Fine Tuning Your Practice with Nutrition-Focused Physical Examination
Functional Assessment: Walking, Gripping, Getting Things Done
Handgrip Dynamometry, Manual Muscle Testing, Chair-Stands, Walk Challenge, ADL Questionnaire
Buiding on the Best-DNS Symposium, Baltimore MD, June 12, 2015
Lindsay Dowhan MS, RD, CSO, LD, CNSC - Advanced Practice Clinical Dietitian, Center for Gut Rehabilitation &
Transplant, Cleveland Clinic
Mary Russell MS, RDN, LDN, FAND - Senior Manager, Medical Affairs, Baxter Healthcare
We have no relevant commercial relationships to disclose.
Objectives: At the end of this session, the participant will be able to correctly perform a hand grip strength
assessment, and will be able to describe the basic components of at least two common functional assessment
procedures.
1. How to Assess Body Composition
a. Bedside Ultrasound/CT/MRI
b. Skinfold caliper measurements
c. DEXA, Bod-Pod and BIA
d. Hand-grip dynamometry
2. Value of Body Composition Assessment
a. Lean body mass key component of functional ability and quality of life; it’s not easily determined
by traditional assessment methods
b. Body composition assessment could be used as a screening tool for under-nutrition
c. BIA and DEXA precise modalities for assessment of body composition
d. Several BIA equations have been validated (e.g., in patients with COPD, HIV, post-transplant,
and the elderly); none have been validated in patients with extreme obesity, dehydration, or
fluid overload
3. Handgrip Strength (HGS)
a. Reflects the maximum strength derived from combined contraction of extrinsic and intrinsic
hand muscle-a dynamic indicator of muscle mass (1)
b. Originally developed to assess hand strength following surgery
c. Reduction in strength of ~25% in malnourished vs. adequately nourished (1)
4. Application in Practice
a. Academy/A.S.P.E.N. Consensus Statement recommends use for identification & documentation
of malnutrition (3)
b. Potentially valuable settings
a. Weight loss surgery, dialysis (including home), oncology centers
b. Hospitalized patients, particularly pre- and post-surgery
c. Outpatient clinics
5. Recovery – weight gain does not translate to > FFM (1)
a. Myopathic changes seen after 2 weeks of starvation; alterations in muscle contraction patterns
noted
b. Overall pathogenesis of muscle dysfunction unclear
6. Decreased HGS in elderly suggestive of decreased functional status, increased fall risk. Increased chance
of disability, increased mortality
7. Factors that influence HGS, in addition to nutritional status:
a. Age
b. Gender
c. Obesity
d. Physical Activity
e. Depression
f. Disease severity
g. Clinical status
h. Medications (e.g., muscle relaxants, corticosteroids)
i. Immobilization/bed rest
Table: Advantages and Limitations of Using Hand-Grip Strength Measurements (1, 8-12, 14)
Advantages
Responds earlier to nutritional deprivation and
repletion than other body composition
assessments
Disadvantages
Reflects only upper body strength – but has
been shown to correlate to criteria such as
knee extension strength
Standards for defining malnourished state not
Correlated with SGA in some groups studied
available (<10% of range has been used)
Correlated with clinical outcomes
Reliability affected by posture, dominants vs.
non-dominant hand, dynamometer model
Non-invasive
Inexpensive
Patient must be motivated, and given visual
feedback/verbal encouragement
Easy to perform
Regular calibration required
Objective
Assessors must be trained
Relatively low observer and intra-individual
variability
Must be adjusted to hand size
Predicts length of stay, post-op
complications,all-cause mortality in middleaged and elderly, loss of functional status, 15yr fracture risk in perimenopausal women
May not reflect nutritional status in people >
75 years
Normative Grip Strength Data
Sammons Preston Roylan. Jamar® Hydraulic Hand Dynamometer Owner’s Manual
Demonstration and Practice: Proper Grip Strength Testing Procedures
1. Sit, shoulder adducted.
2. Elbow flexed 90 degrees, forearm in neutral position.
3. Three measurements
4. Dominant versus non-dominant hand
Figure. Hypotheses for the Pathogenesis of Impaired Muscle Function in Malnutrition (1).
8. Functional Status Assessment may help to determine:
a. Presence or severity of disease
b. Level of care an individual may need
c. Status changes over time
9. Components of Functional Status Assessment
a. Vision, hearing, mobility, continence
b. Nutrition, mental status, affect
c. Home support & ADLs
10. Functional Status (15) Assessment Tools commonly used
a. 6-minute walk test (16)
b. Get-up and Go (17)
Instructions:
Ask the patient to perform the following series of maneuvers:
1. Sit comfortably in a straight-backed chair.
2. Rise from the chair.
3. Stand still momentarily.
4. Walk a short distance (approximately 3 meters).
5. Turn around.
6. Walk back to the chair.
7. Turn around.
8. Sit down in the chair.
Scoring:
Observe the patient's movements for any deviation from a confident, normal performance. Use
the following scale:
1 = Normal
2 = Very slightly abnormal
3 = Mildly abnormal
4 = Moderately abnormal
5 = Severely abnormal
"Normal" indicates that the patient gave no evidence of being at risk of falling during
the test or at any other time.
