[
research report
]
H. JAMES PHILLIPS, PT, PhD1 • JOSEPH BILAND, PT, DPT2 • RICARDO COSTA, PT, DPT3 • REGINE SOUVERAIN, PT, DPT4
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Five-Position Grip Strength Measures
in Individuals With Clinical Depression
C
linicians involved in the measurement of muscular strength
are often concerned with the sincerity of effort in their patients.
One test purported to identify sincerity of effort is 5-position (or
5-rung) grip strength dynamometry. First described by Stokes
in 1983,20 the dynamometer allows adjustment of a single handle in
each of 5 positions, ranging from a very close grip to a very wide grip.
Based on muscle length-tension relationships, patients offering true
maximal effort should produce a skewed,
bell-shaped curve, plotted as force output against handle position, while those
exerting less than maximal effort should
produce an erratic or “flat” force curve.
TTSTUDY DESIGN: Case-control study.
the participants’ diagnosis.
TTOBJECTIVES: To compare the results of
5-position grip strength testing between a group of
individuals newly diagnosed with clinical depression and a group of age-matched and sex-matched
individuals without depression.
TTBACKGROUND: Clinicians often employ 5-position (or 5-rung) grip strength dynamometry as a
measure of sincerity of effort. However, patients
with clinical depression are known to show altered
performance on motor skill tests. Therefore, the
results of 5-position grip strength dynamometry
in the clinically depressed may be subject to
misinterpretation.
TTMETHODS: Consecutive patients newly
Several subsequent studies have verified
the original claim of Stokes that the test
is an effective measure of sincerity of effort,7,11,14,15,21 while others have questioned
the claim,1,18 suggesting that factors other
diagnosed with clinical depression (n = 45) and
age- and sex-matched individuals without clinical
depression (n = 45) were recruited over a 3-month
period. Each group underwent identical 5-position
grip strength testing of both hands. Measures
were analyzed using a statistical analysis method
based on an 8.5-lb (3.83-kg) SD cutoff and visual
analysis of force curve plots by clinicians naïve to
TTRESULTS: Participants with clinical depression
had an SD equal to or less than 8.5 lb in 60 of 90
hands tested, while the participants in the control
group had an SD equal to or less than 8.5 lb in 1
of 90 hands. Clinicians who analyzed force plots
considered participants with depression to have
exerted “limited effort” in 70% of cases and those
who were not depressed to have exerted limited
effort in 18% of cases.
TTCONCLUSION: A high percentage of individuals
diagnosed with clinical depression produced
statistical and graphical representations of 5-position grip strength measures that suggested poor
volitional effort, which is often interpreted as lack
of sincerity of effort. Clinicians unaware of the
presence of clinical depression in patients could
misinterpret the results of 5-position grip strength
testing in this population. J Orthop Sports Phys
Ther 2011;41(3):149-154, Epub 2 February 2011.
doi:10.2519/jospt.2011.3328
TTKEY WORDS: dynamometry, hand, sincerity
of effort
than effort may influence the shape of the
force output curve.5,8,18,22
One group of patients known to have
altered performance on motor skill tests
are those with clinical depression.4,17
Studies have shown ease of fatigability
and lack of asymmetry of grip strength
among depressed boys,4 generally reduced force output among depressed individuals compared to age-matched and
sex-matched nondepressed persons,17 and
a correlation of improved grip strength to
improved affect following intervention.13
However, to the authors’ knowledge,
5-position grip strength testing has never
been administered to clinically depressed
individuals.
