RU2269927C2 - Method for increasing objectivity level of manual muscle testing - Google Patents

Abstract

FIELD: medicine.

SUBSTANCE: method involves using relative characteristics of mechanical force. It comprises two stages of provoking action and recording mechanical force. Patient applies pressure to examiner hand and the examiner resists with submaximum force at the first stage. The examiner applies supramaximum force to patient extremity at the second stage. Recording is carried out with mechanical force transducer. The data are saved in computer and relative parameters of SD/M and dMax/M are calculated and their values are compared to threshold values for given parameters. Conclusions on muscle weakness are drawn using offered criteria, that is, a muscle is considered to be weak if general test time is less than 3 s or dMax/M is lower than its threshold value or SD/M is greater than its threshold value.

EFFECT: high reliability of obtained data.

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Description

The invention relates to manual medicine and medical equipment and is intended for non-invasive diagnosis.

The branch of modern manual medicine - applied kinesiology (PC) - proposed G.Goodheart (1964) [Schmidt I.R. Introduction to Applied Kinesiology // Manual Medicine. 1994. No8. P.30] and is one of the rapidly developing areas of modern integrative medicine. The diagnostic procedure for PC is based on manual muscle testing (MMT), i.e. identification of the phenomenon of muscle weakness in response to a provocative effect on the patient. Manual muscle testing is performed by a specially trained examiner with manual force on the test muscle of the patient, most often by pressure on the limb of the patient. During the diagnostic procedure of PC, manual muscle testing is used as an indicator for provocative effects on the patient’s body, in particular: touching the zones of therapeutic localization (projection zones of sensitivity of the corresponding internal organs) [Smith Kr., Sheifer J. Applied kinesiology. England; Italy, 1993. 226 pp.], And the result of each test (strength or muscle weakness) is evaluated subjectively by the examiner, which, of course, depends on medical qualifications and negatively affects the reliability of this diagnostic method.

One of the ways to increase the reliability of the MMT method is to objectify it using various physical methods, for example, measuring mechanical parameters.

As mechanical parameters of objectification of the MMT method, it was proposed to use, for example, limb strength and time displacement or to record the slope of the leading edge of the force pulse (Carruso W., Leisman G. A force / displacement analysis of muscle testing // Percept Mot Skills 2000 Oct . V.91 (2), P.683-92) or record the amplitude of the low-frequency component (below 2 Hz) of the dynamic force spectrum between the examiner's arm and the limb of the patient (Chernysheva TN, Korenbaum VI, Apukhtina TP Objectivization of Manual Muscle Testing Through Analysis of Dynamic Force Spectrum // ICAK Proceedings. Chicago, USA. 2003, pp. 17-22).

A common drawback of all these parameters of an objective assessment of MMT is their low reliability.

There is a method of objectification of manual muscle testing by measuring the electromyographic parameters of the tested muscle of the patient, and the provocative effect is carried out by presenting the patient homeopathic nosodes (RF Patent No. 2171623, publ. 10.08.2001). The disadvantage of this method is the inconvenience of the examination, associated with the need to attach special electrodes to the patient's body.

There is a method (prototype) of objectification of manual muscle testing by provoking and measuring the maximum mechanical force between the limb of the patient and the hand of the examiner using an electronic dynamometer, while the measurement of effort is carried out in case of pressure from the patient on the examiner's arm, and the examiner resists this effort. The value of the maximum mechanical force is determined by the recorded schedule of changes in effort. The decision on muscle weakness is made by comparing the maximum effort value with a threshold value for a given parameter (Hsieh CY, Phillips RB Reliability of manual muscle testing with a computerized dynamoneter. Journ. Manipulative Physiol. Ther. 1990. V.13. No. 2. P. 72-82).

However, the prototype does not provide the necessary reliability of the assessment of the obtained test results, because it uses as an objectification parameter the absolute value of the maximum mechanical effort, which is very variable and varies from patient to patient.

The objective of the invention is to increase the reliability of evaluating the results of manual muscle testing by using new parameters to objectify, additionally taking into account the slightly changing characteristics of mechanical effort.

