Muscle strength is very important for all of our functional activities, from heavy work such as climbing stairs or a hill to fine work such as sewing or typing on a keyboard. While losing feeling in a part of the body can be more disabling, losing muscle power always has consequences for our function and our independence, especially as we get much older when our power levels decline anyhow. We may lose muscle power for a wide variety of reasons: disuse; pain; injury; disease or neurological illness. Physiotherapists are skilled at the assessment of muscle power and in progressive strengthening techniques to restore power within the patient's capacity. Physiotherapists rate muscle power by using the five step Oxford Scale to record the assessment and progress of treatment. It is important to know the muscle and tendon anatomy well as well as the movement actions the muscles perform so that the joint can be positioned best to allow muscle function to be apparent. The physiotherapist will often palpate over the tendon and over the muscle belly to feel any activity that may not be visually very obvious. Ratings are recorded in the form 1/5 or 5/5, with a + or a " sign used to indicate greater or lesser power but not sufficient to give the muscle an entire grade lower or higher on the scale. If there is no muscle activity, either visible or with the physiotherapist feeling the tendon and muscle belly after several attempts by the patient to perform the muscle action then the muscle is graded as zero. A small muscle contraction such as a twitch, without any joint movement, is rated as one. When the muscle can do its joint action but without the force of gravity resisting the movement then this is graded as two, but the joint needs to be in the right position for correct testing. If the muscle can perform its typical action against the force of gravity then it is rated as three. An example is bending the elbow whilst standing up, where the biceps is working against gravity. To be rated as 4/5 on the Oxford Scale a muscle must be able to move its joint through full range against resistance and gravity. The physiotherapist will decide what degree of resistance is reasonable for this test, bearing in mind the characteristics of the patient such as age, sex, activity levels and medical status. The normal rating of 5/5 is given only when the muscle can move the joint painlessly to the extent that the tester feels is entirely adequate, given the personal status of the patient. Full power for a younger, strong man will be very different for a child or old person. If the patient can raise their arm up above the head to some extent but not very strongly nor to full range, the physiotherapist might grade that as 3/5 for the deltoid muscle but because it is not full it might be rated 3-/5. If the muscle will take good manual resistance but does not appear to be normal for that patient then the grading could be 4+/5. This grading scale allows the physiotherapist to test all the appropriate muscles and record them in the patient's notes, enabling progress to be charted against time as the strength improves. This can be very useful in tracking the progress of patients recoveries or recording their neurological status such as in spinal cord injury. Muscle strengthening begins with encouraging muscle activity with gravity counterbalanced if the muscle is weak. Once a functional level of muscle activity is reached the patient can be encouraged to perform normal daily activities to power up their muscles. At a higher level resistance must be added as it is the intensity of work which develops muscle strength. This causes a breakdown of muscle fibres which regenerate with increased strength, a cycle which can be repeated with increased levels of applied intensity of resistance. Once simple resistance has been managed, the patient is taught to perform dynamic exercises using their bodyweight as this is the ultimate expression of muscle strength.
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