The interpretation of results of 5-position grip strength testing has been questioned. In a review of related literature,
Shechtman et al18 found no less than 4
different methods of interpretation: (1)
visual inspection of the force curve for the
skewed, bell-shaped curve; (2) analysis
of variance (ANOVA), with a significant
interaction between handle and effort
deemed as an indicator of maximal effort;
(3) calculation of SD of the 5 scores, with
a significantly smaller SD expected for
those exerting submaximal effort; and (4)
normalization of the 5 scores, expressed
as a percentage of the third position, or
maximum score, plotted by handle position. Shechtman et al18 investigated
these 4 interpretation methods among
individuals asked to exert full effort, then
feign weakness, in both their injured and
1
Associate Professor, Seton Hall University, South Orange, NJ. 2Adjunct Instructor, Seton Hall University, South Orange, NJ. 3Staff Physical Therapist, MSI Physical Therapy,
Kenilworth, NJ. 4Staff Physical Therapist, Memorial Sloan Kettering, New York, NY. The protocol of this study was approved by The Institutional Review Board of Seton Hall
University. Address correspondence to Dr H. James Phillips, Department of Physical Therapy, Seton Hall University, South Orange, NJ 07079. E-mail: howard.phillips@shu.edu
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METHODS
Participants
O
ne hundred consecutive individuals, newly diagnosed but untreated for clinical depression at a
single private psychiatry practice, were
A
Force (lb)*
uninjured hands. On visual inspection
of the 5-position curve, they found no
difference between the uninjured hand
feigning weakness and the injured hand
exerting full effort. They did, however,
see significant differences using the SD
method, which suggested that individuals
exerting true maximal effort might have
greater differences among grip positions,
thus a higher SD, and those offering less
than maximal effort might have less difference among positions, thus a lower
SD. In a separate study, Gutierrez and
Shectman8 found that an SD cutoff of 8.5
lb (3.83 kg) provided optimum sensitivity and specificity in detecting insincere
effort (0.70 and 0.83, respectively). But
they also found a strength-dependent
correlation, with stronger individuals
producing typical bell-shaped curves and
weaker individuals producing somewhat
flatter curves, and cautioned against the
use of this test as a measure of sincerity of
effort. However, Hoffmaster et al11 found
differences in the 5-position curve pattern between sincere and feigned efforts
that supported the original paradigm of
Stokes. An acknowledged shortcoming of
these studies is that the participants were
asked to feign weakness by exerting 50%
or less effort, whereas individuals intentionally feigning weakness may behave
quite differently.
The purpose of this study was to have
individuals newly diagnosed with clinical
depression, but not yet treated, undergo
5-position grip strength testing and compare their results to age-matched and
sex-matched individuals without depression. Both the results of visual inspection
of plotted 5-position graphs by clinicians
from various disciplines in rehabilitation
medicine and the SD method were used
for comparison between groups.
research report
130
120
110
100
90
80
70
60
50
40
30
20
10
0
1
2
3
4
5
Hand Position
B
Force (lb)*
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[
130
120
110
100
90
80
70
60
50
40
30
20
10
0
1
2
3
4
5
Hand Position
FIGURE. Sample 5-position graphs for clinician
sorting. (A) Right-hand grip, 40-year-old, righthanded male. Example of participant with depression
producing a “flat” force curve, resulting in clinician
sorting as “less than full effort.” (B) Left hand
grip, 55-year-old, right-handed male. Example of a
participant in the control group, producing a typical
bell-shaped curve, resulting in clinician sorting as
“full effort.” *1 lb is equivalent to 0.45 kg.
invited to participate in the study, 45 of
whom agreed to participate. The psychiatry practice was located in a major
Northeast inner city, with a largely Spanish and Portuguese population. Investigators working with the participants in
the study were fluent in English, Spanish,
and Portuguese. All diagnoses were made
by a single board-certified psychiatrist
with over 35 years of clinical practice.
