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Grip strength is a fundamental procedure used by therapists and physicians t o assess patient status following injuries, surgical techniques, and treatment procedures. An accurate, quantifiable assessment of hand grip strength helps t he clinician establish realistic treatment goals.
Grip strength is a fundamental procedure used by therapists and physicians t o assess patient status following injuries, surgical techniques, and treatment procedures. An accurate, quantifiable assessment of hand grip strength helps t he clinician establish realistic treatment goals.
Grip strength is a fundamental procedure used by therapists and physicians t o assess patient status following injuries, surgical techniques, and treatment procedures. An accurate, quantifiable assessment of hand grip strength helps t he clinician establish realistic treatment goals.
Jamar Grip Dynamometer George F. Hamilton, MS, PT, OCS' Carolyn McDonald, BS, PT2 Thomas C. Chenier, PhD3 H and grip strength is a fundamental proce- dur e used by thera- pists and physicians t o assess patient sta- tus fbllowing injuries, surgical tech- niques, and treatment procedures t o t he hand and upper extremity. An accurate, quantifiable assessment of hand grip strength helps t he clinician establish realistic treatment goals, provides treatment outcome data, and is frequently utilized during de- termination of hand disability ratings. Over t he years, several instru- ments and methods for measuring hand grip strength have been devel- oped. In t he 1950s. instruments such as t he Sklar, Narrangansett, Geckler, and Collins dynamometers were used but were proven unsatisfactory for standardized grip strength measure- ment (5, 1 I). In 1954, Bechtol introduced t he Jamar dynamometer. It consisted of a sealed hydraulic system with ad- justable hand spacings that regis- tered hand grip force in pounds per square inch (PSI) (1). It became t he most accepted instrument in Califor- nia for quantitative measurement of hand grip (5). Brewer et al discussed two meth- ods for hand grip strength measure- ments. The Lansbury method, used Quantitative measurement of grip strength is an important variable when plotting the prog- ress of a hand-injured patient. When utilizing traditional commercially available apparatuses, obtain- ing meaningful grip strength measurement in these subjects is frequently difficult due to severe deformity, high tissue sensitivity, and low levels of force generated. The purpose of this study was to measure hand grip strength using two instruments having different physical characteristics and units of measurement to determine the reliability of repeated measures with each instrument. Addition- ally, validity of the sphygmomanometer for strength measurement was established through compari- son with the values obtained from measurements using the research-validated lamar dynamometer. Twenty-nine right hand dominant female college-age subjects volunteered to perform hand grip strength testing. Measurements were taken with a sphygmomanometer and a lamar dynamometer while utilizing standardized measurement procedures. A Spearman Rho correlation coefficient test utilized in measuring within-instrument reliability showed a high correlation for each instrument at .85 for the sphygmomanometer and .82 for the lamar dynamometer. Construct validity testing performed to determine validity of the measurements by the sphygmomanometer compared with the lamar dynamometer produced a .75 correlation. A formula for conversion of the sphygmoma- nometer scores into lamar units was developed to enhance reporting of sphygmomanometer scores utilizing the lamar standard. The study showed that the sphygmomanometer and lamar dynamome- ter exhibit good within-instrument reliability. Validity of the sphygmomanometer as a grip measure- ment device i s acceptable and reportable using the conversion formula developed. Therefore, it can be utilized with confidence as essentially equal to the lamar unit for grip strength measurement. Key Words: grip strength, hand injury, reliability Professor, Department of Physical Therapy, School of Allied Health Sciences, East Carolina Uniwrsity, Creen- ville, NC 27858 Staff physical therapist, Department of Physical Therapy, Nash General Hospital, Rocky Mount, NC 'Assistant professor, Epidemiology and Statistics, School of Allied Health Sciences, East Carolina University, Creenville. NC prior t o 1958, consisted of a sphyg- momanometer cuff folded twice and inflated t o 20 mmHg. The Winthrop torqueometer was a device used t o measure hand