"Severely abnormal" indicates that the patient appeared at risk of falling during the
test. Intermediate grades reflect the presence of any of the following as indicators of
the possibility of falling: undue slowness, hesitancy, abnormal movements of the trunk
or upper limbs,staggering, stumbling.
A patient with a score of 3 or more on the Get-up and Go Test is at risk of falling.
c. Karnofsky Performance Status Scale (18)
11. Manual Muscle Testing (MMT)
a. Evaluates the strength of muscle groups to determine impairment and asymmetry (19)
b. Subject is asked to move a limb against gravity and, if able, against manual resistance provided
by a clinician
c. Muscle strength is generally graded on a scale from 0 to 5 with 0 corresponding to no evidence
of contractility and 5 reflecting full range of motion against full resistance
d. MMT includes a degree of subjectivity, especially in judging resistance, but reliability can be
improved by using the same tester, using consistent testing procedures, and preventing the
subject from using collateral muscles to compensate for a deficit in performance.
12. MMT scoring system (20)
Score
Description
0
No visible or palpable muscle contraction
1
Visible or palpable contraction, however no range of motion
1+
Moves limb without gravity loading less than one half of range of motion
2-
Moves limb without gravity loading greater than one half of range of motion
2
Moves full range of motion, gravity is eliminated
2+
Moves against gravity less than one half range of motion
3-
Moves against gravity greater than one half range of motion
3
Moves full range of motion against gravity
3+
Moves against gravity with moderate resistance less than one half range of motion
4-
Moves against gravity with moderate resistance greater than one half range of
motion
4
Moves full range of motion against gravity and has moderate resistance
5
Moves full range of motion against gravity and has maximal resistance
13. Advantages to using MMT
a. Reliable testing methods for functional status (19)
b. Simple, quick, noninvasive, and easy to perform
c. Requires no equipment and can evaluate muscle groups from both the upper and lower body
d. Can be customized to compensate for individuals with physical limitations
e. Safe procedure which can be easily incorporated into a nutrition-focused physical examination
14. MMT procedures
Bed
Test
Primary
Muscle(s)
Position
Procedure
Hip
extension
Gluteus maximus;
semitendinosus;
semimembranosu
s; biceps femoris
HOB
30º
Starting position: leg resting on surface of
bed, knee straight, with foot at rest.
Foot of
bed flat
ROM: Ask subject to raise leg off bed surface
while keeping knee straight.
MMT: Ask subject to raise leg off bed surface
while keeping knee straight. Stabilize knee
joint by lightly placing one hand over knee,
palm facing downward. Place other hand
under lower leg just above ankle, palm
facing upward. Ask subject to lower leg while
applying upward pressure.
Verbal instructions: “Bring your foot down.
Don’t let me lift your leg.”
Ankle
dorsiflexion
Tibialis anterior
HOB
30º 50º
Foot of
bed flat
Starting position: leg resting on surface of
bed, knee straight, with foot at rest.
ROM: Ask subject to raise foot so toes point
towards head, then point toes away from
body while keeping leg in same position.
MMT: Start with subject’s leg resting on
surface of bed, knee straight, bottom of foot
at 90º angle to lower leg with toes pointing
upward. Stabilize ankle by placing one hand,
palm facing downward, on leg just above the
ankle, and the other hand on the superior
surface of the foot. Ask subject to raise foot
so toes point towards head while applying
opposite pressure.
Verbal instructions: “Bring your foot up.
Hold it. Don’t let me push it down.”
Elbow
flexion
Biceps brachii;
brachialis;
brachioradialis
HOB
50º
Starting position: arms relaxed at sides with
palms facing towards body
Foot of
bed flat
ROM: Ask subject to bend elbow while
keeping palm facing towards body and bring
wrist to shoulder. If subject unable to
complete full range of motion against
gravity, assist patient in holding upper arm
at 90º angle to body by supporting arm
under wrist and elbow. Ask patient to move
wrist towards body by keeping upper arm
stable and bending elbow.
MMT: Ask subject to keep arm at side and
bend elbow at 90º angle while keeping palm
facing towards body and hold in flexed
position. Place one hand on shoulder to
stabilize joint and the other hand, palm
facing downwards, on the inside of the
subject’s wrist. Ask the subject to hold arm
in flexed position while applying downward
pressure.
Verbal instructions: “Hold it. Don’t let me
pull it down.”
Elbow
extension
Triceps brachii
HOB
50º
Starting position: arms relaxed at sides with
palms facing upwards
Foot of
bed flat
ROM: same as elbow flexion. If subject
unable to complete full range of motion
against gravity, assist patient in holding
upper arm at 90º angle to body by
supporting arm under wrist and elbow. Ask
patient to bend elbow at 90º angle, then try
to straighten arm by unbending elbow while
keeping upper arm in the same position.
