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Gonnella and research of poliomyelitis. This numer- tional definition of "normal strength. The authors' de- the subjectivity of grading within with the primary responsibility of scription of this numerical index ad- these ranges of muscle strength.
The dresses the reliability of the grades in reliability of the testing procedures a large-scale research project. The In , Silver et alZ6described the implemented was not addressed. The standardized test was ad- used to define the natural history of Method ministered to 20 nondisabled subjects strength loss in patients with DMDl by three evaluators who assessed 12 and as an outcome measure for docu- Subjects muscle groups per subject using the menting the effectiveness of various MMT method of Daniels and Wor- pharmacologic agents in the treatment Subjects were boys, aged 5 to thingham.
As CIDD Group study partici- interrater reliability of MMT grades planP7 places greater importance on pants, all subjects fulfilled study entry obtained by assessing middle trape- individual muscle group assessment. Eleven apy for genetic muscle diseases in ness before 5 years of age, 3 proxi- staff physical therapists, with an aver- which normal precursor cells are in- mal weakness, and 4 serum creatine age of 2. Informed patients referred for physical therapy. We therefore believe it is examining the effects of prednisone coefficients ranging from.
Their con- of MMT grades of individual muscle poses of this trial, muscle strength clusions indicated that the use of the groups in a population of boys with was operationally defined by the MMT MMT to make accurate clinical assess- DMD. A previous prednisone ments of patient status was of ques- trial36 had reported an increase in tionable value. In this study, the sam- Documenting the reliability of mea- muscle strength after 6 months of ple was not strictly defined and the surements is of particular importance prednisone treatment in an open positions and procedures for testing in the assessment of children with therapeutic trial using historical con- were not standardized between exam- DMD because this is a population trols.
This design probably gives us with which a high rate of intellectual signed to clarify those results and a realistic idea of the interrater reli- impairment and emotional distur- document the reliability of the evalua- ability of grades in current clinical bance has been associated. Based on to cooperate and perform the MMT.
Subject characteristics and muscle strength in patients with ability in muscle force measurements functional abilities are summarized in Duchenne's muscular dystrophy has also been documented and attrib- Table 1.
DMD and to document change in uted to physiologic factors rather than muscle strength over time. The au- to motivation o r voluntary effort.
All examiners therapeutic trials. Reliability of the a measurement tool, in assessing the were physical therapists with 16 to MMT grades was not addressed. The to 15 years of specialty experience in Florence et a described the in- two research questions were 1 What neuromuscular disorders.
All examin- trarater and interrater reliability of a is the intrarater reliability of individ- ers have been involved with the CIDD total muscle score used in the assess- ual MMT grades? This composite score was obtained for various muscle groups? Definitions of the indi- vidual muscle testing grades are shown in Table 2. All positions and procedures for testing were standard- - Table 2.
Range Muscle holds the joint against a The muscle groups tested included combination of gravity and y shoulder abductors and external rota- moderate resistance y tors; elbow and wrist flexors and ex- Same as grade 4, but muscle y tensors; thumb abductors; hip flexors, holds the joint only against Function extensors, and abductors; knee flexors minimal resistance Ambulated independently and extensors; ankle dorsiflexors, Muscle moves the joint fully plantar flexors, inverters, and everters, against gravity and is capable of Required long leg braces bilaterally; and neck flexors and transient resistance, but collapses for ambulation abruptly Required wheelchair for extensors.
Muscle cannot hold the joint ambulation against resistance, but moves the Data Analysis joint fully against gravity Muscle moves the joint against cular disease clinic. Examiners were Data were analyzed using the gravity, but not through full trained in the assessment protocol at weighted Kappa, as described by Co- mechanical range of motion the CIDD Group coordinating center hen,43 to determine the reliability of Muscle moves the joint when prior to data collection.
The intrarater individual MMT grades and grades gravity is eliminated and interrater reliability of all assess- obtained for individual muscle A flicker of movement is seen or ments have been documented yearly groups.
Cohen's Kappa is a reliability felt in the muscle as part of the CIDD Group study pro- index used for nominal and categori- No movement tocol at group meetings at which ex- cal data. Kappa is a chance-corrected aminers tested the same patients. The scribed previ0usly.
