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Hand-Grip Dynamometry Predicts Future Outcomes in Aging Adults

Bohannon, Richard W. PT, EdD

Journal of Geriatric Physical Therapy: 2008 - Volume 31 - Issue 1 - p 3–10
Research Reports

Background and Purpose: One use of clinical measures is the prediction of future outcomes. The purpose of this systematic review was to summarize the literature addressing the value of grip strength as a predictor of important outcomes.

Methods: Relevant literature was located using 4 bibliographic databases, searching article reference lists, and perusing personal files.

Results: Forty-five relevant research articles were found. The research involved both healthy subjects and patients; it tended to focus on middle-aged and older adults. The primary outcome addressed was mortality/survival (24 articles), but disability (9 articles), complications and/or increased length of stay (12 articles), and other outcomes were also examined. Low grip strength was shown consistently to be associated with a greater likelihood of premature mortality, the development of disability, and an increased risk of complications or prolonged length of stay after hospitalization or surgery.

Conclusions: Given its predictive validity and simplicity, dynamometrically measured grip strength should be considered as a vital sign useful for screening middle-aged and older adults.

Department of Physical Therapy, Neag School of Education, University of Connecticut, Storrs, CT and Physical Therapy Consultants, West Hartford, CT

Address all correspondence to: Dr Richard W Bohannon, PT, NCS, FAPTA, FAHA, Department of Physical Therapy, Neag School of Education, University of Connecticut, Storrs, CT, 06269–2101, Ph: 860–486–0048, Fax: 860–486–1588 (richard.bohannon@uconn.edu).

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INTRODUCTION

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.

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METHODS

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.

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RESULTS

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

Table 1

Table 1

Table 1

Table 1

Table 1

Table 1

Table 1

Table 1

Table 1

Table 1

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

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DISCUSSION

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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REFERENCES