To be eligible for the study, individuals
had to have been diagnosed with major depressive disorder (DSM IV 296.3)
and to have presented with “moderate”
symptoms. Those with “mild” or “severe”
symptoms were excluded. To prevent the
possibility of coercion, the treating physician was then blinded to the individuals’ participation in the 5-position grip
]
strength testing study. Forty-five agematched and sex-matched individuals
without clinical depression were recruited as a control group. Age matching for
each participant in the control group was
within 0 to 5 years of a participant with
depression. Individuals in the control
group were from a sample of convenience
and represented a diverse ethnic population recruited via flyer on the campus of
Seton Hall University. All participants in
the control group were naïve to the purpose of the 5-position grip strength testing (no healthcare practitioners or health
professions students were recruited) and
deemed to represent the general campus community. Informed consent was
obtained from all participants in accordance with the policies and procedures
of the Seton Hall University Institutional
Review Board. Exclusion criteria included pregnancy, rheumatoid arthritis or
other systemic arthritis affecting joints
of the upper extremities, any neurological
or musculoskeletal disorders that could
affect arm function, and any psychological comorbidities other than clinical
depression.
Setting
Grip strength testing for all individuals
newly diagnosed with clinical depression
was conducted in a single private psychiatry office on the day of their diagnosis.
Individuals without clinical depression
were tested in various settings but always
following the identical methodology described below.
Instruments/Procedure
A single JAMAR 5-position grip strength
dynamometer (Sammons Preston,
Bolingbrook, IL) was calibrated according to the manufacturer’s specifications
and used for all testing.10 Individuals
newly diagnosed with depression but not
yet treated were invited to join the study
on the day of their initial psychiatric examination. Individuals were encouraged
to sit upright in an armless chair, with
their elbow bent to 90° and forearm in
neutral position. One measure represent-
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ing a maximal effort was taken for each of
the 5 positions for each hand, beginning
with the narrowest and progressing to the
widest position of the dynamometer, with
individuals alternating hands at each grip
setting. Results were recorded in tabular
form in 1-lb (0.45-kg) increments for
later statistical and graphic analyses.
The clinicians participating in this study
used pounds, rather than kilograms, because they indicated that this was the
most common measure used, particularly when producing 5-position graphs
for visual examination. Age-matched and
sex-matched individuals without clinical
depression were tested in the same manner in various settings but always with
similar seating, identical commands, and
the same calibrated dynamometer.
The SD for the force produced in the 5
handle positions for each hand was determined, with a cutoff of less than or equal
to 8.5 lb8 considered an exertion of less
than full effort. Grip strength measures
were plotted against hand position, using
a separate line graph for the right and left
hands of each individual (FIGURE). Grip
dynamometer measures were recorded
in 1-lb (0.45-kg) increments and rounded
to the nearest 10-lb (4.5-kg) increment to
facilitate graphing. Each graph was plotted by a single investigator and received
a numeric code, known only by the primary author, to identify the participant
as clinically depressed or not depressed.
Left- and right-hand graphs for each participant were printed on separate pages,
with gender, age, and handedness noted.
The pages were stapled together for later
interpretation by clinicians.
Next, 4 clinical rehabilitation specialists (TABLE 1) familiar with interpretation
of 5-position grip strength graphs were
asked to sort the graphs according to
whether they considered the participant
to have exerted full effort or less than full
effort. Each clinician indicated that they
routinely used graphical interpretation of
5-position grip strength testing in clinical
practice, usually with data measured in
pounds and plotted in 10-lb increments.
They received no further instruction in
TABLE 1
Profiles of the Practitioners Who
Visually Sorted 5-Position Graphs
Practitioner
CHT
Years Experience
Practice Setting
Physical therapist
No
22
Private practice
Occupational therapist
Yes
30
Private practice
Physiatrist
No
24
Private practice
Psychologist
No
28
Veteran’s hospital
Abbreviation: CHT, certified hand therapist.
TABLE 2
Groups
Number of Participants in Each Group
With an SD Less Than or Equal to,
and Above, 8.5-lb (3.83-kg) Cutoff
Less Than or Equal to 8.5-lb SD
Greater Than 8.5-lb SD
Depressed, right hand (n = 45)
29
16
Depressed, left hand (n = 45)
31
14
Nondepressed, right hand (n = 45)
1
44
Nondepressed, left hand (n = 45)
0
45
how to interpret the graphs, relying on
past experience for interpretation rather
than a new construct. Raters were instructed to designate the participant as
exerting “less than full effort” if either the
left- or right-hand graph suggested less
than full effort. Raters were naïve to the
purpose of the study and the psychological disposition of the participants, and
did not have access to results of the SD
calculations. Each clinician rater calculated the percentage of those deemed less
than full effort out of the total number of
participants (n = 90). Reliability among
the 4 raters was calculated using percent
agreement.