This object is achieved in that in the method of objectifying manual muscle testing by provoking a patient and simultaneously registering the mechanical force between the patient’s limb and the examiner's hand, followed by comparing the obtained value of the mechanical force with the threshold value of this parameter, the provoking effect is performed in two phases, in the first of which the patient puts pressure on the examiner's arm, and the examiner resists with submaximal effort, on the second - the examiner exerts supramaximal force on the patient’s limb, while the mechanical effort is recorded in time in the form of a graph, the dynamic stress is calculated in the form of the derivative of the mechanical effort in time between the limbs of the examiner and the patient, the initial and final times are determined to measure the steady-state mechanical stress in the first phase of testing for the first minimum of the derivative after the first maximum of dynamic force and the last minimum of the derivative Before the second maximum of dynamic force, then the average value (M) and standard deviation (SD) of steady-state mechanical force in the first phase of testing and the maximum value of mechanical force (Max) in the second phase are determined from the obtained graphs, the difference (dMax) between the maximum value of mechanical efforts in the second phase of testing and the value of the steady-state mechanical force at the end of the first phase of testing, the total test execution time and the relative parameters SD / M, dMax / M, while the sub maximum effort is chosen by preliminary subjective testing by the examiner of the obviously strong and obviously weak state of the patient’s studied muscle, the amount of supramaximal effort is selected on the basis of preliminary subjective testing by the examiner of the obviously weak state of the patient’s studied muscle, and the decision on muscle weakness is made if the total test time is less than 3 sec or dMax / M is less than the threshold value of this parameter, or SD / M is more than the threshold The new value of this parameter.

The proposed method, in contrast to the prototype, provides the determination of little-changing (normal) relative characteristics of mechanical effort (dMax / M and SD / M) between the limbs of the examiner and patient, and thereby leads to an increase in the reliability of evaluating the results of manual muscle testing.

To clarify the essence of the invention, figure 1 shows a mechanical force sensor, which contains a sensor element SBA-100L (CAS Corporation, Korea), installed between two ebonite flanges.

Figure 2 shows a fragment of a typical record of mechanical effort (F) and its derivative (F '), measured in volts, in two consecutive attempts: "a" for the strong muscle, "b" for the weak. The horizontal axis represents time in seconds. The vertical axes show the relative amplitudes of the mechanical force F (above) and its derivative F '(below) in Volts. A and B are the moments of the beginning and end of the calculation of the average value and standard deviation of the mechanical force in the first phase of MMT. C is the point of measurement of the maximum mechanical force (Max) in the second phase of the MMT (relative to time point B). T is the total duration of MMT from the beginning of pressure on the sensor in the first phase of MMT to the end of pressure on the sensor in the second phase of MMT.

Figure 3 shows a photograph of a measuring installation consisting of a mechanical force sensor connected to a MacLab-4E information-measuring system (ADInstruments) connected to a Macintosh Performa 6360 personal computer.

The method is as follows. The examiner takes in his hand a mechanical force sensor (electronic dynamometer) for its upper mushroom-shaped flange (figure 1). The lower flat flange of the mechanical force sensor is placed on the patient’s arm bent at the elbow and a measurement and recording of changes in the mechanical force on the PC during two-phase manual muscle testing (MMT) is performed. During the first phase of MMT, the patient is asked to raise his hand and press it through the mechanical force sensor onto the hand of the examiner for at least 3 seconds. At this time, the examiner exerts resistance with submaximal effort. During the second phase of MMT, the examiner acts on the patient's arm with supramaximal effort. The values of submaximal and supramaximal efforts are previously determined by the examiner individually for each patient with subjective testing of a knownly strong and obviously weak state of the muscle under study (1-2 attempts for each state). The submaximal force is chosen so as not to exceed the force of the obviously weak muscle, and the supramaximal force is chosen so as to exceed the force of the obviously weak muscle, without reaching the excess of the force of the obviously strong muscle. This procedure provides an individual adjustment of the efforts made to the limb of the patient by the examiner.

