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Tests and Measures

Quantitative Testing of Muscle Strength: Issues and Practical Options for the Geriatric Population

Bohannon, Richard W. EdD, PT, NCS

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Topics in Geriatric Rehabilitation: December 2002 - Volume 18 - Issue 2 - p 1-17
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Muscle strength is defined herein as the maximum voluntary force or torque brought to bear on the environment under a given set of test conditions. Granting that some authorities eschew the term "strength" in favor of the more generic word "performance" or the phrase "force control," I will use the more traditional term strength. The concept of muscle strength will not be limited, as it sometimes is, to the context of a single isometric maximal voluntary contraction.

This review will focus on issues and practical options relevant to measuring muscle strength in the geriatric population. Although the issues and options are not unique to these individuals, the tendency of strength to decrease with age1-4 makes them particularly relevant to this group.


Why measure muscle strength?

The body and its various segments, as well as objects encountered by the body within the environment, have mass. If an individual is to accelerate or decelerate these masses, forces must be generated. Skeletal muscles are the means by which accelerative and decelerative forces are produced. Although maximum force is seldom required in everyday life, a sufficient force must be generated if a task is to be completed successfully. An individual with a high force-producing capacity (strength) is less likely to be thwarted by more demanding activities (eg, opening a tight jar lid). Other things being equal, the greater force-generating capacity of stronger individuals will render them less functionally limited by a pathology (eg, stroke) that results in impaired strength. It also will provide them with a reserve that will enable them to persist longer at submaximal activities. These realities render strength important and worth measuring.

A wealth of correlational research also provides support for measuring muscle strength. Muscle strength has been shown to correlate concurrently with overall functional performance as well as with performance at specific functional activities such as walking, climbing steps, and attaining a standing position (Fig 1).5-17 Muscle strength also has been found to correlate with important nonfunctional variables. Among these variables are nutritional status and bone mineral density.18-21 Moreover, muscle strength is a predictor of such diverse outcomes as postoperative complications,22-24 functional decline,25,26 and survival.27-29

Fig 1.
Fig 1.:
Box plot illustrating the difference in bilateral knee extension force (expressed as a percentage of body weight) between acute rehabilitation patients who are unable versus able to complete a sit-to-stand independently without using their upper extremities.

Why measure strength quantitatively?

Undoubtedly, manual muscle testing is the procedure used most often by clinicians to measure muscle strength. Since it requires no equipment, it can be applied quickly and easily in any setting. The widespread use and advantages of manual muscle testing notwithstanding, its subjectivity and insensitivity limit its value relative to quantitative options.

Manual muscle testing is demonstrably subjective. This subjectivity does not pose much of a problem during the testing of weaker muscles whose scores are based on the presence of a contraction or the amount of joint excursion, either with gravity eliminated or against gravity. Once the tester has to apply and grade resistance, however, subjectivity becomes problematic. While testers are clearly able to modulate their forces, they are limited in their ability to apply consistent forces30(Fig 2). In addition, there are differences in the maximal forces they are able to apply.31

Fig 2.
Fig 2.:
Line graph illustrating that while 10 testers could modulate the forces they applied for three manual muscle test grades, they varied considerably in the forces they applied for each grade. Source: Reprinted with permission from Knepler C, Bohannon RW, Subjectivity of Forces Associated with Manual-Muscle Test Grades of 3+, 4−, and 4, Perceptual and Motor Skills, Vol 87, pp 1123-1128, © 1998.

The subjectivity of manual muscle testing renders it insensitive, particularly at the higher grades. More than 50 years ago, Beasley32 demonstrated that 20% to 25% differences in strength were not discernible by testers using manual muscle testing. He also noted that children, whose strength was only 50% of normal, were misjudged as having normal strength. Since the publication of Beasley's work, numerous other investigators33-38 have documented the insensitivity and limited responsiveness of manual muscle testing compared with various quantitative alternatives.


Quantitative strength testing options are those that yield measurements in real numbers. To be practical they must be rapidly applicable in a variety of settings. Three quantitative options are excluded from this review because they lack such practicality: weights, fixed dynamometry, and isokinetic dynamometry. Determining strength (eg, a one-repetition maximum) using weights involves trial and error and possibly the transportation of weights. The setup time is prohibitive for both fixed and isokinetic dynamometers. Moreover, isokinetic dynamometers are very difficult to move from place to place. Three options without these limitations follow.

