find that the patient is unable to put this strength to work. An effective treatment program is geared to the individual patient's needs. Testing must not be limited to one phase of the neuromuscular involvement.

40 J.A.P.T.A., Vol. 43, No. 1 Treatment programs are directed toward helping the patient to resume an active role in society. Gross motions, diagonal patterns, developmental postural reactions, and many other reflex responses may be utilized to stimulate muscle action; but our optimal goal is voluntary muscle control in a position of function, sitting or standing. 1, 8 Since we are already aware that, for various reasons, the ability of the patient varies with his position, it seems wise to evaluate him in the positions which he will eventually assume. One of the first questions in evaluating the patient in terms of more generalized functional motions is how to grade his performance. Basically, this can be divided into three categories the activities he can perform normally, the movements that are restricted in some manner, and the movements he is unable to perform at all. The activities he cannot perform and those which he does with normal strength, endurance, and co-ordination are relatively easy to determine and record. The problem is grading the degree of involvement between the two extremes. It may be possible to furnish the doctor with the necessary information with relatively few grades by using progress notes to indicate improvement or regression. HISTORY OF PROPOSED TESTS Specific muscle testing techniques have proved valuable in poliomyelitis, peripheral nerve injuries, and other disorders where muscle strength is lost without interruption of the higher mechanisms of control and integration in the brain and spinal cord. Our scope of testing must be enlarged to meet the additional problems (such as proprioceptive loss, inco-ordination, and abnormal reflex activity) of damage to the central nervous system. In an attempt to solve these problems, the Functional Muscle Examination and Gait Analysis for upper motor neuron lesions were devised at Letterman General Hospital in 1959. Seventy-eight patients have been tested by Functional Muscle Examination and fifty-three by Gait Analysis. A total of 247 tests were administered, including repeat evaluations. Over seventeen different diagnoses were tested including cerebral vascular accidents, traumatic conditions of the brain and spinal cord, tumors and many degenerative neuromuscular disorders. In February 1960, the original tests were distributed to twelve of the larger Army hospitals for six month's trial and evaluation. All of the installations participating in the evaluation were very co-operative, within the limits of their patient load. Many useful suggestions were received. These were compiled and reviewed, and the results of the primary survey plus a revision of the tests were redistributed for further study in October 1960. The second evaluations were received in March 1961 and the tests were again reviewed, revised, and discussed with military and civilian physical therapists. A year later, the revised tests were sent to all of the Army Physical Therapy sections for final evaluation in clinics of varying size and patient load. The final reports were received in February 1962, and the tests presented now are the latest compiled from three years of research and study. ADVANTAGES Although the Functional Muscle Examination and Gait Analysis were developed together, either may be used separately for a specific problem. They appear to have the following advantages in the evaluation of upper motor neuron lesions and some other neuromuscular disorders: 1. They are not time-consuming. Both can be administered in an hour or less, even by therapists who are not familiar with this type of testing. 2. Any member of the medical staff can read them easily as the grades are defined on the test, and the activities and motions are self-explanatory. 3. The tests aid the physical and occupational therapists in planning treatment programs. 4. They may indicate vocational possibilities limitations or necessary changes. For example, a person whose previous occupation required manual dexterity might need to be reevaluated, and perhaps re-trained if he had difficulty with the co-ordination activities on the test, such as straightening the fingers and buttoning buttons. 5. The tests provide a written record of progression or regression of the patient's illness and/or disability. 6. The tests may be useful as a stop-gap evaluation between the voluntary muscle test and the activities of daily living test in lower motor neuron or muscular disorders as well as upper motor neuron lesions. 7. The patient is tested in the position you expect he will assume in a functional activity; for example, hip flexors and triceps as mentioned earlier. 8. The examiner and/or evaluator is reminded, by the activities and motions listed, of possible deviations from normal and of what to look for in patients.

