We all know that it’s super important to assess strength with our patients and clients. But is manual muscle testing enough?
We don’t think so.
Here’s why and what we use at Champion.
To view more episodes, subscribe, and ask your questions, go to mikereinold.com/askmikereinold.
#AskMikeReinold Episode 331: How to Measure Strength in the Clinic
Listen and Subscribe to Podcast
You can use the player below to listen to the podcast or subscribe. If you are enjoying the podcast, PLEASE click here to leave us a review in iTunes, it will really mean a lot to us. THANKS!
Show Notes
Transcript
Mike Bearden:
All right. Christine from Florida, she asked a two-part question. So part one, “what is the best way to measure strength for an outpatient clinic?”
Sean Riley:
And then the second part of that question is, “how do you choose a handheld dynamometer, something not too cheap or not too expensive?”
Mike Reinold:
Awesome. Was that the first shared question we’ve ever had? I like that. Two students, Mike, Sean, you guys nailed it. Great job. So let’s see, Christine, right? So really good question. I do like the two parts here, and I think Christine actually started to answer the question a little bit here, but how do you measure strength well in the outpatient clinic? And then she wants to know specifically about a handheld dynamometer. So I’ll start with this and then maybe we’ll jump to the PTs and talk about what we do. But I’ll talk about why manual muscle testing isn’t enough.
We’ve talked about this probably in the past. We always say this, but we think it’s super important to actually quantify that number of strength or force output to be specific. But we really want to quantify a number and that’s super helpful for lots of reasons. But the main reason why we do it is because, in manual muscle tests, it’s really hard to detect subtle differences in weaknesses. And you’ve had patients that you’ve probably had that were a little weak, they go back to the doctor. The doctor said, “No, your strength looks awesome.” And you’re like, “Ugh.” You’re like, “No, their strength’s not awesome.” It is because manual muscle testing isn’t perfect.
So one little internal study we did back in the day, and we probably had over a hundred subjects, so this isn’t a small study… But we tried to find what was the detectable difference in manual muscle testing. And we found that to get a four out of five in manual muscle testing, you had to have 85% strength of the shoulder. So you could be 13% weak. And we think you’re five out of five, right? Our hands can’t detect that subtle difference, and I’m sure that number’s a lot higher with the knee and the hip and the bigger joints. So we just know that about the shoulder. So that’s why we quantify. So PTs, I’m not sure, Kev, Len, Dave, who wants to start this and kind of talk about why we use handheld dynamometers and just your feedback on dynamometers, but let’s give her some info on the how and the why I guess.
Dave Tilley:
Yeah, I can jump in and say, I was just talking to someone the other day about this, that you don’t realize what you don’t have until you go to another clinic and you’re using it regularly. So I worked another job and I did grad school, kind of MMT, stuff like that. But when I got to Champion and we were doing dynamometry for shoulders and then shortly thereafter we started researching the hip and doing it for that, and then we got the dynamo to do it for knee extension and hamstring.
And then you start putting it as part of your normal routine and you realize, oh man, I really was letting… I don’t want to say letting stuff slide. It’s just crazy how much information you didn’t have to make clinical decisions. And so I think for me, handheld dynamometry is oftentimes a very important chunk of data for us to have internally to compare against, to look at a baseball player off season or in season, or a gymnast will look at their hips in season versus postseason or whatever.
But it’s also a really big educational tool for the patient because many times the people that we work with, they’re not feeling discomfort or pain until they do something very high level. So we worked with someone yesterday who’s a professional like circ acrobat, and she didn’t have any pain at all until she did literally a triple back off trapeze. And it wasn’t until we did her dynamometry testing, she started to feel some soreness with max effort testing, but we could show her ratios of ER to IR and her cuff strength and she was like, “Oh, wow, I didn’t realize I had that big of a deficit on this side. It makes sense why my shoulder hurts.” And then now we can track that across multiple months.
So yeah, I think it’s a really big educational tool for the patients and it’s a very important flag for us to keep looking at numbers throughout serial measurements.
Mike Reinold:
Dave, I love that. I love how you put both into that. It’s not just us. Of course, that number helps us a ton, but the educational value and the person seeing that number that really hits hard, that hits them hard when they see that number. And then, you know, you know our patients… Now, how many of our patients come back and they’re like, “Can we test today?” Like they want to test and they’re like, “I want to 40 today.” They have these things. It’s an interesting thing. Awesome. Good stuff. Kev, what do you think?
Kevin Coughlin:
Yeah, I think Dave made a lot of good points there. Whether it’s just educating the patient and sometimes they feel symmetrical or they feel something’s off and the manual muscle test just doesn’t get us the information we need. And that being said, I think, and I don’t know about cost, I think you or Lenny could speak to this better, but we have the VALD platform and the dynamo that we use with them is awesome, but prior to that, we were using the Lafayette. I think that can go a long way too. That’s kind of a standard run of the mill handheld dynamometer. And then I think if you do purchase something like that, the important thing would just be to standardize whatever joint that you guys decide to test.