RESULTS
U
sing the SD method with a cutoff of less than or equal to 8.5 lb
(3.83 kg), we found that individuals with depression had a SD score of 8.5
or less in 60 of 90 cases (66.6%), while
those without depression had scores of
8.5 or less in just 1 of 90 cases (1.1%)
(TABLE 2).
Results of clinician sorting of graphs
are shown in TABLE 3. Overall, for the
group recently diagnosed with clinical
depression, clinicians perceived 70%
(67% to 76%, depending on the clinician) of the graphs as representing less
than full effort, compared to 18% (11% to
24%, depending on the clinician) of the
graphs for those without clinical depression. Percent agreement among the 4 raters was 88.2%.
Given the observable differences between the 2 diagnostic groups using
both methods, tables of relative risk of
misidentifying an individual with depression as volitionally exerting less than
full effort were developed (TABLES 4 and
5). On average, clinicians selected individuals with clinical depression as exerting less than full effort 4 times as often
as individuals in the control group. Using the SD method, with a cutoff of less
than or equal to 8.5 lb, the relative risk
of misidentifying individuals with clinical depression as exerting less than full
effort was 60 times that of misidentifying
individuals without clinical depression.
DISCUSSION
T
he aim of this study was to determine if individuals with clinical
depression would perform differ-
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[
TABLE 3
research report
Results of Clinicians Asked to Sort
5-Position Graphs as Limited or Full Effort*
Groups
Depressed (n = 45)
Nondepressed (n = 45)
Physical therapist, limited effort
34 (76%)
7 (16%)
Occupational therapist, limited effort
30 (67%)
9 (20%)
Physiatrist, limited effort
30 (67%)
5 (11%)
Psychologist, limited effort
31 (69%)
11 (24%)
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*Values are n (%). Overall rate of individuals with depression sorted as performing a limited effort
was 69.75%. Overall rate of individuals without depression sorted as performing a limited effort was
17.75%.
TABLE 4
Relative Risk of Persons With
Clinical Depression Labeled as Providing
“Less Than Full Effort” by Clinician Raters*
Depressed (n = 45)
Nondepressed (n = 45)
Less than full effort
32
8
Full effort
13
37
*Relative risk: 4.0; 95% CI: 1.7, 9.6.
TABLE 5
Relative Risk of Persons
With Clinical Depression Labeled
as Providing “Less Than Full Effort” Using
the 8.5-lb (3.83-kg) Cutoff SD Method*
Depressed (n = 90 hands)
Nondepressed (n = 90 hands)
SD Less than or equal to 8.5†
60
1
SD greater than 8.5
30
89
*Relative risk: 60.0; 95% CI: 8.2, 440.
†
An SD less than or equal to 8.5 is considered less than full effort.
ently than individuals without depression
when tested with 5-position grip strength
testing. While decreased motor output
among individuals with clinical depression has been previously described,4,13,17
to our knowledge, this is the first time
5-position grip strength testing has been
utilized for this population.
Using the criterion of an SD cutoff of
less than or equal to 8.5 lb, we observed a
difference in individuals newly diagnosed
with clinical depression: they fell below
8.5 lb in 66% of cases, compared to just
1% of cases in those without depression.
Similarly, clinicians naïve to the psychological disposition of the participants,
who visually analyzed the 5-position force
curves, categorized those with depression
as exerting less than full effort in 67% to
76% of cases. Calculated another way,
persons with clinical depression had a
relative risk of being identified as exerting less than full effort 4 times more often
than those without depression by clinicians using interpretation of graphs, and
60 times more often by clinicians using
the method of SD less than or equal to
8.5 lb.