Hand-grip dynamometry

Hand-grip dynamometry refers to the use of instrumentation to measure the grasping strength of the hand (Fig 3). Modified sphygmomanometers or similar devices can be used to measure grip strength, but they should probably be avoided since they measure pressure, which is influenced by the area over which force is applied.39 The Jamar is apparently the most widely employed dynamometer,40 but the use of others has been described regularly in the literature.

Fig 3.
Fig 3.:
Measurement of hand-grip strength with a J-Tech Commander hand-grip dynamometer.

Several methods for measuring grip strength have been described. Since elbow and shoulder position, as well as the width of the grasp, can affect the force measured,41-44 it is important that the procedure be conducted consistently. The American Society of Hand Therapists suggested use of the Jamar dynamometer in its second (most narrow) handle position, with the subject seated, the shoulder adducted and in neutral rotation, the elbow flexed to 90°, and the forearm and wrist in neutral.45 When a consistent technique is used, grip dynamometry is highly reliable.46,47 Hand-grip dynamometry is obviously limited to the measurement of a single task (ie, hand grasp). It can be used, however, to characterize overall muscle strength (particularly of the tested upper extremity).48 The internal consistency of muscle strength measures justifies such a generalization.49

Several investigators47,50-54 have presented normative values for grip strength obtained with a dynamometer. These studies are listed in Table 1. The normative values that I use to make judgments about impairments—those of Mathiowetz et al50—are presented in Table 2.

Table 1
Table 1:
Summary of studies presenting normative values for grip strength obtained by hand-grip dynamometry
Table 2
Table 2:
Reference values for grip strength (lbs)

Hand-held dynamometry

Hand-held dynamometry involves the use of a dynamometer that is held by a tester and applied to the tested segment of a patient's body (Fig 4). A modified sphygmomanometer can be used, but it is not recommended for the same reasons as noted earlier in the section on hand-grip dynamometry.55 Several models of hand-held dynamometers are marketed commercially. Dynamometers incorporating load cells are more expensive than those relying on springs, but they probably retain their accuracy better over time.56

Fig 4.
Fig 4.:
Measurement of hip flexion strength with a J-Tech Commander hand-held dynamometer.

Many factors influence the measurements obtained with hand-held dynamometers. Procedures must be incorporated to account for these factors. At a minimum, I suggest the use of make tests rather than break tests; the forces associated with make tests are lower and not influenced by spasticity.57,58 Moreover, I suggest that the individuals tested be asked to come to maximum force over a period of 1 to 2 seconds and that they continue with their maximum effort for no more than 3 to 4 seconds. Testing should be conducted with the joint in the middle half of its range and the effect of gravity eliminated or lessened. The tester must have sufficient strength to hold the dynamometer steady while the tested individual pushes against it. If the tester is not strong enough, valid and reliable measurements will not be obtained59 unless supplementary stabilization is employed. Belts have been used effectively to this end.60,61 Testers of adequate strength who employ consistent methods can obtain valid and reliable measurements using hand-held dynamometry.62-64

Although not so prevalent as for hand-grip dynamometry, normative values for hand-held dynamometry have been published.65-71 These studies are summarized in Table 3. For judgments regarding impairments in extremity strength, I recommend the values presented in Table 4.

Table 3
Table 3:
Summary of studies presenting normative values for extremity strength obtained by hand-held dynamometry
Table 4
Table 4:
Reference values for extremity muscle strength (as a percentage of body weight) obtained by hand-held dynamometry
Table 4
Table 4:
Table 4
Table 4:


Muscle strength also can be tested functionally; that is, it can be measured by quantifying the time or repetitions associated with specific bodily maneuvers. These functional tests use the weight of the body or various body segments for resistance.