So when we test baseball players and we test the shoulder, we have a very standardized way we do it. We set them up the same way every time. We use the same cues. And then if you’re doing other joints, say like the hip, there’s a lot of literature out there on ways you can standardize the testing and you just want to make sure that as a clinic you’re all on the same page. So then if I test someone for, I’m seeing one of Lenny’s patients and he asked me to strength test, it’s going to be reliable. And then if you were to test, we get the same thing. So I think once you have everyone working as a clinic to standardize, everything’s going to be really important as well.
Mike Reinold:
I think that’s actually enormous feedback. And what Kevin didn’t mention too, because Kevin’s been doing this for a while now too, there’s a learning curve, right? You have to get comfortable with having consistency with setup, consistency with cues, consistency with the way you apply the pressure, for example. There are lots of different things. So a standardized setup is like step one. If you don’t have a set protocol that you’re following, it’s going to be really hard.
But remember that there’s a learning curve with dynamometry, so keep that in mind. At least if you’re doing it side to side, your poor reliability will be symmetrical until you get better at it and you’ll learn over time. But I usually tell people it takes months. I think it’s a while.
But yeah, Kevin brought up a couple of different devices. I’ll say this with the devices, we’ve tested some of the cheaper ones, so the low hundreds, like one to $300 type thing. And we’ve been using the thousand dollars give or take ones for 20-something years. So we’re really familiar with dynamometers. The cheaper ones between one and 300, and we actually did some comparative studies just internally again in the clinic looking at this, they just weren’t reliable. The numbers were all over the place.
So I don’t think you should get a really cheap dynamometer. I don’t think that’s the goal because the expensive one’s a thousand dollars. You’re talking about a product that you can amortize over five to ten years that shouldn’t be that big of a cost for a clinic. Even with us as a small cash-based startup at the time, we saw the importance of that. And you could argue it’s marketing too. They see the numbers, they’re doing something there that they’re not doing elsewhere. It’s a good purchase. So I would say don’t skimp out to buy a $300 one versus $1,000 one, it’s not that big of a difference.
But one other quick point, there’s another one, the Tindeq, that everybody’s kind of talking about right now. The Tindeq one’s pretty good. So the Tindeq one, and I haven’t done a bunch of extensive testing on, it’s pretty good. But the only reason why I don’t use a Tindeq and we don’t use one here is it’s just a pull-based dynamometer, not a push-based dynamometer. And our preference here at Champion is to do push unless you have the big joints like knee extension or knee flexion. But otherwise, we want to do a push test. And I do think that’s a big difference. And again, it just has to do with setup, it has to do with technique. And just a couple of tips on that, but Dave, did you have something you wanted to add?
Dave Tilley:
I was just going to say, Kev said this the other day, and I want to say it for him. He said, “If you interview at a clinic and they don’t have a dynamometer and they’re not willing to entertain the conversation of getting a thousand-dollar dynamometer, which will help the entire clinic, you should find a new place to interview.”
Mike Reinold:
It’s one of those things, you’re right. We’re not talking about a $20,000 purchase. I don’t even know if a thousand dollars would be a capital purchase for somebody. That’s not that big of a purchase. So I would say I wouldn’t hesitate. Lenny, not to draw attention to your age, but tell us about isokinetics, right? So you and I used isokinetics back in the day. We haven’t used it in years. I think they’re becoming less and less used because they’re huge. They’re expensive. Right? What’s your experience and what’s your thoughts on isokinetics, and are you happy or are you satisfied with not having an isokinetic machine anymore?
Lenny Macrina:
Yeah, they’re still out there. What is it? CSMI, I think he’s a local guy out of Massachusetts who has a device that I think is known, and probably will be at some of the shows that are coming up for APTA. But I think there’s definitely value. I think that was considered the gold standard. There are studies that do show you can use an isometric type contraction that would correlate to an isokinetic value when you’re doing, for example, ACL testing. So we have resorted to isometric contractions because it’s a smaller footprint in the clinical. Like you said, it’s definitely cheaper and it gives us the information that we need to make a determination on quad strength, hamstring strength. That is probably not as good as an isokinetic device, but good enough. And again, it plays into the value of the test and all that.
So isokinetic is good, very good. It’s the gold standard, you know what I mean? At different degrees per second, measuring strength and power and all that. But I think us using VALD, going back to pricing, we use VALD for our pushing and pulling testing. It’s about a thousand dollars-ish per year. It is a subscription, so be ready for that. Or you can get the Lafayette or micro fed devices that are now around $1500. We just bought one for our other clinic and it was about $14-1500, so it’s no longer $800 or $1000. The market has increased people using it more, so I think that’s why the price went up. But it’s the same device. It’s the same old device.
Mike Reinold:
Makes no sense.
Lenny Macrina:
So be ready for that.
Mike Reinold:
It was $800 10 years ago. It’s not more expensive to manufacture. But anyway that’s a longer discussion.
Lenny Macrina:
Yeah. Right, right.