grip and rotational ability (2). Kirkpatrick reported t he find- ings of a California Commission that examined grip strength measure- ment instruments based upon pneu- matic, spring, and hydraulic systems. They concluded that grip is a force rather than a pressure and that it should be measured in force units such as Ibs or gms; they recom- mended use of t he Jamar dynamom- JOSPT Volume 16 Number 5 November 1992 R E S E A R C H S T U D Y et er (5). Most of t he recent studies of grip strength measurement have re- ported t he Jamar dynamometer t o be t he most reliable and accurate de- vice for measurement of hand grip strength (6-9). However, Solgaard et al tested three units utilized in grip strength measurement; two were steel spring force dynamometers ("Collins" and "My-Gripper") and one was pneumatic ("Martin Vigori- meter"). Accuracy of t he units was tested by placing each instrument be- tween two compressible plates of a machine that yielded force and de- flection information. Machine test results demonstrated near linearity of all units, with the pneumatic unit performing the best. Th e instru- ments were also subjected t o a clini- cal test of measured grip strength in 100 normal men and women sub- jects. Th e pneumatic unit demon- strated t he highest precision and was deemed t o be t he superior instru- ment for grip strength measurement by those investigators (1 2). Due t o problems of discomfort conformity and convenience in hand-injured pa- tients, many clinicians continue t o utilize the soft cuff of t he Sphygmo- manometer t o measure grip strength. Th e purpose of this study was t o determine t he repeated measures re- liability of t he sphygmomanometer under well-controlled test conditions, t o compare those reliability out- comes t o values obtained for t he re- search-validated Jamar dynamome- ter, and t o test for construct validity of t he sphygmomanometer's meas- urement scale (mmHg) by compari- son with t he Jamar (PSI) unit. If t he sphygmomanometer proved t o be valid and reliable, then clinicians might use this instrument with greater confidence when obtaining hand grip measurements. METHODS Subjects Twenty-nine normal healthy fe- male college-age subjects with no known history of orthopaedic disor- ders of their dominant hand volun- teered t o participate in this study. Descriptive characteristics of the sub- jects ar e listed in Table 1. Apparatus Apparatuses used in this experi- ment were an Aneroid type adult sphygmomanometer U.A. Preston, Inc., 60 Page Road, Clifton, New Jersey, 270 12) (Figure 1). which measures force in units of mmHg, and a Jamar dynamometer (Item 3363, G.E. Miller, Inc., 484 Broad- way, Yonkers, New York, 10705) (Figure 2). which measures in units of PSI. Many dinicians continue to utilize the soff cuff of the sphygmomanometer to measure grip strength. The sphygmomanometer cuff was evenly rolled, forming a circum- ference of approximately 7 in t o conform with a normal functional hand position for grip.A rubber band was placed around each end of t he cuff t o hold it in position. Th e cuff was inflated t o 20 mmHg, which was t he starting position for meas- urement of each subject. Th e Jamar dynamometer was set at t he third handle space, which is reported t o be t he most commonly used position for measurement (1). Additionally, it provided t he closest hand grip di- mension t o the rolled up sphygmo- manometer cuff. The Jamar dynamometer was calibrated by suspending a range of weights, comparable t o anticipated study values, from t he handle of the FIGURE 1. The sphygmomanometer. FIGURE 2. The lamar dynamometer. Factor Units Total Mean SD Age (yean) 29 23.8 4.9 Height (in) 29 66.1 2.2 Weight (Ibd 29 131.9 26.3 TABLE 1. Subject characteristics. Volume 16 Number 5 November 1992 JOSPT R E S E A R C H S T U D Y fixated instrument. Dial readings ob- tained were identical t o those of t he suspended weights, thus, confirming the validity of t he Jamar dynamome- ter with which t he sphygmomanome- ter would be compared. Design Under the direction of the same operator, 29 subjects performed hand grip strength testing for each instrument. A mean score was calcu- lated from three measurements per instrument, obtained at each of three independent measurement ses- sions occurring approximately 1 week apart. Spearman Rho correlation coef- ficient tests were administered t o de- termine relationships within and be- tween the instruments. Repeated measures reliability was obtained by calculating correlation coefficients between sessions 1 and 2, sessions 1 and 3, and sessions 2 and 3 for each instrument. The relationship