Clinical Nutrition 30 (2011) 135e142
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Clinical Nutrition
journal homepage: http://www.elsevier.com/locate/clnu
Review
Hand grip strength: Outcome predictor and marker of nutritional status
Kristina Norman a, *, Nicole Stobäus c, M. Cristina Gonzalez b, Jörg-Dieter Schulzke c, Matthias Pirlich a, d
a
Department of Gastroenterology, Hepatology and Endocrinology, Charité e University Medicine Berlin, Berlin, Germany
Post Graduation Program in Health and Behaviour e Catholic University of Pelotas, Pelotas, Brazil
c
Department of General Medicine, Charité e University Medicine Berlin, Berlin, Germany
d
Abteilung für Innere Medizin, Evangelische Elisabeth Klinik, Berlin, Germany
b
a r t i c l e i n f o
s u m m a r y
Article history:
Received 7 July 2010
Accepted 23 September 2010
Background & aims: Among all muscle function tests, measurement of hand grip strength has gained
attention as a simple, non-invasive marker of muscle strength of upper extremities, well suitable for
clinical use. This review outlines the prognostic relevance of grip strength in various clinical and
epidemiologic settings and investigates its suitability as marker of nutritional status in cross-sectional as
well as intervention studies.
Methods: Studies investigating grip strength as prognostic marker or nutritional parameter in crosssectional or intervention studies were summarized.
Results and conclusions: Numerous clinical and epidemiological studies have shown the predictive
potential of hand grip strength regarding short and long-term mortality and morbidity. In patients,
impaired grip strength is an indicator of increased postoperative complications, increased length of
hospitalization, higher rehospitalisation rate and decreased physical status. In elderly in particular, loss of
grip strength implies loss of independence. Epidemiological studies have moreover demonstrated that
low grip strength in healthy adults predicts increased risk of functional limitations and disability in
higher age as well as all-cause mortality.
As muscle function reacts early to nutritional deprivation, hand grip strength has also become a popular
marker of nutritional status and is increasingly being employed as outcome variable in nutritional
intervention studies.
Ó 2010 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
Keywords:
Hand grip strength
Muscle function
Disease-related malnutrition
Outcome
1. Introduction
Impaired muscle strength is a well-known phenomenon occurring in disease-related malnutrition. Reduced nutritional intake
results in a compensatory loss of whole body protein which is
preferably lost from muscle mass, the body’s largest protein
reserve.3,4 Simultaneously, muscle protein synthesis can also be
reduced in disease-related malnutrition.
Since muscle function correlates closely with whole body
protein,10,11 body cell mass,12 anthropometrically measured arm
muscle mass,13 and even with body mass index (BMI),14,15 loss of
weight or muscle mass invariably results in decreased muscle
strength, i.e. weakness, which is reflected in deteriorating function
tests as well as in prominently altered muscle morphology.
Reduced muscle strength is in turn associated with loss of
physical functionality and with negative impact on recovery of
health after illness or surgery, which partly explains the high
* Corresponding author. Medizinische Klinik und Poliklinik, Charité e Universitätsmedizin Berlin,10098 Berlin. Tel.: þ49 30 450 514139; fax: þ49 30 450 514901.
E-mail address: kristina.norman@charite.de (K. Norman).
predictive power of muscle function tests. Various studies have
shown a close correlation between muscle strength and outcome
in acute and chronic disease.16e19
2. Measurement of hand grip strength as indicator of muscle
function
Just as measuring body composition offers a qualitative aspect of
nutritional status, muscle function represents a dynamic indicator
of muscle mass. Measurement of muscle function as indicator of
functional as well as nutritional status has therefore gained
considerable attention in the past years. There are several methods
for the measurement of voluntary and involuntary muscle function.
Electrical stimulation at various frequencies but constant isometric
length is used for the determination of involuntary muscle contraction.20e22 While it is considered the superior procedure in
regard to objectivity, it is not suitable for clinical routine. Among
the measurements of voluntary muscle strength (e.g. hand grip,
knee extension or hip flexion strength), hand grip strength is
a validated and most feasible bed side method, which makes it
attractive and the most frequently used tool for clinical purpose.
