PHYSIOTHERAPY PRACTICE. I . 1985.

71-76
0 Longman Croup 1985

REVIEW

Reliability and Repeatability of Methods for

Measuring Muscle In Physiotherapy

Maria Stokes
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The reliability a n d repeatability of various methods of measuring muscle size,

strength a n d activation a r e discussed. T h e examples used in this review describe
methods which the author has used in h e r experience of investigations of skeletal
muscle. The importance of measuring muscle after injury a n d in disease is
highlighted, and physiotherapists a r e encouraged to develop a n d i m p r o v e methods of
measurement.

I NTR0D UCTI 0N Muscle Size

Indirect methods of measuring muscle size have
For personal use only.

Whether measurements ofmuscle are being made
for research purposes or as part of a clinical
assessment, the methods used must be both
reliable and repeatable. There is little point in
making inaccurate measurements, or making
repeated measurements which are so variable
that the error involved might be greater than the
changes occurring in the muscle. T h e purpose of
this paper is to point out the hazards of different
methods of measurement, but also to encourage
physiotherapists to use and develop these methods
which are vital in clinical assessment and research
me thodology .
Reliability of measurements
It is important to know that the particular
function of the muscle which we want to measure
is actually being measured by the technique we
have chosen to use. The examples used below
describe methods of measuring muscle size,
strength and activation.
Maria Stokes PhD MCSP, University Department of
Medicine, Royal Liverpool Hospital, PO Box 147,
Liverpool L69 3BX.
been used eg. lean body mass (Forbes and Reina,
1970; MacLennan et al., 1980) and limb circum-
ference (often used by physiotherapists), but these
methods d o not enable individual muscles or even
muscle groups to be studied. Imaging techniques
are now available which allow the cross-sectional
area (CSA) of individual muscles to be measured
viz. computerised axial tomography or CAT
scanning (Ingemann-Hansen and Halkjaer-Kris-
tensen, 1980), and compound ultrasound B-
scanning (Ikai and Fukunaga, 1968; Young et al.,
1980). These techniques produce an image of a
cross-section through the limb from which the
outline of the muscle can be accurately identified
and its area measured (Fig. 1). Of the two
techniques, ultrasonography is suitable for use by
physiotherapists as it is safe, does not involve
exposure to radiation, is inexpensive, widely
available and can be used independently by
physiotherapists. The quadriceps have been stu-
died extensively using both CAT scanning and
ultrasonography, but the examples used in this
review will describe studies using ultrasound B-
scanning as they are more applicable to physio-
therapists.
It has been demonstrated, using ultrasono-
graphy, that limb circumference measurements
71
 72 PHYSIOTHERAPY PRACTICE
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Fig. 1. Photograph of an ultrasound scan of quadriceps made through mid-thigh.
(RF= Rectus Fernoris, VM = Vastus Medialis, VL = Vastus Lateralis, VI = Vastus
Intermedius)
made using a tape measure underestimate both
muscle wasting (Young et al., 1982) and muscle
For personal use only.
growth (Young el al., 1983). The presence of the
other limb muscles and variable amounts of
subcutaneous fat contribute to the inaccuracy of
using a tape measure to estimate muscle size. A
study of patients with unilateral knee injury and/
or immobilisation showed that a 5% difference in
mid-thigh circumference concealed a 22-33%
difference in quadriceps CSA (Young et al., 1982).
Assessment ofjoint swelling using a tape measure
may be more accurate than assessing muscle size
but the repeatability of this method is poor
(Nicholas et al., 1976 and vide infra). Accurate,
direct measurements of muscle size are essential
for any research studies which involve measuring
changes in muscle size.
Muscle Strength
The MRC or Oxford scale may be useful for
measuring the strength of very weak muscles
(Grades 1-3) but it is insensitive above grade 4
and so has only limited clinical use. Many patients
who apparently demonstrate 'Grade 5' strength
have considerable weakness when measured using
strain gauge equipment. The M R C method is not
accurate enough for research studies. There are
various machines available for measuring muscle
strength. The Cybex (and other such expensive
devices), which measure both isometric and isoki-
netic force of limb muscles, are probably not
available to many of us here in the UK. Isometric
force can be measured using a hand-held
myometer (developed by Edwards and McDon-
nell, 1974) such as the manual Hammersmith
myometer (Edwards and Hyde, 1977; Hyde el al.,
1983) or the later electronic version (Manufac-
turer, Penny and Giles Ltd, Dorset). The
myometer can be used for many of the smaller
muscles of the body and for larger muscles in
children and weak adults.
Maximum isometric muscle strength can be
measured accurately using a strain gauge
attached to a chair (Edwards et al., 1977) (Fig. 2).
For quadriceps testing, the subject is seated with
the lower leg dependant and the knees at 90". The
subject tries to straighten his knee against an
inextensible strap placed around the ankle which
is attached to a strain gauge. The force exerted at
the ankle is recorded on paper and then mea-
sured. Although this method relies on the motiva-
tion of the subject, it has been shown that it is
possible to achieve the same maximum force
voluntarily as is produced by supra-maximal
stimulation of the femoral nerve. (NB. This
experiment should not be repeated as it is very
uncomfortable.) The potential problem of volun-
tary tests being dependant on motivation is