MMT: Ask subject to keep arm at side and
bend elbow at 90º angle while keeping palm
facing towards body and hold in flexed
position. Place one hand underneath elbow,
palm facing upward, to stabilize joint. Place
the other hand underneath the subject’s
wrist, palm facing upward. Ask the subject to
hold arm in flexed position while applying
pressure to move wrist towards shoulder.
Verbal instructions: “Hold it. Don’t let me
push your arm.”
Shoulder
flexion
Deltoids;
coracobrachialis
HOB
50º
Starting position: arms at sides, elbows
slightly flexed, palms facing down.
Foot of
bed flat
ROM: Ask subject to raise arm vertically
above head while keeping elbow straight
MMT: Ask patient to raise arm parallel to
floor, palm facing downward, with elbow
straight. Place one hand on shoulder to
stabilize joint and the other hand, palm
facing downward, on the subject’s arm just
above the elbow. Ask the subject to hold
arm in same position while applying
downward pressure.
Verbal instructions: “Hold it. Don’t let me
move your arm.”
References
1. Norman K, Schutz T, Kemps M, Josef LH, Lochs H, Pirlich M. The Subjective Global Assessment reliably
identifies malnutrition-related muscle dysfunction. Clin Nutr. 2005;24:143-150.
2. Windsor JA, Hill GL. Grip strength: a measure of the proportion of protein loss in surgical patients. Br J
Surg. 1988;75:880-882.
3. White JV, Jensen G, Malone A, et al. Consensus Statement: Academy of Nutrition and Dietetics and
American Society for Parenteral and Enteral Nutrition: Characteristics recommended for identification
and documentation of malnutrition (undernutrition). JPEN J Parenter Enteral Nutr. 2012;36:275-283.
4. Webb AR, Newman, LA, Taylor M, Keogh JB. Handgrip dynamometry as predictor of postoperative
complications reappraisal using age standardized grip strengths. JPEN J Parenter Enteral Nutr.
1989;13:30-33.
5. Baldwin CE, Paratz JD, Bersten AD. Muscle strength assessment in critically ill patients with handheld
dynamometry: An investigation of reliability, minimal detectable change, and time to peak force
generation. J Crit Care 2013; 28:77-86.
6. Bohannon RW. Hand-grip dynamometry predicts future outcomes in aging J Geriatr Phys Ther.
2008;31:3-10
7. Matos, LC et al. Handgrip strength as a hospital admission nutritional risk screening method. European
Journal of Clinical Nutrition. 2007; 61(9): 1128-1135.
8. Stenholm S, Sallinen J, Koster A, et al. Association between obesity history and hand drip strength in
older adults – exploring the roles of inflammation and insulin resistance as mediating factors. J Gerontol
Biol Sci Med Sci. 2001;66(3):341-348.
9. Krause KE, et al. Sarcopenia and predictors of the fat free mass index in community-dwelling and
assisted-living older men and women. Gait Posture. 2012;35(2):180-185.
10. Webb AR, Newman LA, Taylor M, Keogh JB. Hand grip dynamometry as a predictor of postoperative
complications reappraisal using age standardized grip strengths. JPEN J Parenter Enteral Nutr
1989:13:30-33.
11. Kerr A, Syddall HE, Cooper C, et al. Does admission grip strength predict length of stay in hospitalised
older patients? Age Ageing. 2006;35:82-84.
12. Humphreys J, de la MP, Hirsch S, Barrera G, Gattas V, Bunout D. Muscle strength as a predictor of loss of
functional status in hospitalized patients. Nutrition. 2002;18:616-620.
13. Rasheed S, Woods RT. An investigation into the association between nutritional status and quality of life
in older people admitted to hospital. J Hum Nutr Diet. 2014; 27:142-151
14. Mendes J, Azevedo A, Amaral TF. Handgrip strength at admission and time to discharge in medical and
surgical inpatients. JPEN J Parenter Enteral Nutr. 2014; 38:481-488
15. Tomey KM, Sowers MR. Assessment of physical functioning: A conceptual model encompassing
environmental factors and individual compensation strategies. Physical Therapy 2009; 89:705-714
16. Six Minute Walk Test. https://www.thoracic.org/statements/resources/pfet/sixminute.pdf, accessed
1/6/2015
17. Mathias S, Nayak USL, Isaacs B. Balance in elderly patients: the “get-up and go”test. Arch Phys Med
Rehabil. 1986;67:387-389.
18. Karnofsky Performance Status.
http://www.pennmedicine.org/homecare/hcp/elig_worksheets/Karnofsky-Performance-Status.pdf,
accessed 1/6/2015
19. Wadsworth CT, Krishnan R, Sear M, Harrold J, Nielsen DH. Intrarater reliability of manual muscle testing
and hand-held dynamometric muscle testing. Phys Ther. 1987;67:1342-1347
20. Clarkson HM. Musculoskeletal assessment: Joint Range of Motion and Manual Muscle Strength.
Philadelphia, PA: Lippincott, Williams & Wilkens; 2000.
Additional resource:
Russell MK. Functional assessment of nutritional status. Nutr Clin Pract. 2015 Apr;30(2):211-218. Epub 2015
Feb 13