Critical Issues in the Use of Muscle Testing for the Determination of Sincerity of Effort

Over the past 20 years, there have been numerous attempts to identify methodologies that are capable of the determination of sincerity of effort during muscle testing. The ensuing paper reviewed this literature and drew several conclusions. Injured patients and healthy volunteers do produce less force and more variable force while performing submaximal contractions than maximal contractions. However, submaximal efforts during strength testing can be reproduced and the use of force variability is not adequate to distinguish sincerity of effort. Visual examination of the shape of force output curves is also not adequate for distinguishing sincerity of effort. Furthermore, much of the research using strength ratios, difference scores, and an assortment of different parameters derived during strength testing has not established reliable and clinically useful methods of differentiating effort levels. Methods examining motion variability, radial/ulnar force output ratios, difference scores of eccentric-concentric ratios, and electromyography offer some promise, but numerous critical issues need to addressed. The use of the coefficient of variation, for example, is statistically untenable given the number of trials appropriate for clinical samples. Several studies have inadequate sample size to number of variable ratios. Many studies have questionable or at least unknown generalizability to patient samples and actual functional capacity. It is critical that other explanatory variables such as fear of injury, pain, medications, work satisfaction, and other motivational factors be considered. It is our opinion that there is not sufficient empirical evidence to support the clinical application of muscle testing to determine sincerity of effort.