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Fig. 2. Maximal voluntary isometric quadriceps strength is
recorded as the subject tries to straighten his knee against
an inextensible strap placed above the ankle.
For personal use only.
discussed below (see ‘Reliability of Voluntary
Testing’).
Muscle Activation
Surface integrated electromyography (IEMG) is
a useful technique for measuring the electrical
excitation of muscle cell membrane and is often
used eg. to quantify muscle activity during exer-
cise or to see which muscles are recruited during
certain activities such as walking.
There are certain problems with surface elec-
trodes vir: the activity is not only recorded from
the underlying muscle but from a very large area
by ‘pick up’ from other muscles. Surface E M G is
therefore not useful for studying small muscles or
the different heads of large muscles (needle
electrodes can be used if a more localised study of
the muscle is required); fixation of the electrodes
can be difficult depending on the relative shapes
and sizes of the electrode and the skin surface, and
movement of the electrode may result during
exercise; skin resistance can effect the recording of
activity and should always be reduced by abra-
sion of the skin (with eg. sand paper), and
cleaning with alcohol. Surface EMG is reliable
and repeatable (vide infra) provided that care is
taken to use appropriate electrodes, reduce skin
PHYSIOTHERAPY PRACTICE 73
resistance, always to place the electrodes in
exactly the same position on the skin and always
to place the patient in the same position so that
muscle length is constant.
Surface IEMG has been used to investigate
reflex inhibition ofquadriceps after meniscectomy
(Stokes, 1984; Stokes and Young, 1984a,b;
Shakespeare el al., 1985).The maximal voluntary
activation (MVA) of quadriceps was measured
during straight leg maximal contractions before
and after surgery, and the post-operative reduc-
tion in MVA was taken as a measure ofinhibition.
Reliability of Voluntary Testing
Voluntary muscle testing is comparable with
respiratory function testing as they are both
reliant on the motivation of the subject. Usually
three or more maximal efforts are made for each
test eg. quadriceps contractions, peak flow, and if
the attempts are consistant they are taken as
maximal. Encouragement from the operator is
necessary in most cases, and the ability to recog-
nise whether a patient is trying hard is also
important.
Repeatability of measurements
If changes in muscle are to be measured, the
methods used must be shown to be repeatable
once they are shown (or known) to be reliable. If
the variability of repeated measurements is large,
the magnitude of changes in the muscle will be
inaccurate or may be completely obscured. Each
method used for measuring muscle must therefore
be tested for its repeatability, not only when used
by the same operator but the interoperator
repeatability must also be tested. The latter is
most important for clinical assessments over a
long period of time during which patients may be
seen by more than one therapist.
All research studies should include some form of
statistical analysis of the repeatability of the
methods used, and the number of operators
performing tests should be kept to a minimum.
The statistic commonly used is the coefficient of
variation (CV) which indicates the variation
about the mean (calculated as follows-standard
deviation divided by the mean, multiplied by
100).The CV is expressed as a percentage and the
 74 PHYSIOTHERAPY PRACTICE
lower the value obtained the more repeatable the
method. The usual CV of biological systems is
about 10-1570. The criteria for acceptance of
maximal strength, and most respiratory results
are: if three or more consistantly maximal efforts
are achieved, the best one is taken as the maxi-
mum result is required; if, however, the results are
very different, more tests should be carried out
until a degree of consistancy is reached. The CV is
calculated using the best result from each occa-
sion.
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Muscle Size
Repeated measurements of limb circumference
using the tape measure for estimating muscle size
are influenced by a number of factors vir. 1) the
amount of subcutaneous fat, which may vary; 2)
the rate of atrophy or growth of the other limb
muscles which may differ from those occurring in
the quadriceps; 3) accuracy in relocating the site
of measurement on different occasions; 4) the
degree of tension with which the tape measure is
For personal use only.
placed around the limb; 5) whether units of
measurement (ie. inches and cm) are rounded off
or not.
Some of these points (mentioned above) were
illustrated by a small repeatability study of calf
circumference conducted during a research
course for physiotherapists and occupational
therapists. All members of the course (about 30)
were asked to measure the maximum calf circum-
ference of the same subject, and without prior
knowledge, were asked to repeat this the following
day. Various ways of locating the level of maxi-
mum calf bulk were used; some therapists mea-
sured in inches and others in cm (either rounded
or in mm); one person even included her own
finger in the measurement by placing it behind
the tape measure! Needless to say, the inter-
operator variability was great, and the within
operator variability was also large.
Measurements of quadriceps CSA using ultra-
sound scanning in normal subjects have been
shown to be repeatable with CV of 4% (Young et
al., 1980) and 1.2% (Stokes, 1985, in prep-
aration). In the latter study, the improved repea-
tability was probably due to the more accurate
method of relocating the level on the thigh at
which the scans were taken vir. marking the scan
level, together with permanent skin blemishes on
a transparent sheet (Dons et al., 1979), as opposed
to measuring the height of the level from the floor
(Young et a/., 1980). A detailed account of the
method of scanning quadriceps is being prepared,
which describes the difficulties experienced when
taking and interpreting the scans and includes the
repeatability study mentioned above (Stokes,
1985 in preparation). Physiotherapists wishing to
use ultrasound scanning should seek the collabo-
ration of colleagues in Diagnostic Imaging in the
Radiology Departments of their hospitals. Ultra-
sound B-scanning is too time consuming for
routine clinical use but is essential for research
and helpful for the occasional patient whose
clinical management is proving difficult. The
relationship between quadriceps size and its
isometric strength has been documented for nor-
mal females (Young et al., 1984) and males
(Young et al., 1985). As well as using this
relationship to monitor a patient over a period of
time, it may also be of diagnostic value which is
discussed by Stokes (1985, in preparation) in an
account of ultrasound scanning experience.
Muscle Strength
Measurements of isometric quadriceps strength
using the chair dynamometer (Edwards et al.,
1977) have been shown to be repeatable on
different days in normal males and females of
different ages and the CV in all groups of subjects
was 8% (Young et al., 1984 & 1985). Preliminary
data obtained using the myometer in boys with
muscular dystrophy indicate that their between
days measurements of quadriceps strength are
much more variable than normal (Edwards et al.,
unpublished data). This stresses the importance
of testing the repeatability of measurements in the
population in which they are to be used.
The repeatability of the MRC method relies on
the subjective judgement of the therapist and
adherence to the standardised positioning of the
patient for each of the different muscles. The use
of hand held myometer again requires careful
positioning of the patient and of the operator so
that the action of the muscle being tested is
opposed correctly. The advantage of using the
quadriceps chair is that hip and knee angles, and