Sit-to-stand test

Although there are many functional strength tests, the sit-to-stand test (chair-stand test) is probably used most often with older individuals. All sit-to-stand tests employ a chair (preferably armless) of standard height. Ideally the chair should have a hard or firm surface and be stabilized against a wall. Tested individuals stand up and sit down as quickly as they can without the use of their upper extremities; some instructions call for the arms to be folded in front of the chest (Fig 5).72 Performance is either quantified on the basis of the number of repetitions completed in a given period of time (ie, 10 or 30 seconds)73-76 or the time required to perform a given number of repetitions (usually 5 or 10).72,77-79

Fig 5.
Fig 5.:
Measurement of sit-to-stand performance.

The sit-to-stand test has been shown to possess both convergent construct and discriminant validity. The former is supported by the correlation between sit-to-stand performance and knee extension force73,74 and leg press force.76 The latter is shown by the lower sit-to-stand performance among individuals who are older, who have lower habitual activity levels, and who report a higher need for assistance with activities of daily living.72,76,77 Reliability coefficients reported for different versions of the test vary. Measurements of the time for a single chair stand (intraclass correlation coefficient [ICC] = .25)78 lack reliability compared with measurements of the time for five or more repetitions (reliability coefficients ≥ .67).78-80 Jones et al76 reported test-retest reliability coefficients of .77 to .95 for the number of chair stands performed in 30 seconds.

Many older individuals are unable to perform one or more repetitions of the sit-to-stand maneuver. In the study by Guralnik et al,72 more than 25% of the men and 30% of the women over 80 years of age were unable to perform five chair stands. For those able to perform the requisite number of repetitions or to continue for the allotted time, however, reference values have been published. Csuka and McCarty77 published regression equations for predicting normal performance for 10 stand-ups. For women the predicted time in seconds was 7.6 + .17 · age; for men the predicted time in seconds was 4.9 + .19 · age. Guralnik et al72 reported mean and median times for five stand-ups to be 13.2 and 12.6 seconds, respectively, for males and 14.4 and 13.7 seconds, respectively, for females 71 to 79 years. For individuals age 80 years or more they documented mean and median times of 15.0 and 14.0 seconds, respectively, for males and 16.1 and 15.0 seconds, respectively, for females. Table 5 presents normative values reported by Rikli and Jones81 for the number of sit-to-stands performed in 30 seconds.

Table 5
Table 5:
Reference values for repetitions of sit-to-stand in 30 seconds

Other functional tests

Several functional tests other than the sit-to-stand test have been described in some detail in the literature. These include other lower extremity tests such as step-ups and standing toe-raises as well as tests of upper body and trunk strength.

Amundsen and Graves described a procedure for quantifying lower extremity strength on the basis of patients' "ability to step up onto and off of platforms of progressively increasing height (10.2, 20.3, 30.5, and 40.6 cm)."82(p25) Overall, patients' ability correlated significantly with their peak knee extension torque (normalized against body weight) of the left (r = .72) and right (r = .59). Others have described step tests, but the tests they describe have either been used with young individuals or to characterize other aspects of motor performance (eg, endurance or agility).83 Lundsford and Perry84 described a "heel-rise" test to quantify ankle plantar flexion strength. For 203 individuals age 20 to 59 years they documented the number of unilateral heel-rises performed. The average number of repetitions completed was 27.9 (range, 6 to 70). The lower limit of the 99% confidence interval was 25 repetitions.

Although used primarily with younger individuals,85-87 pull-ups, push-ups, and sit-ups can be employed with some older individuals.88 The validity of push-ups has been established by the correlation of push-up and bench-press performance.85 Normative values obtained from a sample of older Canadian men and women are available for the push-ups and sit-ups.88 The number of push-ups completed in 60 seconds was 6.1 ± 4.6 for men 65 to 69 years and 3.7 ± 3.6 for men 70 to 75 years; the number completed was 4.3 ± 5.5 for women 65 to 69 years and 3.3 ± 3.4 for women 70 to 75 years. The number of sit-ups completed in 60 seconds was 8.7 ± 6.1 for men 65 to 69 years and 7.2 ± 6.8 for men 70 to 75 years; the number completed was 4.0 ± 5.8 for women 65 to 69 years and 4.0 ± 5.6 for women 70 to 75 years.


There are numerous quantitative alternatives to manual muscle testing for quantifying muscle strength. Although all of these alternatives merit broader application, circumstances will determine the best choice for specific situations.


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muscle; measurement; aging

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