Acute Care Facilities

Often patients seen in acute care facilities are either acutely ill or are postoperative patients. In the acutely ill patient, manual muscle testing may be used to assess the patient’s mobility status in order to inform a discharge plan. A manual strength exam performed as part of a general assessment may provide information concerning the amount of assistance the patient requires and whether the patient will need an assistive device. Assessing the patient’s strength to help ensure safe transfers from bed to chair, to a standing position, or on and off the toilet is an essential part of the acute-care patient management process. A strength assessment may also inform the therapist of the patient’s ability to follow directions and/or to verbalize concerns such as following a stroke or in the presence of delirium or other cognitive loss.1,2

Strength assessment may also indicate the presence of pain before full-body movements such as transfers. Strength assessment could take the form of active movement followed by resistance, such as in a manual muscle test or in a 10-repetition maximum such as in a seated shoulder dip.

Strength assessment in the postoperative patient informs the therapist of the integrity of the patient’s nervous system. The therapist may be the first person requiring the patient to move actively after surgery, and thus may be the first one to observe the patient’s ability to contract a muscle. Although this scenario is rare, clearly the consequences of assuming an attitude of “all is well” and finding out during a transfer that the patient cannot use part of an extremity would have avoidable consequences. Strength testing in this scenario might take the form of isometric contractions, especially if there are contraindications to joint movement, suspected postsurgical pain as in a newly repaired fractured hip, or in restricted range of motion such as in a total hip arthroplasty. If testing is done in a manner that differs from the published directions, documentation should describe how the test was performed. For example, if isometric testing was done at the hip because the patient was not permitted to move the hip through full range after a hip arthroplasty, the therapist should document the test accordingly: “Patient’s strength at the hip appeared to be under volitional control, but pain and postsurgical precautions prevented thorough assessment.”

Key movements that should be assessed for viability and for the strength necessary to perform transfers or gait include elbow extension, grip, shoulder depression, knee extension, hip abduction, ankle plantar, and dorsiflexion. Functional tests that might be useful in assessing the patient include gait speed, chair stand, timed transfer, or the timed up-and-go test (see Chapter 9).

Special considerations for the acute care setting may include the patient’s rapid fluctuations in response to medications, illness, or pain. Reassessment may be necessary when any changes in strength are documented along with therapist’s insights into why the changes are occurring. Clearly, strength gains are not possible in the short time a typical patient is in acute care, but rather should be attributed to increased confidence in moving, less pain, better understanding of the movement to be performed, motor learning, and so forth.

Acute Rehabilitation Facilities

Strength assessment in the acute rehabilitation setting may be performed as a baseline assessment to determine progress over time and to identify key impairments that affect the patient’s mobility-related and other functional goals. Knowledge of community-based norms for mobility such as chair stands, distance walked, stair climbing speed, floor transfer ability, and gait speed will inform the therapist’s clinical decision-making. (See Chapter 9 for a more complete description of these tests.) A standard manual muscle test and/or a 10-repetition maximum (10-RM) strength assessment are other methods used to assess relevant strength abilities.

As in the acute care setting, assessment of strength for mobility tasks is critical in the acute rehabilitation setting. Recognition of key muscle groups in specific mobility tasks, such as the plantar-flexors in gait speed, is key to informed clinical decision-making.

Special considerations for the acute rehabilitation setting often include rapid change over a short period. Positive changes may be attributed to increased comfort and less pain, less apprehension, neuroplasticity, and a change in medications. Negative changes may be attributed to a decline in medical status, pain, or depression, for example. Muscle fatigue resulting from poor fitness and excessive sedentary behavior or general body fatigue related to frailty or post–acute care implications may affect the perception of strength. The patient may not be able to assume a proper test position because of postsurgical restrictions or a lack of range of motion, requiring the therapist to do a strength-screen rather than a strength test. This screen cannot serve as an accurate baseline because of the lack of standardization. Functional testing may be more informative and accurate in these situations. The therapist should take special care to document any deviations from the standardized manual muscle test.