The signal from the mechanical force sensor is recorded on a PC in the form of a time diagram (Fig. 2 "a" and "b" - the upper part), characterizing each attempt of MMT (attempts, as a rule, as many as provocations). Then, in the post-processing mode, the dynamic mechanical force is calculated in the form of a derivative of the mechanical force in time (Fig. 2 “a” and “b” - the lower part) in order to accurately find the required time intervals for further processing of the signal of mechanical force. According to the obtained graph of the derivative (F '), the first minimum (A) is found after the first maximum of dynamic force (Fig. 2) and the last minimum (B) before the second maximum of dynamic force (Fig. 2), and according to the schedule of mechanical force (F), the maximum mechanical force in the second phase (C) (figure 2) and the total duration (T) of the MMT (figure 2), fixing the points of signal rise above the background level (beginning of the interval) and the signal falling to the background level (end of the interval). Then calculate the average value of the mechanical force (M) and its standard deviation (SD) between the lines A and B. After that, calculate the difference (dMax) between the mechanical force at time C and time B, which characterizes the increment of mechanical force in the second phase of the MMT maneuver, and then relative parameters are calculated: the relative increment of the force (dMax / M) from the first to the second phase of the MMT and the relative fluctuations of SD / M in the first phase of the MMT.

The experiments and analysis of the results showed that a muscle is considered weak if at least one of the following conditions is met:

- the total duration of MMT is less than 3 seconds (T <3 s), i.e. provided that the maneuver is correctly performed, this means that the patient is not able to develop a continuous effort and, therefore, the muscle is weak;

- the relative increment of the force dMax / M from the first to the second phase of MMT testing is less than the threshold value for this parameter.

It is known that in order to detail the threshold values depending on the anthropometric characteristics of the subjects, additional studies are required, therefore, we conducted experiments on a group of 11 volunteers aged 16 years, which showed that the threshold value dMax / M for a similar group is the value (П1) 0 , 2.

- relative fluctuations of SD / M in the first phase of MMT testing are greater than the threshold value for this parameter. And, although, as in the previous case, depending on the anthropometric characteristics of the subjects, additional studies are required to determine the threshold value of this parameter, our experiments on a group of 11 volunteers aged 16 indicate that for a similar group the threshold value of this parameter (SD / M) is the value (P2) of 0.06.

If none of the above conditions is met, the muscle is believed to be strong.

An example embodiment of the invention. The mechanical force meter (Fig. 1) contains two ebonite flanges, between which a device based on the SBA-100L sensitive element (CAS Corporation, Korea) is placed. The electric signal from the element, compressed between the flanges, is fed to the input of the computer information-measuring system "MacLab-4E" (ADInstruments) connected to a personal computer "Macintosh Performa 6360" (figure 3). Digital recording of signals is carried out in a specialized software package "Chart-3.6.1 (ADInstruments)". Processing of recorded files is performed using the specialized software package "Chart-4.1 for Windows (ADInstruments)" on a Pentium II personal computer. The signal from each MMT attempt of a particular patient is recorded in the form of a time chart (F) (Fig.2 "a" and "b" - the upper part). Using the extension "Differential" (window width 31, scale 7) in the post-processing mode, the first derivative (F ') is calculated (Fig.2 "a" and "b" - the lower part). For each attempt, the cursor marks the points and lines A, B on the schedule of the derivative of mechanical effort (F '), and marks the points C on the schedule of mechanical effort (F) (figure 2) and measures the total duration of MMT - T. Then, for each attempt Using the "Data Pad" extension, the parameters M, SD, dMax are calculated, which are entered into the table. The table is exported to the Microsoft Excel-97 software package, using which the relative values of dMax / M, SD / M are calculated, and based on the analysis and comparison of the results obtained with the conditions for evaluating muscle strength derived from the claimed invention, the result of the MMT attempt is evaluated.