be- tween the two instruments was ob- tained by applying a Spearman Rho correlation coefficient test utilizing t he mean value of all observations from each instrument and by plot- ting a simple linear regression t o as- sess construct validity of t he sphyg- momanometer for measurement of hand grip strength. Procedure All subjects signed a personal consent form, after which we re- corded their ID number, age, height, and weight. The American Society of Hand Therapists' stand- ardized arm position for hand strength testing was utilized (4). Each subject was positioned in a straight back chair with both feet flat on t he floor. Arm positioning was demonstrated by t he operator, then each subject was instructed t o place her left hand on her right thigh and assume a position of adducted and neutrally rotated shoulders. For the arm t o be tested, the elbow was flexed t o 90". t he forearm and wrist were in neutral positions, and the fingers were flexed as needed for a maximal contraction (Figure 3). Fach subject was instructed t o breathe in through her nose and blow out through pursed lips as a maxinlum grip effort was made. At this time, a verbal command of "Squeeze! Harder! Harder! Relax!" was given by the examiner. Demon- stration of maximum hand grip per- formance was given prior t o t he first session, and re-instruction was given prior t o t he ot her two sessions as needed. The instrument t o be tested first was assigned by random order t o each subject. Four minutes o r Results demonstrated high within-instrument repeated measures reliability and an acceptable correlation between sphygmomanometer and lamar dynamometer measurements. greater were allowed between each grip measurement. Th e mean score among three trials of each instru- ment was recorded for data calcula- tions. The second and third sessions for hand grip measurements were repeated approximately 1 week apart using each instrument. Extraneous variables were con- trolled by using t he same room with an average temperature of 74" F, subjects of t he same gender, right hand dominance, and approximately t he same age group, and approxi- mately the same time of day. The FIGURE 3. Positioning of a subject while performing hand grip strength measurements using the sphygmomanometer and the lamar dynamometer. same instructions were given t o each subject regarding position of the u p per extremity, hand grip strength performance, and breathing tech- nique. Each subject was encouraged not t o do any strenuous activity with t he dominant upper extremity dur- ing the study. RESULTS Mean and standard deviation grip strength scores for each instru- ment at each of t he three sessions ar e presented in Table 2. Spearman Rho correlation coefficient test out- comes for each possible pair of Ja- mar and sphygmonianometer read- ings collected over all sessions are presented in Table 3. The average r value for t he three observational pe- riods was .85 for the sphygmoma- nometer and .8 1 for the Jamar (Ta- ble 3A), each with a statistically sig- nificant relationship (/I < .OO 1) for scores obtained between the three test intervals. Sphygnionianometer vs Jamar mean scores for all observational pe- riods produced a correlation coeffi- cient of .75 (Table 3C). Using the inverse regression technique (3). we calculated an in- JOSPT * Volume 16 * Number 5 * November 1992 R E S E A R C H S T U D Y Sessions 1 2 3 Mean Sphygmomanometer (mmHg) Mean 205.96 200.17 199.83 203.12 SD 22.53 21.53 14.85 21.10 jamar dynamometer (PSI) Mean 63.09 69.21 66.23 64.83 SD 9.43 8.08 10.50 9.07 TABLE 2. Mean and standard deviation for three grip strength sessions using the sphygmomanometer and the lamar dynamometer, plus the mean and standard deviation values for all grip sessions. A Sphyg 1 vs Sphyg 2 Rho = .8426 p < .001 Sphyg 1 vs Sphyg 3 Rho = .8616 p < .001 Sphyg 2 vs Sphyg 3 Rho = ,8401 p < .001 Jamar 1 vs Jamar 2 Rho = ,8764 p < .001 Jamar 1 vs Jamar 3 Rho = .8049 p < .001 Jamar 2 vs Jamar 3 Rho = .7844 p < .001 B Sphyg 1 vs Jamar 1 Rho = .6079 p < .001 Sphyg 2 vs Jamar 2 Rho = .7455 p < .001 Sphyg 3 vs Jamar 3 Rho = .5723 p = .001 C Mean scores of Sphyg vs mean scores of jamar Rho = .7497 p < .001 - - - - TABLE 3. Spearman Rho correlation coefficient values showing within (A) and between (6) instrument rekability in hand grip strength measurement for the sphygmomanometer and the lamar dynamometer. FIGURE 4. Inverse regression prediction line showmg the relationship between sphygmomanometer (mmHg) and lamar (PSI) readings and the formulas for conversion of sphygmomanometer to lamar scores. reliability and an acceptable correla- tion between sphygmomanometer and Jamar dynamometer measure- ments. Although statements ar e available in the literature expressing the inadequacy of pressure-related instrumentation for grip strength measurement (5. 