1. Rothstein JM, Echternach JL. Primer on Measurement: An Introductory Guide to Measurement Issues. Alexandria, VA: American Physical Therapy Association; 1993:65-67.
2. Guide to Physical Therapist Practice. Phys Ther. 1997; 77: 1163-1650.
3. Bohannon RW. Dynamometer measurements of hand-grip strength predict multiple outcomes. Percep Motor Skills. 2001; 93: 323-328.
4. Newman AB, Kupelian V, Visser M, et al. Strength, but not muscle mass, is associated with mortality in the Health, Aging and Body Composition Study cohort. J Gerontol: Med Sci. 2006;61A:72-77.
5. Fujita Y, Nakamura Y, Hiraoka J, et al. Physical-strength tests and mortality among visitors to health-promotion centres in Japan. J Clin Epidemiol. 1995;48:1349-1359.
6. Metter EJ, Talbot LA, Schrager M, et al. Skeletal muscle strength as a predictor of all-cause mortality in healthy men. J Gerontol: Bio Sci. 2002;57A:B359-B365.
7. Al Snih S, Markides KS, Ray L, et al. Handgrip strength and mortality in older Mexican Americans. J Am Geriatr Soc. 2002;50:1250-1256.
8. Rantanen T, Harris T, Leveille SG, et al. Muscle strength and body mass index as long-term predictors of mortality in initially healthy men. J Gerontol: Med Sci. 2000;55A:M168-M173.
9. Rolland Y, Lauwers-Cances V, Cesari M, Vellas B, Pahor M, Grandjean H. Physical performance measures as predictors of mortality in a cohort of community-dwelling older French women. Eur J Epidemiol. 2006;21:113-122.
10. Anstey KJ, Luszcz MA, Giles LC, Andrews GR. Demographic, health, cognitive, and sensory variables as predictors of mortality in very old adults. Psychol Aging. 2001;16:3-11.
11. Milne JS, Maule MM. A longitudinal study of handgrip and dementia in older people. Age Ageing. 1984;13:42-48.
12. Giampaoli S, Ferrucci L, Cecchi F, et al. Hand-grip strength predicts incident disability in non-disabled older men. Age Ageing. 1999;28:283-288.
13. Sarkisian CA, Liu H, Ensrud KE, et al. Correlates of attributing new disability to old age. J Am Geriatr Soc. 2001;49:134-141.
14. Rantanen T, Guralnik JM, Foley D, et al. Midlife hand grip strength as a predictor of old age disability. JAMA. 1999;281:558-560.
15. Shinakai S, Watanabe S, Kumagai S, et al. Walking speed as a good predictor for the onset of functional dependence in a Japanese rural community population. Age Ageing. 2000;29:441-446.
16. Shinkai S, Kumagai S, Fujiwara Y, et al. Predictors for the onset of functional decline among initially non-disabled older people living in a community during a 6-year follow-up. Geriatr Gerontol Int. 2003;3:S31-S39.
17. Reeve J, Walton J, Russell LJ, et al. Determinants of the first decade of bone loss after menopause at spine, hip and radius. Q J Med. 1999;92:261-273.
18. Albrand G, Munoz F, Sornay-Rendu E, DuBoeuf F, Delmas PD. Independent predictors of all osteoporosis-related fractures in healthy postmenopausal women: The OFELY study. Bone. 2003;32:78-85.
19. Shibata H, Haga H, Nagai H, et al. Predictors of all-cause mortality between ages 70 and 80: the Koganei Study. Arch Gerontol Geriatr. 1992;14:283-297.
20. Laukkanen P, Heikkinen E, Kauppinen M. Muscle strength and mobility as predictors of survival in 74-84-year-old people. Age Ageing. 1995;24:468-473.
21. Rantanen T, Volpato S, Ferrucci L, Heikkinen E, Fried LP, Guralnik JM. Handgrip strength and cause-specific and total mortality in older disabled women: exploring the mechanism. J Am Geriatr Soc. 2003;51:636-641.
22. Onder G, Penninx BWJH, Ferrucci L, et al. Measures of physical performance and risk for progressive and catastrophic disability: results from the Women's Health and Aging Study. J Gerontol: Med Sci. 2005;60A:74-79.
23. Bohannon RW, Maljanian R, Ferullo J. Mortality and read-mission of the elderly one year after hospitalization for pneumonia. Aging Clin Exp Res. 2004;16:22-25.
24. Vecchiarino P, Bohannon RW, Ferullo J, Maljanian R. Short-term outcomes and their predictors for patients hospitalized with community-acquired pneumonia. Heart & Lung. 2004;33:301-307.
25. Humphreys J, de la Maza P, Hirsch S, et al. Muscle strength as a predictor of loss of functional status in hospitalized patients. Nutrition. 2002;18:616-620.
26. McAniff CM, Bohannon RW. Validity of grip strength dynamometry in acute rehabilitation. J Phys Ther Sci. 2002;14:41-46.
27. Guo C-B, Zhang W, Ma D-Q, et al. Hand grip strength: an indicator of nutritional state and the mix of postoperative complications in patients with oral and maxillofacial cancers. Br J Oral Maxillofac Surg. 1996;34:325-327.
28. Kerr A, Syddall HE, Cooper C, et al. Does admission grip strength predict length of stay in hospitalized older patients. Age Ageing. 2006;35:82-84.
29. Phillips P. Grip strength, mental performance and nutritional status as indicators of mortality risk among female geriatric patients. Age Ageing. 1986;15:53-56.
