One of the accepted purposes of measurements is the prediction of critical outcomes.1 Such prediction is important for identifying individuals who are at risk of untoward future events and for determining appropriate targets for risk-reducing efforts.1 Although muscle strength is an essential component of the physical examination,2 it is not routinely used clinically to predict outcomes. A literature review published several years ago intimated that dynamometrically measured grip strength may have value as a predictor of important outcomes.3 That review, however suggestive, was insufficiently comprehensive to justify the routine inclusion of hand grip dynamometry among screening tools. The purpose of this systematic review, therefore, was to establish the adequacy of evidence for supporting the inclusion of hand-grip dynamometry as a predictor of important outcomes.
For this systematic review, which was limited to peer-reviewed journal articles, the four major electronic databases were searched: Medline/PubMed, Cumulative Index of Nursing and Allied Health, EMBASE, and Science Citation Index. The final search was conducted in June 2006. Terms used in the search included: hand, grip, and strength in combination with outcome, mortality, survival, disability, function, complications, hospital, or surgery. The author examined for relevance all identified articles, as well as articles located by examination of reference lists. Additionally, personal files were searched for pertinent articles. Finally, a list of journal articles identified by these means was reviewed by a content expert (Nicaola Massy-Westropp, OT, PhD: University of South Australia) for omissions.
Inclusion of articles was dependent on their: (1) indication that hand-grip dynamometry was used to measure strength and (2) presentation of statistics describing a relationship between grip strength and an outcome other than strength. Articles were excluded if they: (1) were in a language other than English, (2) did not contain original data (eg, reviews), (3) described only cross-sectional relationships, or (4) addressed relationships between changes in grip strength and a relevant outcome.
Journal articles meeting inclusion criteria and not excluded were abstracted. Specifically recorded in a Word table were: the important outcome addressed, key sample characteristics (eg, sex, size and age), dynamometer measurement specifics (eg, dynamometer and measurement used) follow-up/time period, and findings relevant to the relationship between grip strength and outcomes. When findings were adjusted for factors other than grip strength (eg, demographics, health), adjustments were designated.
Altogether, 45 articles were identified and found relevant on the basis of inclusion and exclusion criteria (Table 1). Sixteen of the articles involved mostly healthy community-dwelling subjects.4–20 Twenty-eight articles included subjects who were described by authors as disabled or having functional limitations21,22 hospitalized,23–29 postsurgical,30–37 or as having specific health prob-lems such as pneumonia,23,25 arthritis,38–43 cancer,27,30 renal or liver disease,35,44–46 coronary artery disease,31 or hip fracture.47,48
The majority of studies focused on middle-aged and older adults, though a few also included younger individuals33,34 or did not specify age.32,37,48 The time between the measurement of grip strength and the determination of outcome was not always indi-cated specifically, but it ranged from a few days in the case of studies focusing on hospitalization or the postoperative period25–37,48 to 15 or more years in several studies of initially healthy men6,8,25 or patients with rheumatoid arthritis.38,41,43 The specific dynamometer employed was not always stated. Among dynamometers designated, the Jamar was used most often.4,7,21,23,24,26,28,35 The grip strength measure used in the studies varied. In a few cases it was not specified,5,14,15,41,42,47 but more often the measurement used was the strength of the right hand,4,7,11,43 stronger hand,20,21,23,24,28,31,44 non-dominant hand,17,27,30,32–34,37,45,48 dominant hand,9,10,12,16,22,36 or both hands.,13,18,25,26,29,36,38,39 Mortality/survival was the most commonly measured outcome.4–11,21,23,24,30,31,38–40,42–45,47 However, disability,12–16-,22,25,26,41 complications and increased length of stay,26,27,30–34,37,46 and other outcomes17,18,24,28,35,36 were also measured.