As an example of the proposed method, we present the results of a clinical study conducted with 11 volunteers (age 16 years) who are not aware of the experimental procedure. Each patient used 10 points of therapeutic localization for provocation (thalamus, heart, left and right kidneys, left and right lungs, stomach, spleen, etc.). Manual muscle testing of the deltoid muscle was performed in all of them by one experienced doctor-examiner. In this case, the mechanical force meter was installed on the bend of the arm in the region of the elbow joint. Patients were asked to raise their elbows to shoulder level, and in this state they performed two-phase MMT testing. Digital recording of signals was carried out in the software package "Chart-3.6.1 (ADInstruments)". Processing recorded files - in the software package "Chart-4.1 for Windows (ADInstruments)". The signals from each MMT attempt of each patient were presented in the form of a time chart (similarly to Fig.2, "a" and "b" - the upper part). Using the extension "Differential" (window width 31, scale 7) in the post-processing mode, the first derivative (F ') was calculated (Fig.2 "a" and "b" - the lower part). For each attempt, the cursor marked the points A, B and C (figure 2) and measured the total duration of MMT - T. Then, for each attempt, using the Data Pad extension, the parameters M, SD, dMax were calculated, which were entered in the table. The table was exported to the Microsoft Excel-97 software package, with which the relative values of dMax / M, SD / M were calculated. Objective diagnostic conclusions about the state of the muscles (strong or weak) for each provocation were made on the basis of the conditions proposed according to the invention.

At the same time, the examiner recorded subjective diagnostic conclusions about the state of the muscles with each provocation. The results obtained by the coincidence of objective and subjective diagnostic conclusions are given in the table.

Table.
Consent of diagnostic conclusions made objectively and subjectively. A patient Absolute coincidence in the totality of the proposed conditions Relative coincidence on the totality of the proposed conditions,% one 5 out of 10 fifty 2 6 out of 10 60 3 8 out of 10 80 four 6 out of 10 60 5 7 out of 10 70 6 7 out of 10 70 7 9 out of 10 90 8 8 out of 10 80 9 9 out of 10 90 10 8 out of 10 80 eleven 6 out of 10 60 Total 79 out of 110 71.8

Moreover, P1 = 0.2; P2 = 0.06.

The results presented in the table show a significant interindividual variation in the coincidence of objective and subjective diagnostic conclusions - from 50% to 90%. At the same time, the average percentage of consent for the group is 71.8%, which is acceptable in practice.

Thus, the proposed method for objectifying MMT on the basis of the proposed relative assessment criteria gives a fairly good agreement with the results of subjective assessment (71.8%). Moreover, in some cases, objective conclusions look more accurate than subjective assessments, due to the significant variability of the maximum effort (observed by hardware) introduced by the examiner in the second phase of the MMT maneuver when moving from one attempt to another.

The proposed method can be used in manual medicine when teaching doctors the technique of manual muscle testing and in practical activities to increase the reliability of diagnosis using the manual muscle testing procedure.

Claims (2)

1. A method of manual muscle testing, including a provocative action by the examiner's hand on the patient’s limb, measuring the amount of mechanical force between the patient’s limb and the examiner's hand using a mechanical force sensor, registering it in the form of a first time diagram and processing, comparing the obtained value of the mechanical force with a threshold value this parameter, characterized in that the provoking effect is performed in two phases, during the first of which the patient exerts pressure n hand of the examiner, and the examiner resists the movement of the limb of the patient with submaximal effort, and during the second - the examiner exerts supramaximal effort on the limb of the patient, the values of which are previously individually determined for each patient in subjective testing, when processing the values of the dynamic mechanical force are calculated in the form of a derivative of mechanical effort in time with registration of the derivative in the second diagram, which determines the first minimum after the first the maximum dynamic mechanical force and the last minimum before the second maximum dynamic mechanical force, determining from them the initial and final time instants of the steady mechanical force in the first phase of testing, then the average value of M and the standard deviation SD of the steady mechanical force in the first phase of testing are determined from both diagrams, as well as the maximum value of the mechanical force Mmax in the second phase, calculate the difference dMmax between the maximum value of the mechanical force in the second phase of testing and the value of the steady-state mechanical force at the end of the first phase, the total time of this test and the relative parameters SD / M, dMmax / M, and the decision on muscle weakness is made if at least one of the following conditions is fulfilled: the total test time is less than 3 s, dMmax / M is less than the threshold value for this parameter, SD / M is greater than the threshold value for this parameter. 2. The method according to claim 1, characterized in that the values of the submaximal and supramaximal efforts are selected by testing the examiner with the obviously strong and obviously weak state of the patient’s studied muscle so that for the submaximal effort not exceed the effort of the obviously weak muscle, and for supramaximal effort, exceed the force deliberately weak muscle, not having reached the excess of the effort of a deliberately strong muscle.

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