As such, patients with undiagnosed or
undisclosed clinical depression might be
misidentified as “malingerers” or “symptom magnifiers” by clinicians admin-
]
istering this test. This finding may be
important, as Haggman et al9 found that
physical therapists often missed signs of
clinical depression in patients presenting
with low back pain and suggested implementation of a simple screening device
that would alert them to this common
malady. In a recent editorial, Ross and
Boissonnault16 identified clinical depression as a condition that can adversely influence the prognosis of individuals seen
by physical therapists but may not receive
the attention of clinicians, who may be
otherwise focused on screening for red
flags that suggest more serious pathology.
Study Limitations
Because some individuals with clinical
depression declined participation in the
study (55 of 100 consecutive patients declined), a level of self-selection occurred.
While all potential participants with clinical depression were diagnosed with major depressive disorder (DSM IV 296.3)
with moderate symptoms, there is a spectrum of behavioral presentations in this
cohort. According to the 1 investigator
(R.C.) who collected grip strength data
for this group, patients who appeared to
have the highest level of depression often
declined participation, indicating that
they were unwilling to participate and
simply wanted to be treated. However, we
have no objective criteria to definitively
differentiate between those who participated and those who declined. Therefore,
we can only speculate that those who
participated might have had less severe
symptoms of depression than those who
declined. Had those with a more significant presentation of depression participated, we speculate that the differences
between groups would have been even
greater than that shown.
Age- and sex-matched participants
in the comparison group were not specifically screened for depression due to
Institutional Review Board concerns. As
such, some of these individuals might
have had unknown clinical depression
that affected their performance. However, this would have resulted in groups
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having more similar results rather than
the differences seen.
One potential limitation in methodology is that the researcher plotting
the force curves was not blinded to the
participant group assignment, which
presents a possible bias in producing the
graphs. However, the graphs consisted of
a simple plotting of numeric data, rounded to the nearest 10 lb and marked as an
x. Accuracy of the plots was left to the
integrity of the researcher. Additionally,
rounding to the nearest 10-lb increment
might have caused a “flattening” of the
force curves, particularly for those with
lower measures. However, changing the
scale to 5-lb (2.27-kg) increments, for
example, would only have resulted in a
1- or 2-mm difference in the placement
of the marks, producing minimal change
in the “flatness” or curvilinear shape of
the curve.
Another potential limitation is that
participants were tested on the same day
that they were diagnosed with clinical depression. Their reaction to this new diagnostic label might have affected their
behavior, including the grip strength testing. However, keeping “time living with
diagnosis” the same for all participants
had the benefit of standardizing this potential covariate.
As noted previously, individuals with
clinical depression were of largely Spanish and Portuguese ethnicity, while those
in the control group were a more mixed
ethnic group. However, the investigators
are not aware of any studies that show
any differences among ethnic groups with
regard to grip strength testing outcomes.
Percent agreement among the 4 clinicians analyzing the graphs was calculated
at 88.2%. Considering that the dichotomous choices of full effort and less than
full effort spread over 4 raters would
produce agreement of 20% by chance
alone, this represents fairly good reliability among the clinicians. To the authors’
knowledge, this is the first time that clinicians’ rating of 5-position graphs was
conducted, which suggests that more research is needed in this area.
Finally, clinical depression, ease of fatigue, and volitional limitation of effort
are not mutually exclusive. For instance,
persons undergoing grip strength testing may be clinically depressed and consciously self-limit their effort for a variety
of known and unknown reasons. Patients
seen for physical therapy care may present with a cluster of physical and psychological conditions, making any one
assessment tool insufficient for clinical
determination of sincerity of effort.
CONCLUSION
A
large percentage of individuals newly diagnosed with clinical
depression were erroneously considered to have provided less than full effort on the basis of their performance on
the 5-position hand grip strength test. t
KEY POINTS
FINDINGS: A large percentage of indi-
viduals newly diagnosed with clinical
depression were erroneously considered
as providing less than full effort on the
basis of their performance on the 5-position hand grip strength test.
