Download muscle strength testing gradation chart

CLINICAL SUPPLEMENT:
BACK - 2011
Herniated Nucleus Pulposus (HNP):
1. Disk herniations usually occur in posterolateral direction. The posterior direction is
caused by loading of the spine and thinner posterior aspect to annulus fibrosis. The
lateral direction is caused by the shape of the posterior longitudinal ligament which
prevents direct posterior herniations in most cases.
2. Herniations usually affect the nerve exiting at the level of the disk herniation in the
cervical and thoracic spine – C4/5 disk herniation will affect C5 nerve root, T1/2 disk
herniation will affect T1 nerve root.
3. Herniations at lumbar disk levels do not usually affect the nerve exiting directly at that
level because of the angle and position of exit of these nerves as they exit directly
beneath the pedicle they essentially escape injury by the HNP. The nerve level that is
usually affected is one level lower – L4/5 disk herniation will affect L5 nerve root, L5/S1
disk herniation will affect S1 nerve root. (see Relation of Spinal Nerve Roots to
Vertebrae image in Netter’s Atlas)
Spondylolysis/Spondylolisthesis:
1. Pars interarticularis is the region of the vertebra between the superior and inferior
articular processes that make up the zygapophysial or facet joints. The pars
interarticularis is on the lamina of the lumbar vertebrae and pedicle of the cervical
vertebrae.
2. A unilateral fracture or defect in pars interarticularis = spondylolysis; A bilateral fracture
or defect in both pars articularis = spondylolisthesis and is usually accompanied by
forward translation (slippage) of the vertebral elements above the defects over the
elements below the defects. (Please note, the wording of this latter term on p.85 of
your text is somewhat misleading…rely on the definition given herein)
Innervation of intervertebral disk/zygapophysial joint:
Disk – sinuvertebral nerve from ventral ramus recurrent branch
Joint – dorsal rami nerves
Spinal cord ends at L1/2 vertebral level.
Dural sac ends at S1/2 vertebral level.
Innervation of suboccipital muscles via suboccipital nerve (posterior/dorsal ramus C1).
Petit’s Hernia – lumbar hernia in lumbar (Petit’s) triangle.
Spinal stenosis: narrowing of vertebral canal housing spinal cord, due to pathology in
hypertrophied ligamentum flavum, or facet (zygapophysial) joint disease/degeneration. Typical
symptoms – bilateral extremity pain and/or numbness, weakness.
Scoliosis – pathological lateral bending of vertebral column
Kyphosis – pathological excess of normal (primary) curvature seen in thoracic spine
(hunchback).
Lordosis – pathological excess of normal lordotic lumbar (secondary) curvature (swayback).
MUSCLE STRENGTH TESTING GRADATION CHART
MUSCLE GRADATIONS
5 = normal
4 = good
3 = fair
2 = poor
1 = trace
0 = zero
DESCRIPTION (ROM=range of motion)
Complete ROM against gravity with full resistance
Complete ROM against gravity with some resistance
Complete ROM against gravity
Complete ROM against gravity eliminated
Evidence of slight contraction, no joint movement
No evidence of contraction, no joint movement
REFLEX GRADING CHART (reported as 1/4, 2/4…)
Grading Scale
Description
0
1
2
3
4
Absent
Hypoactive
Normal
Hyperactive without clonus
Hyperactive with clonus
Nerve Root Diagnostic Testing:
C5:
Motor – deltoid muscle, biceps brachii muscle
Reflex – biceps brachii muscle tendon
Sensory – lateral shoulder (skin over deltoid) and lateral arm
C6:
Motor – biceps brachii muscle, wrist extension
Reflex – brachioradialis muscle tendon
Sensory – lateral forearm, lateral palm including first digit and possibly second digit
C7:
Motor – triceps brachii muscle, wrist flexion
Reflex – triceps brachii muscle tendon
Sensory – middle finger
C8:
Motor – finger flexion
Reflex – none
Sensory – fifth digit and medial forearm, possibly 4th digit also
T1:
Motor – finger adduction/abduction
Reflex – none
Sensory – medial arm
L4:
Motor – tibialis anterior muscle
Reflex – patellar tendon
Sensory – medial leg, medial aspect foot including medial malleolus
L5:
Motor – extensor hallucis longus muscle, extensor digitorum longus; (walk on heels)
Reflex – tibialis posterior muscle tendon
Sensory – dorsum of foot
S1:
Motor – fibularis longus muscle, (walk on toes)
Reflex – calcaneal (Achilles) tendon
Sensory – lateral aspect foot