Sample sizes after Procedure ment among raters. Weighted Kappa deletion of missing data ranged from differentially weighs discrepancies for ankle dorsiflexors to for Data were collected as part of a between pairs of scores so that the wrist extensors.
Neck flexors and month therapeutic trial to docu- further apart the two scores, the more neck extensors, not being paired, con- ment the effects of prednisone on effect that observation has on lower- tributed fewer observations for muscle strength in patients with DMD. The weights used in extensors and for flexors.
The design of the protocol required this analysis were equal to the num- duplicate visits two identical assess- ber of grades separating a pair of Assessment of the reliability of indi- ments performed within 5 days of scores.
Nunnallp9 states that the minimally acceptable reliability for a scale depends on the use of the mea- - Table 4. Nunnally proposes that reli- Welghted Welghted ability of around. Shoulder external rotators Hip abductors Hip extensors Intrarater reliability of MMT grades Shoulder abductors obtained with the modified MRC scale Elbow extensors for individual muscle groups, as de- Neck flexors termined by the weighted Kappa, is Neck extensors shown in Table 3.
Grades of proximal Elbow flexors muscle groups were more reliable Ankle dorsiflexors than were grades of muscle groups Knee flexors located distally. Ankle plantar flexors Thumb abductors Intrarater reliability of MRC grades larly in this pediatric sample. Based Wrist extensors 0 to 5, as determined by the weighted on comparisons of voluntary versus Wrist flexors Kappa, is shown in Table 4, along electrically stimulated comparisons, with the number of assignments however, variability in muscle force within each grade.
The reliability var- measurements has also been attrib- intrarater reliability of the total mus- ied among individual grades, with uted to physiological factors.
The ICC 1,l for the total mus- musculature could be attributed to transforming individual muscle grades cle score was. Though muscle scores found in patients with DMD. These are ordinally scaled, parametric analy- Manual muscle testing, using the MRC joint contractures not only limit ap- sis of the overall total muscle score scale, provides reliable grades for the propriate positioning for the individ- was deemed appropriate because of assessment of strength of individual ual muscle tests, but they also limit its linear relationship to other vari- muscle groups within a sample of the available range of motion ROW ables previously documented in the boys with DMD when tests are re- through which the muscle may work.
Intrarater reliability ranged able ROM may have a greater effect Reliability denotes the stability of the from.
The weighted Kappa on the distal than on the proximal measure and whether one can obtain values for the proximal muscles were musculature. For example, a similar measurements of the same more consistent than those for the degree wrist o r hip flexion contrac- variable on separate occasions.
There distal muscles, and the weighted ture would leave one with 50 degrees are no universally accepted standards Kappa values for the lower-extremity of motion at the wrist versus de- for reliability, but the following crite- muscles were generally more reliable grees of motion at the hip. The lower ria have been proposed by Landis and than those for the upper-extremity reliability values obtained for the Koch47for interpreting agreement of muscles.
MMT grades, as all measures of mus- the lowel--extremity composite. Though weighted Kappa values for that the subjectivity inherent in MMT intrarater reliability varied among in- grades in the Good to Normal range One limitation of this study was the dividual muscle groups. Use of a composite ity coefficients ranging from. A second limitation is that MMT score for patient follow-up may elimi- The reliability coefficients in our MMT strength measurements of individual nate information regarding individual study ranged from.
This was the muscle group analysis and creates a ability to measure change over time case for using Kappa when analyzing more stable measure when attempting of these methods of measurement of the individual muscle groups and to follow muscle strength changes in muscle strength are needed to deter- MRC grades, whereas the derived total individua.
Our study sug- grading most reliably 8. Fair; similarly, Beasley21 found poor grade, however, may represent such a The degree of reliability depends on differentiation in grades below Fair. If MMT that had no subdivisions no plus or day-to-day basis. Our study was population Normal minus 5- and that the most part of the examiner.
The weighted specific. All examiners had extensive reliable grades are those made with Kappas for the MRC grades 4- to training in working with the DMD the factor of gravity eliminated, 5 ranged from.
It may be clinical research setting. Manual muscle testing. In: score. Depending on the situation, a portable medical scale is a good choice for home use. It can be either a digital scale or a manual scale. Whether a person can read and document their correct weight is what matters. A scale that's difficult to read or one that gives inconsistent measurements probably will not be used.
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