IMPLICATION: Individuals with clinical
depression asked to perform 5-position
grip strength testing as a measure of
sincerity of effort could easily be mislabeled as volitionally self-limiting effort
by clinicians unaware of their mental
condition. Clinicians need to consider
the mental health status of persons
undergoing this form of testing before
reaching clinical decisions.
CAUTION: This study only looked at 5-position grip strength and was limited
to individuals newly diagnosed with
clinical depression on the day of their
diagnosis.
ACKNOWLEDGEMENTS: We thank William Mahalchick, PT, OCS, Mary Grossman, OTR,
CHT, Peter Schmaus, MD, and Lawrence
Weinberger, PhD for their assistance in serving as clinician interpreters of the 5-position
grip strength graphs.
REFERENCES
1. B
ohannon RW. Is it legitimate to characterize muscle strength using a limited number of measures? J Strength Cond Res.
2008;22:166-173. http://dx.doi.org/10.1519/
JSC.0b013e31815f993d
2. Carney CE, Ulmer C, Edinger JD, Krystal AD,
Knauss F. Assessing depression symptoms in
those with insomnia: an examination of the beck
depression inventory second edition (BDI-II). J
Psychiatr Res. 2009;43:576-582. http://dx.doi.
org/10.1016/j.jpsychires.2008.09.002
3. Dubowitz H, Feigelman S, Lane W, et al. Screening for depression in an urban pediatric primary
care clinic. Pediatrics. 2007;119:435-443. http://
dx.doi.org/10.1542/peds.2006-2010
4. Emerson CS, Harrison DW, Everhart DE, Williamson JB. Grip strength asymmetry in depressed
boys. Neuropsy Neuropsy Be. 2001;14:130-134.
5. Ghori AK, Chung KC. A decision-analysis model
to diagnose feigned hand weakness. J Hand
Surg Am. 2007;32:1638-1643. http://dx.doi.
org/10.1016/j.jhsa.2007.09.010
6. Golden J, Conroy RM, O’Dwyer AM. Reliability
and validity of the Hospital Anxiety and Depression Scale and the Beck Depression Inventory
(Full and FastScreen scales) in detecting depression in persons with hepatitis C. J Affect Disord.
2007;100:265-269. http://dx.doi.org/10.1016/j.
jad.2006.10.020
7. Goldman S, Cahalan TD, An KN. The injured
upper extremity and the JAMAR five-handle
position grip test. Am J Phys Med Rehabil.
1991;70:306-308.
8. Gutierrez Z, Shechtman O. Effectiveness
of the five-handle position grip strength
test in detecting sincerity of effort in men
and women. Am J Phys Med Rehabil.
2003;82:847-855. http://dx.doi.org/10.1097/01.
PHM.0000083667.25092.4E
9. Haggman S, Maher CG, Refshauge KM. Screening for symptoms of depression by physical
therapists managing low back pain. Phys Ther.
2004;84:1157-1166.
10. Harkonen R, Harju R, Alaranta H. Accuracy of the Jamar dynamometer. J Hand Ther.
1993;6:259-262.
11. Hoffmaster E, Lech R, Niebuhr BR. Consistency
of sincere and feigned grip exertions with repeated testing. J Occup Med. 1993;35:788-794.
12. Homaifar BY, Brenner LA, Gutierrez PM, et al.
Sensitivity and specificity of the Beck Depression Inventory-II in persons with traumatic brain
injury. Arch Phys Med Rehabil. 2009;90:652-656.
http://dx.doi.org/10.1016/j.apmr.2008.10.028
13. Neuberger GB, Aaronson LS, Gajewski B, et al.
Predictors of exercise and effects of exercise
on symptoms, function, aerobic fitness, and
disease outcomes of rheumatoid arthritis. Arthritis Rheum. 2007;57:943-952. http://dx.doi.
org/10.1002/art.22903
14. Niebuhr BR, Marion R. Detecting sincerity of
journal of orthopaedic & sports physical therapy | volume 41 | number 3 | march 2011 |
41-03 Phillips.indd 153
153
2/24/2011 4:36:56 PM
[
effort when measuring grip strength. Am J Phys
Med. 1987;66:16-24.