hence muscle length, are always the same. This is
important as muscle length affects force.
Muscle Activation
Repeated measurements of quadriceps MVA
using surface IEMG in the meniscectomy patients
was measured with a between days CV of 6%
(Stokes, 1984). The MVA of the human triceps
has been measured with a between days CV of
16% in normal subjects (Yang and Winter,
1983).
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The importance of measuring muscle
T he effectiveness of any treatment can best be
evaluated by making objective measurements of
the tissue or organ at which the treatment is
directed. If only functional tests are used to
monitor progress after injury, the lack of informa-
tion about the muscle itself may lead to inappro-
priate treatment being given and may lead to
further injury. For example, rapid progression of
For personal use only.
exercises and activities following knee injury may
cause excessive loading of the joint due to weak
quadriceps (which may be inhibited) and will
lead to further joint damage (Basmajian, 1970;
Stokes and Young, 1984a,b). While it is true that
the ultimate aim of treatment is to regain full
function, all components of function must be
examined as far as possible.
In the case of muscle disease, it is essential that
patients are monitored so that the effects of any
treatments can be seen. Regular tests also provide
important information about the natural history
of the disease. Measurements which can be made
by physiotherapists include: respiratory function
tests (the most important determinant of life
expectancy in many muscle diseases); tests of
strength and contractile properties of muscle
(Edwards et af., 1977); and joint angle and
contracture measurements. Whole muscle size
measurements can be made by ultrasonography
when appropriate, but CAT scanning may be
necessary (eg. in muscular dystrophy when the
replacement of muscle by fat prevents the pene-
tration of ultrasound waves). Ultrasound can also
be used for diagnostic purposes and allows patho-
logical changes in muscle to be monitored (Heck-
matt et al., 1980; Cady et al., 1983). The needle
PHYSIOTHERAPY PRACTICE 75
biopsy technique (Young et al., 1982; Edwards et
al., 1983) allows measurement of muscle fibre size
and also provides information about the meta-
bolic properties of muscle by histochemical and
biochemical analyses. T h e effects of any treat-
ments which may evolve from sophisticated
research techniques can only be evaluated by
examining the muscle tissue and its functions in
patients with the disease.
Acknowledgements
I wish to thank Dr Archie Young (Consultant
Geriatrician, Royal Free Hospital, London) for
teaching me the techniques described in this
review which were used for investigation carried
out while I was working with D r Young at the
Nuffield Orthopaedic Centre in Oxford. I am
grateful to all the subjects and co-workers
involved in the studies, to the Department of
Health and Social Security for financial support
a t that time, and to Professor RHT Edwards for
his help and adivce in writing this review.
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