J.A.P.T.A., Vol. 43, No. 1 41 FUNCTIONAL MUSCLE EXAMINATION FOR UPPER MOTOR NEURON LESIONS SCALE: 0 PATIENT UNABLE TO PERFORM ACTIVITY 1 - PARTIAL PERFORMANCE ONLY 2 - PERFORMANCE POSSIBLE NOT PRACTICAL - ADEQUATF EXAMINER N - NORMAL STRENGTH ENDURANCE CO ORD. S - SPASTICITY C- CONTRACTURE T- TRFMQR EXAMINER LEFT RIGHT A. NECK (SITTING) FLEX FROM COMPLETE EXTENSION EXTEND FROM COMPLETE FLEXION TURN TO SIDE B. UPPER EXTREMITIES (SITTING) C. DEXTERITY REACH UP BRING HAND TO MOUTH REACH OUT STRAIGHTENING ELBOW HAND BEHIND BACK PRONATE - SUPINATE GRASP AND HOLD (MEDIUM AND LARGE OBJECTS) PINCH (OPPOSE THUMB TO INDEX FINGER) STRAIGHTEN FINGERS WITH WRIST NEUTRAL BUTTON GARMENTS (SMALL - MEDIUM - LARGE) WRITE D. LOWER EXTREMITIES E. TRUNK LIFT HEEL TO OPPOSITE KNEE (SITTING) STAND FROM SITTING POSITION EXTEND FROM FLEXION WITH HEELSTRIKE (STANDING) STAND ON TOES ALTERNATELY STAND ON HEELS ALTERNATELY SIDESTEP TO RIGHT SIDESTEP TO LEFT BALANCE ON ONE LEG STEP UP (MAXIMUM IN INCHES) SIT FROM LYING POSITION BEND TO SIDE AND RETURN ROTATE TRUNK AND RETURN BEND FORWARD AT HIPS AND RETURN HIKE HIP NAME (LAST, rlrst, Ml) GRADE SN BRANCH WARD TEST REQUESTED BY: DIAGNOSIS: LGH FORM 229-A 10 vjul 62 (PHYS MED) COMMENTS ON REVERSE SIDE ARMY-FT MASON, CALI F

42 J.A.P.T.A.. Vol. 43, No. 1 GAIT AN ALYSIS FOR UPPER MOTOR NEURON LESIONS LE FT KHjfl EXAMINER SL SLIGHT m WUUCKA1C SV - SEVERE EXAMINE R A. APPARATUS (CHECK ONLY IF APPLICABLE) HEAD SUPPORT TRUNK SUPPORT BRACE (INDICATE TYPE) CRUTCH OR CANE B. UPPER EXTREMITIES (CHECK ONLY IF APPLICABLE) C. STANCE PHASE D. SWING PHASE ARM SUPPORTED BY SLING ELBOW HELD IN FLEXION ELBOW HELD IN EXTENSION HIP DYSFUNCTION LEANS TRUNK TO THE SIDE KNEE HYPEREXTENDS KNEE REMAINS FLEXED STANDS ON TOES FOOT IN VARUS FOOT IN VALGUS PUSH -OFF WEAK HIP DYSFUNCTION KNEE HELD IN EXTENSION EXAGGERATES KNEE FLEXION FOOT HELD IN VARUS FOOT HELD IN VALGUS FOOT DROPS E. GENERAL PROBLEMS VARIANCE IN STRIDE IMPAIRMENT IN COORDINATION IMPAIRMENT IN BALANCE NAM E (L AST, FIRST, Ml) GRADE SN BRANCH WARD TEST REQUESTED BY: DIAGNOSIS: LGH FORM 229 COMMENTS ON REVERSE SIDE ARMY-FT MASON, CALIF 10 JUL 62 (PHYS MED)

J.A.P.T.A., Vol. 43, No. 1 43 FUNCTIONAL MUSCLE EXAMINATION In all types of testing, the procedures must be standardized as much as possible if different persons are to administer the test and obtain the same results. Only in this way can there be a reliable test which will serve a useful purpose. With this thought in mind, the following rules have been set up for administering the Functional Muscle Examination for upper motor neuron lesions. 1. Since this is basically a test of muscle strength, endurance, and co-ordination, the patient is tested without any adaptive or supportive equipment that he might normally use. The only exception is a corset or other form of trunk support, if necessary, to maintain the erect position for testing the extremities. 2. All sitting tests should be performed in a straight chair without arms. 3. All standing tests should be done in the parallel bars using one hand on the bars for balance. 4. Grades of three (3) and normal (N) are recorded in black, all others in red. 5. Neck motions may be limited, primarily in older people, by arthritis or other conditions not involved in the patient's immediate problem. If the range of motion is not adequate for his daily use, then a grade of one (1) should be given and this explained in the comments. 6. We use the same standard of testing the upper extremities regardless of hand dominance. 7. Reach-up and reach-out are tests of the shoulder and elbow. Mild resistance by the tester may be necessary to determine a grade of normal (N). Hand function is covered by other test activities and should not influence the grading of the shoulder and elbow. 8. Hand, behind back is tested here for extension and internal rotation of the shoulder with elbow flexion and forearm pronation, as a motion basic to dressing activities. 