Mike Reinold:
That’s pretty funny. There are others as we move past isokinetics, there’s going to be some new technology. The Proteus is an up and coming device that’s coming up. There’s going to be new ways to measure stuff. So I think we’ll get there. But in addition to handheld dynamometry, one thing that I think we’ve embraced here at Champion, and we have a couple of our strength coaches on the call today too, that can do this, but we’re using force plates now too. And I think between let’s say a lower extremity person in ACL with a handheld dynamometer and getting some force plate data, I actually think we get a ton of data.
So Dewey, you want to start off a little bit here about how are we using force plates to measure strength and force in this type of setting? And is this something that you think every PT clinic should have? How much valuable info are we getting this out of our patients and our athletes?
Diwesh Poudyal:
Yeah, I would say once you have some systems in place to be able to extract the value in the data out of the force plates, I think it can be very, very valuable. I know on the training side of things, and I’m talking to you guys, the way that we’re able to be a little bit more specific with our programming and our coaching has definitely gone up. So on the force plates as far as true strength testing and force testing, we’ve been doing isometric with dipole. So just a max effort isometric to test lower body strength. We can get some RFD measures out of it, but it’s mainly to take a look at peak strength and then look at relative to body weight peak strength. And then we can also look at… It also spits out a net peak force that gives us an idea of your baseline isometric strength value.
But then the other stuff that’s probably a little bit more in depth is the force metrics and the power metrics that we get from our jumps testing. So whether it’s a counter movement jump or a squat jump using a stretch shortening cycle or not using a stretch shortening cycle, that’s been able to give us a ton of value in data as far as symmetry, but also where you stack up against your peers. Whether you’ve had an injury and you’re trying to rehab and get back to where you were, we can compare you to your pre-injury data and see where you are compared to that. So it’s been a lot more precise as far as our progress goes.
So I would recommend PT clinics and gyms to definitely start thinking about some of this stuff as far as purchases. Obviously it is an expense, but if you can have systems built around it, it will provide you a lot of value and it’ll allow you to be a lot more specific with your program and your coaching.
Mike Reinold:
I think that’s great. And think about too, force is force, right? But how you use that force could change. And I think that’s where the force plates really help, right? It’s not just about strength, but how you can then use that strength for force production, right? How fast, how can you dissipate that, those types of things. So I think you get another layer, I think, of information that I think is important.
Jonah, we will end it off with Jonah a little bit here. From your thoughts on the sports science stuff, taking those force plates, taking that extra bit of data… What are your thoughts on this here? Strength enough, do we need to look at this together in a continuum with force production? But what are your thoughts on just how we’re using force plates to look at this in our athletes?
Jonah Mondloch:
Yeah, I think early on in someone’s training journey or coming back from an injury, just tracking basic strength works really well, which you can do that even just by tracking their training, giving them opportunities once a month or whatever to do a set where they do as many reps as they can with the weight they’ve been working and tracking that gives you good basic info. But then you do definitely hit a point where you need to be able to get a little more specific dive into what is somebody’s true weakness or what is their strength leading into the season. We want to build on the things that make them really good, which being able to look at a wide range of data, everything from max force output in an isometric strength test, like a mid-thigh pull to more dynamic tests, like a counter movement jump, as well as something more elastic like a hop test, gives you kind of that full spectrum picture of who is this athlete in front of you.
And I think one of the biggest benefits of the isometric mid-thigh pull is it does take some of the skill of lifting out of things. So there’s certain people, say you have a 6’5″ lanky individual, they probably don’t squat all that well. So this takes some of that skill aspect out and you just find out how much force can they produce without the limitations of their levers and the way their body’s built. So it does help you get a little more objective data that’s easier to compare from person to person and take some of the other aspects out of it. But using that holistic picture of data to figure out where somebody needs to improve, whether it’s after an injury or just a general training client, is certainly quite useful.
Mike Reinold:
That’s awesome. And I think when you put it all together, like we have here today in the episode, you can get some really valuable information for people. So our tech stack, we’ve kind of talked about this, but we use the VALD force plates and the VALD DynaMo Plus, I think it’s the plus or the pro, the plus, the one that you can push and pull because we do like to push and pull. I don’t like to do just one, right? We mostly push. We do some pulls with the knee, but putting that together with force plate data, I actually think that’s… I consider that affordable and Lenny can say we’re pretty conservative with our budgets and stuff at Champion. I think it’s worth the cost.
So hopefully that was helpful. Christine, good question. I think a lot of people are having that, and I’d love to see the profession shift in this direction because the more information we can have, the better. So we’re returning people back to sport when they’re ready and we’re maximizing, right? Because just like everything else, if you’re not testing, you’re kind of guessing and that’s not in the best interest of each person. So great question.
If you have anything like that, head to mikereinold.com, click on that podcast link, and be sure to go to Spotify, Apple Podcast, rate, review, subscribe, blah, blah, blah. We’d appreciate all those things. Thanks so much. See you on the next episode.