8). test results from Solgaard et al demonstrated that a pneumatic-based (Martin Vigorime- ter) ball type unit provided highly linear and reliable data for grip strength measurement ( 1 2). Robert- son and Deitz have advocated t he use of t he Martin Vigorimeter for measuring grip strength in preschool children due t o its ability t o accu- rately measure spherical grip verse regression line showing the re- strength, which they indicated was a lationship between Jamar and more effective indicator of hand monianometer scores and a formula function in the child ( 1 0). t o convert sphygmomanometer . , Our scores for s ~h v ~mo ma n o m- 1 , <7 scores t o equivalent Jamar values et er and Jamar grip strength testing (Figure 4). The formula is Jamar = were similar, each yielding correla- .!j4 s~h~gnl Onl anOmet er - 45.12. tion values of .80 o r greater. These < I findings conform with t he previous DISCUSSION work of Mathiowetz et al, who re- ported a high correlation (.80 o r Results demonstrated high greater) in hand grip strength using within-instrument repeated measures t he Jamar dynamometer (8). Data obtained from the two in- struments were used t o construct a formula Uamar = .54 x Sphygmo- manometer - 45.12) by which meas- urements on the sphygmomanome- t er (mmHg) could be converted into t he corresponding Jamar (PSI) meas- urements. An inverse regression technique was used t o make these conversions (3). For these data, it would be inappropriate t o apply the usual regresson analysis. One of the assumptions of t he usual regression analysis is that t he predictor variable is measured without error, o r that the error of t he predictor varible is small relative t o the error of the re- sponse variable. When a regression line is fit t o data where the predictor variable is measured with error, the resulting estimate of the slope of the regression line is biased. In this in- stance, measurements associated with t he sphygmomanometer that are subject t o error are being used t o predict t he values obtained from the Jamar. When measuring grip strength in the hand-disabled subject, there are multiple advantages of the Sphygmomanometer over t he Jamar unit: I) ready availability of a sphyg- momanometer in most clinics, 2) a soft compliant surface that may pro- duce less discomfort t o t he injured hand during testing, and 3) a scale with smaller increments than the Ja- mar and, therefore, greater sensitiv- ity t o small changes in strength. The outcome of this study dem- onstrates t he ability of t he sphygmo- manometer t o provide acceptable levels of repeated measures reliabil- ity in the normal population. How- ever, further studies ar e needed within the hand-injured population t o fully validate its application. JOSPT REFERENCES 1 . Bechtol CO: The use of a dynarnorne- ter with adjustable handle spacings. I Bone joint Surg 36A(4):820-824, 1954 2. Brewer K, Cuyatt AR, Scott IT: Corn- Volume 16 Number 5 November 1992 JOSPT R E S E A R C H S T U D Y paring grip strength. Physiother 61:118, 1975 3. Draper NR, Smith H: Applied Regres- sion Analysis (2nd Ed), pp 47-5 1. New York: lohn Wiley & Sons, 198 1 4. Fess EE, Moran CA: Clinical assessment recommendations booklet. American Society of Hand Therapists, 1002 Van Dora Springs Road, Suite 10 1, Garner, NC 27529, 1981 5. Kirkpatrick I : Evaluation of grip loss: A factor of permanent disability in Cali- fornia. Ind Med Surg 26:285-289, 1957 6. Mathiowetz V, Kashman N, Volland G, Weber K, Dowe M, Rogers S: Crip and pinch strength: Normative data for adults. Arch Phys Med Rehabil66:69- 74, 1985 7. Mathiowetz V, Rennells C, Donahoe L: Effect of elbow position on grip and key pinch strength. I Hand Surg 1 OA:694-697, 1985 8. Mathiowetz V, Weber K, Volland G, Kashman N: Reliability and validity of grip and pinch strength evaluations. 1 Hand Surg 9A:222-226, 1984 9. Mathiowetz V, Wiemer D, Federman S: Crip and pinch strength: Norms for 6 t o 19 year olds. Am I Occup Ther 40:705-711, 1986 10. Robertson A, Dietz I: A description of grip strength in pre-school children. Am I Occup Ther 42:647-652, 1988 11. Schmidt RT, Toews /V: Crip strength as measured by the lamar dynamom- eter. Arch Phys Med Rehabil 5 1:32 1 - 327, 1970 12. Solgaard S, Kristiansen 6, lensen IS: Evaluation of instruments for measur- ing grip strength. Acta Orthop Scand 55:569-572, 1984 JOSPT Volume 16 Number 5 November 1992