9. Pronation and supination are tested with the arms adducted and the elbows flexed to 90. 10. To grasp and hold medium and large objects,, a 3-inch roll of tape might be used for a medium object and a 32 ounce bottle (half full) for a large object. 11. Pinch, in this instance, means opposition of the thumb and index finger. A piece of paper held between the pads of the thumb and index finger as the tester tries to pull the paper away is a good way to determine grades of two (2), three (3), and normal (N). 12. In testing Buttoning garments, the patient should be given the best grade possible for any size button and the size should be indicated by circling small, medium or large. A small button would usually be % inch to % inch in diameter; a medium button % inch to % inch, and a large button anything over 1 inch. Since this is usually a bimanual activity, grade as such. If one hand is less dextrous than the other, grade accordingly. 13. Write indicates handedness. If the patient can sign his name but not write more than that, this usually would be considered possible, not practical, and a grade of two (2) is given. If his normal occupation requires much writing, this should be noted in the comments if the grade is less than normal (N). 14. Lift heel to opposite knee is a test of hip flexion, abduction, and external rotation with knee flexion. These motions, together or in part, may be important to the patient in such things as dressing, transfer activities, and ambulation. 15. Stand from silting position is a test of combined strength (such as quadriceps, gluteus maximus, and trunk) not individual muscle ability. Use grades of (2), (3), or (N) to indicate method used to accomplish activity. 16. Extend from flexon with heel-strike is the motion performed during the second stage of the swing phase of walking and is tested here to determine the ability to dorsiflex while the knee is extending. 17. Side step to right and left tests abduction and adduction of the legs as the patient steps to one side and then the other. 18. Balance on one leg is tested standing still. Balance in ambulation will be tested in the Gait Analysis Test. 19. In stepping-up the patient should be allowed to keep one hand on a rail for balance just as he does in the parallel bars for the other standing tests. The maximum height he can climb, without pushing with his arm, should be recorded. 20. Sit from lying position is not a test of abdominal strength as such, but rather of the patient's ability to do this with any combination of muscle actions. How he does it will be reflected in a grade of three (3) or normal (N), and may be explained under comments if necessary. 21. In bending motions of the trunk, the hands should be allowed to reach toward the floor as the patient attempts to perform the activity. If his balance is poor, the activity might be graded a two (2) from the standpoint of safety. 22. "Hiking" the hip reflects the strength of the stance leg as well as the muscles which elevate the pelvis, lateral abdominals or latissimus, on the side being tested. This is done by asking

44 J.A.P.T.A., Vol. 43, No. 1 the patient to stand on one leg and "hike ' the opposite hip, keeping the hip and knee extended. GAIT ANALYSIS The Gait Analysis for upper motor neuron lesions does not require as many rules and explanations as the Functional Muscle Examination, but some comments are necessary for clarity and standardization. 1. This test is designed to record deviations from the normal pattern of walking. For this reason, only the abnormalities in gait are recorded. 2. The patient should not be tested with parallel bars, unless other ambulation is impossible, since this is not the type of support he would have for daily use. 3. The word braces refers to lower extremity bracing only. The. type of brace may be indicated under comments. 