Low grip strength was a consistent predictor of death and high grip strength was a consistent predictor of survival in studies with diverse samples of subjects. Sixteen of 23 studies provided unqualified support for the use of grip strength as a predictor of mortality/survival.4,7–11,21,23,24,29–31,40,42,45,47 Two studies did not demonstrate grip strength to be predictive of survival; both involved patients with rheumatoid arthritis.39,43 Two studies reported grip strength to be predictive for men but not women5,44 and 2 studies reported grip strength to be predictive for women but not for men.19,38 One study reported grip strength of men greater than 60 years to be predictive but grip strength of men less than 60 years not to be predictive.6
All studies examining the relationship of grip strength with future disability demonstrated that low grip strength was accom-panied by a greater likelihood of functional limitations.12–16,22,25,26,41 However, in 1 study the risk of disability was not increased for a subset of subjects less than 77 years.12 In another study only progressive disability of the upper limb was predicted; catastrophic disability of the upper limb, progressive or catastrophic disability of activities of daily living, and mobility were not predicted by grip weakness.22
The findings of most studies examining the association of grip strength with complications and length of stay were unambiguous. That is, lower grip strength was followed by an increased likelihood of complications or increased length of stay.26–28,30,32–34,36,37,46 Álvares-da-Silva reported grip strength to be “the only technique that predicted a significant increase in major complications” among patients with cirrhosis.46 Hunt et al described grip strength as the “most sensitive single parameter” predicting postoperative compli-cations.32 The results of 3 studies were divided. Davies et al determined that low grip strength was predictive of complications but only for the subset composed of patients at least 80 years of age.48 Vecchiarino et al found low grip strength to be associated with a longer length of stay, but only in bivariate analysis.24 Figueriredo et al observed that low grip strength was associated with a longer length of stay in the intensive care unit but not in the hospital overall.35 For patients undergoing coronary artery bypass grafting, Kerr et al noted greater lengths of stay and more complications in patients whose grip strength was less, but the differences were not significant.30 Discharge home26 or to usual residence30 has been shown to be more likely for patients who have greater grip strength. Although bone loss may not be greater for patients with lower grip strength,17 fractures are more likely.18
This systematic review was conducted to summarize the evidence for using grip strength to predict important outcomes. The evidence gathered from diverse samples of individuals, employing several dynamometers, and using different strength measures supports the value of grip strength as a predictor of mortality, disability, complications, and increased length of stay. In several studies, grip strength was the only significant predictor, the best predictor, or a predictor of comparable or higher value than traditional laboratory or clinical measures. Even when grip strength was adjusted for potentially confounding variables, it was a consistent predictor of important outcomes.
Why might grip strength be such a robust predictor? A causal relationship between grip strength and the outcomes studied is unlikely, except perhaps for disability. It is more probable that grip strength reflects other variables that are potentially causal. As most studies revealing the predictive value of grip strength involved older subjects or a subset of older subjects, several candidate variables come to mind. Chief among the variables is frailty. Decreased strength, most often grip strength, has been prescribed as an important sign of frailty.49–52 Syddall et al even proffered grip strength as a “single marker of frailty.”52 Two other variables, sometimes included among markers of frailty as well, are nutritional status and vitality.49,51,53 Grip strength has been shown to be a legitimate indicator of nutritional status37,45 that may in some populations predict outcomes better than traditional nutritional markers such as weight to height ratios, weight loss, limb circumference, or serum albu-min.34 Davies described grip strength as “a crude but effective will to live meter.”48
Although the evidence of this systematic review is strong, the evidence it consolidates has several limitations. First, a single individual performed all searches and abstracting. Consequently, the reliability of the coalesced evidence cannot be confirmed. Second, studies were not vetted for quality. While quality is important, this was not a consolidation of intervention studies such that inclusion could be limited to randomized controlled trials. The author did not want to arbitrarily exclude observational studies as they provide information relevant to the focus of the review. Third, while the diversity of samples, dynamometers, and measures studied supports the robustness of grip strength as a predictor, it also precludes the application of cut-point scores with known sensitivity and specificity across the population as a whole. Future research, therefore, should investigate a very large population-based sample using a commercially available dynamometer and a single measurement (eg, best grip of the strongest side).
In conclusion, broader utilization of grip strength is support-able because of its predictive validity. Additional support resides in its measurement properties,54,55 simplicity, portability, and afford-ability. Like different physical performance measures examined by Studenski et al, grip strength should be considered as one “vital sign” useful for screening “older adults in clinical settings.”56
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