15. Niebuhr BR, Marion R. Voluntary control of submaximal grip strength. Am J Phys Med Rehabil.
1990;69:96-101.
16. Ross MD, Boissonnault WG. Red flags: to
screen or not to screen? J Orthop Sports Phys
Ther. 40:682-684. http://dx.doi.org/10.2519/
jospt.2010.0109
17. Russo A, Cesari M, Onder G, et al. Depression and physical function: results from
the aging and longevity study in the Sirente
geographic area (ilSIRENTE Study). J Geriatr
research report
18.
19.
20.
21.
Psychiatry Neurol. 2007;20:131-137. http://dx.doi.
org/10.1177/0891988707301865
Shechtman O, Gutierrez Z, Kokendofer E. Analysis of the statistical methods used to detect submaximal effort with the five-rung grip strength
test. J Hand Ther. 2005;18:10-18. http://dx.doi.
org/10.1197/j.jht.2004.10.004
Shechtman O, Mann WC, Justiss MD, Tomita M.
Grip strength in the frail elderly. Am J Phys Med
Rehabil. 2004;83:819-826.
Stokes HM. The seriously uninjured hand--weakness of grip. J Occup Med. 1983;25:683-684.
Stokes HM, Landrieu KW, Domangue B,
]
Kunen S. Identification of low-effort patients
through dynamometry. J Hand Surg Am.
1995;20:1047-1056. http://dx.doi.org/10.1016/
S0363-5023(05)80158-3
22. Watson J, Ring D. Influence of psychological
factors on grip strength. J Hand Surg Am.
2008;33:1791-1795. http://dx.doi.org/10.1016/j.
jhsa.2008.07.006
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• Belgische Vereniging van Manueel Therapeuten-Association Belge des
Thérapeutes Manuels (BVMT-ABTM)
• Comitê de Fisioterapia Esportiva do Estado do Rio de Janeiro
(COFEERJ)
• Canadian Physiotherapy Association (CPA) Orthopaedic Division
• Sociedad Chilena de Kinesiologia del Deporte (SOKIDE)
• Suomen Ortopedisen Manuaalisen Terapian Yhdistys ry (SOMTY)
• German Federal Association of Manual Therapists (DFAMT)
• Hellenic Scientific Society of Physiotherapy (HSSPT) Sports
Injury Section
• Chartered Physiotherapists in Sports and Exercise Medicine (CPSEM)
and Chartered Physiotherapists in Manipulative Therapy (CPMT)
of the Irish Society of Chartered Physiotherapists (ISCP)
• Israeli Physiotherapy Society (IPTS)
• Gruppo di Terapi Manuale (GTM), a special interest group
of Associazione Italiana Fisioterapisti (AIFI)
• New Zealand Sports and Orthopaedic Physiotherapy Association
• Norwegian Sport Physiotherapy Group of the Norwegian Physiotherapist
Association
• Portuguese Sports Physiotherapy Group (PSPG) of the Portuguese
Association of Physiotherapists
• Orthopaedic Manipulative Physiotherapy Group (OMPTG) of the
South African Society of Physiotherapy (SASP)
• Swiss Sports Physiotherapy Association (SSPA)
• Association of Turkish Sports Physiotherapists (ATSP)
In addition, JOSPT reaches students and faculty, physical therapists and
physicians at more than 1,400 institutions in the United States and around the
world. We invite you to review our Information for and Instructions
to Authors at www.jospt.org and submit your manuscript for peer review at
http://mc.manuscriptcentral.com/jospt.
154 | march 2011 | volume 41 | number 3 | journal of orthopaedic & sports physical therapy
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