4. The patient should be tested with braces if he normally uses them, and also without them, if possible, for comparison. The test is recorded in red if he is using any type of bracing or crutches and in black if he is being tested without any support. A separate column is used for each test. 5. Crutch or cane should be checked if applicable and the type he is using can be indicated in the comments. If he normally uses a crutch or cane, he should use one while being tested although he may also be tested without, using a separate column, for comparison. 6. Stance phase refers to the extremity as it bears the body weight to allow the opposite leg to move forward. Swing phase refers to the extremity being moved from the time it leaves the floor until it touches the floor again. 7. Under the stance phase, stands on toes is not used here to test the patient's ability to perform this motion, but as an indication of what he actually does when walking. 8. Hip dysfunction refers to any changes of the hip action during either phase of walking and should be graded, as applicable, under swing or stance phase and explained in a comment on the back of the test. 9. Variance in stride may include timing as well as a lengthened or shortened step. This should be graded as applicable and explained under comments. COMMENTS Medical advancements in the past fifty years have given us new challenges to broaden the scope of our work. Medical and surgical techniques, bracing, and methods of therapeutic exercise have been adapted to meet the increased demands; so must our muscle testing procedures be improved. During the past three years at Letterman General Hospital, a concerted effort has been made to find a feasible method of testing upper motor neuron disorders. Experience indicates the tests presented here are a definite step in that direction and give a clearer picture of the patient's actual abilities and disabilities than any of the other available methods. We wish to express our appreciation to the other Army physical therapists who took part in the evaluation of these tests. REFERENCES 1. Bobath, K. and B.: Observations on adult hemiplegia and suggestions for treatment, Part I and II. Physiotherapy, 45:297, 1959 and 46:5, 1960. 2. Brunnstrom, S.: Muscle group testing. Phys. Ther. Rev., 21:3, 1941. 3. Brunnstrom, S.: Associated reactions of upper extremity in adult patients with hemiplegia: an approach to training. Phys. Ther. Rev., 26:225, 1956. 4. Daniels, L., Williams, M. and Worthington, C.: Muscle Testing: Techniques of Manual Examination, 2nd Ed. Philadelphia: W. B. Saunders Co., 1956. 5. Fay, T.: The use of pathological and unlocking reflexes in rehabilitation of spastics. Amer. J. Phys. Med., 33:347, 1954. 6. Fischer, E.: Physiological bases of methods to elicit, reinforce and coordinate muscular movements. Phys. Ther. Rev., 38:7, 46, 1958. 7. Kendall, H. O. and F. P.: Muscles: Testing and Function. Baltimore: Williams & Wilkins Co., 1949. 8. Knott, M. and Voss, D.: Propricoceptive Neuromuscular Facilitation: Patterns and Techniques. New York: Paul B. Hoeber, Inc., 1956. 9. Latimer, R.: Utilization of tonic neck and labyrinthian reflexes for the facilitation of work output. Phys. Ther. Rev., 33:237, 1954. 10. Lovett, R. W. and Martin, E. G.: Certain aspects of infantile paralysis with a description of a method of muscle testing. J.A.M.A., 66:729, 1916. 11. Magnus, R. Koraperstellung, Berlin, 1924, Chapter III. Abstracted in English by S. Brunnstrom. Phys. Ther. Rev., 33:281, 1953. 12. Michaels, E.: Evaluation of motor function in hemiplegia. Phys. Ther. Rev., 39:589, 1959. 13. Rood, M.: Neurophysiological reactions as a basis for physical therapy. Phys. Ther. Rev., 34:444, 1954. 14. Treanor, W. O., Psaki, O., Cole and Debato: Rehabilitation of the brain injured (3 articles). Phys. Ther. Rev., 34:605, 1954. 15. Wright, W. G.: Muscle training in the treatment of infantile paralysis. Boston M. & S. J., 167:567, 1912.