30. Kalfarentzos F, Spiliotis J, Velimezis G, Dougenis D, Androulakis J. Comparison of forearm muscle dynamometry with nutritional prognostic index, as a preoperative indicator in cancer patients. J Parent Enter Nutr. 1989;13:34-36.
31. Cook JW, Pierson LM, Herbert WG, et al. The influence of patient strength, aerobic capacity and body composition upon outcomes after coronary artery bypass grafting. Thorac Cardiov Surg. 2001;49:89-93.
32. Hunt DR, Rowlands BJ, Johnston D. Hand grip strength- A simple prognostic indicator in surgical patients. J Parent Enter Nutr. 1985;9:701-704.
33. Mahalakshmi VN, Ananthakrishnan N, Kate V, Sahai A, Trakroo M. Handgrip strength and endurance as a predictor of postoperative morbidity in surgical patients: Can it serve as a simple bedside test? Int Surg. 2004;89:115-121.
34. Klidjian AM, Foster KJ, Kammerling RM, Cooper A, Karran SJ. Relation of anthropometric and dynamometric variables to serious postoperative complications. Br Med J. 1980;281:899-901.
35. Figueiredo F, Dickson ER, Pasha T, et al. Impact of nutritional status on outcomes after liver transplantation. Transplantation. 2000;70:1347-1352.
36. Schroeder D, Hill GL. Predicting postoperative fatigue: impor-tance of preoperative factors. World J Surg. 1993;17:226-231.
37. Webb AR, Newman LA, Taylor M, Keogh JB. Hand grip dynamometry as a predictor of postoperative complications. Reappraisal using age standardized grip strengths. J Parent Enter Nutr. 1989;13:30-33.
38. Pincus T, Brooks RH, Callahan LF. Prediction of long-term mortality in patients with rheumatoid arthritis according to simple questionnaire and joint count measures. Ann Intern Med .1994;120:26-34.
39. Pincus T, Callahan LF, Vaughn WK. Questionnaire, walking time and button test measures of functional capacity as predictive markers for mortality in rheumatoid arthritis. J Rheumatol. 1987;14:240-251.
40. Callahan LF, Pincus T, Huston JW, Brooks RH, Nance EP, Kaye JJ. Measures of activity and damage in rheumatoid arthritis: depiction of changes and prediction of mortality over five years. Arthritis Care Res. 1997;10:381-394.
41. Corbett M, Dalton S, Young A, Silman A, Shipley M. Factors predicting death, survival and functional outcome in a pro-spective study of early rheumatoid disease over 15 years. Br J Rheumatol. 1993;32:717-723.
42. Mitchell DM, Spitz PW, Young DY, Blocj DA, McShane DJ, Fries JF. Survival, prognosis, and causes of death in rheumatoid arthritis. Arthritis Rheum. 1986;29:706-714.
43. Pincus T, Callahan LF, Sale WG, Brooks AL, Payne LE, Vaughn WK. Severe functional declines, work disability, and increased mortality in seventy-five rheumatoid arthritis patients studied over nine years. Arthritis Rheumatism .1984;27:864-872.
44. Stenvinkel P, Barany P, Chung SH, Lindholm B, Heimbürger O. A comparative analysis of nutritional parameters as predictors of outcome in male and female ESRD patients. Nephrol Dial Transplant. 2002;17:1266-1274.
45. Wang AY-M, Sea MM-M, Ho ZS-Y, Lui S-F, Li PK-T, Woo J. Evaluation of hand-grip strength as a nutritional marker and prognostic indicator in peritoneal dialysis patients. Am J Clin Nutr. 2005;81:79-86.
46. Álvares-da-Silva MR, Reverbel daSilveira T. Comparison between handgrip strength, subjective global assessment, and prognostic nutritional index in assessing malnutrition and predicting clinical outcome in cirrhotic outpatients. Nutrition. 2005;21:113-117.
47. Meyer HE, Tverdal A, Falch JA, Pedersen JI. Factors associated with mortality after hip fracture. Osteoporos Int. 2000;11:228-232.
48. Davies CWT, Jones DM, Shearer JR. Hand-grip-A simple test for morbidity after fracture of the neck of femur. J Royal Soc Med. 1984;77:833-836.
49. Hirsch C, Anderson ML, Newman A, et al. The association of race with frailty: The Cardiovascular Health Study. Ann Epidemiol. 2006;16:545-553.
50. Klein BEK, Klein R, Knudtson MD, Lee KE. Frailty, morbidity and survival. Arch Gerontol Geriatr. 2005;41:141-149.
51. Boyd CM, Xue Q-L, Simpson CF, Guralnik JM, Fried LP. Frailty, hospitalization, and progression of disability in a cohort of older women. Am J Med. 2005;118:1225-1231.
52. Syddall H, Cooper C, Martin F, Briggs R, Sayer AA. Is grip strength a useful single marker of frailty? Age Ageing. 2003;32 650-656.
53. Bartali B, Frongillo EA, Bandinelli S, et al. Low nutrient intake is an essential component of frailty in older persons. J Gerontol: Med Sci. 2006;61A: 589-593.
54. Wade DT, Langton Hewer R, Skilbeck CE, David RM. Stroke. A critical approach to diagnosis treatment and management. Chicago, Ill: Year book Medical Publishers, Inc; 1985:74-77.
55. Bohannon RW. Hand-grip dynamometry. Considerations in clinical application. J Human Muscle Perform. 1991;1:16-36.
56. Studenski S, Perera S, Wallace D, et al. Physical performance measures in the clinical setting. J Am Geriatr Soc. 2003;51:314-322.
Keywords:

muscles; epidemiologic measures; equipment and sup-plies; health status indicators

© 2008 Lippincott Williams & Wilkins, Inc.