0261-5614/$ e see front matter Ó 2010 Elsevier Ltd and European Society for Clinical Nutrition and Metabolism. All rights reserved.
doi:10.1016/j.clnu.2010.09.010
136
K. Norman et al. / Clinical Nutrition 30 (2011) 135e142
M ALN U T R I T I O N
Protein
Synthesis
Proteolysis
fibre atrophy
Glycolytic Enzyme
Activities [5;7-9]
muscle glycolysis ↓
reduced
muscle mass
R ED U CED
Creatine
[1;2]
Mitochondrial
Complex Activites
[5;6]
Intracellular
Calcium [7;8]
creatinephosphate ↓ oxidative
phosphorylation ↓
impaired free energy
change from ATP
hydrolysis
M U SCLE
impaired cell energetics &
impaired cell membrane
potential
FU N CT I O N
Fig. 1. Hypotheses 1,2,5,6,9 for the pathogenesis of impaired muscle function in malnutrition.
Hand grip strength reflects the maximum strength derived from
combined contraction of extrinsic and intrinsic hand muscles
which lead to the flexion of hand joints.23 Originally developed for
hand surgery in order to determine the capacity after trauma or
surgery, hand grip strength has quickly become the focus of interest
in numerous studies due to its feasibility and prognostic relevance.
Although hand grip strength correlates well with other muscle
function tests such as knee extension strength or peak expiratory
flow, it cannot be used as surrogate for muscle function of lower
extremities when evaluating physical performance.24
3. Determinants of hand grip strength
In healthy people, age and gender are the strongest influencing
factors on hand grip strength.25 In acute or chronic disease, however,
various further factors such as disease severity, co-morbidity load,
medical treatment, and immobilisation contribute to a certain
extent to muscle weakness and therefore to the patients’ decreased
well-being. Bed rest and muscle disuse,26 inflammation, infection,
endotoxemia, corticosteroids, muscle relaxants, hypoxia, electrolyte
imbalances and oxidative stress all have adverse effects on muscle
function.27 Moreover, nutritional status which is frequently reduced
in disease invariably has a great impact on muscle strength. In
benign disease, for instance, disease-related malnutrition results in
decreased muscle function. Our group found 25.8% lower absolute
hand grip strength values in malnourished when compared to wellnourished hospitalized patients. This difference was also seen when
patients were analysed according to their body mass index, implying
that loss of weight has more impact on muscle strength than body
mass.12 Similarly, Vaz et al. showed that hand grip strength not
merely reflected body mass but could also differentiate between
undernourished and simply underweight individuals with equal
BMI.28 Moreover, our recent study in cancer patients showed that
when malnutrition is defined by the Subjective Global Assessment,
it can be considered a strong disease-independent predictor for
hand grip strength and other muscle function tests.29
4. Muscle function in obese subjects
There are several reasons why muscle strength might be
affected in obesity. Obese subjects have greater muscle mass which
is a major determinant of muscle strength, at least in normal weight
subjects. Also, a certain training effect induced by bearing and
supporting the higher weight can strengthen the muscles of obese
subjects. On the other hand, high body weight is associated with
decreased sedentary lifestyle,30 as well as reduced physical activity
and mobility. Moreover, higher weight frequently induces pain in
e.g. knees and lower back which in turn has negative impact on
muscle strength.
Obese subjects have been shown to possess fewer type I and
more type IIb muscle fibres than lean people, as fat mass correlates
inversely with type I fibres and positively with type II fibres.30e32
Absolute hand grip strength is not significantly different
between obese and lean subjects, although muscle function of the
lower extremities and fat free mass are higher in obese people.30,33
This is probably because the weight induced training effect is seen
only in the muscles of lower extremities. Rollands et al. demonstrated that apart from knee extension strength, muscle function is
not significantly different between lean and obese subjects when
adjusted for age, height, recreational physical activity, pain,
depression and appendicular skeletal muscle mass.33
When corrected for fat free mass through allometric scaling,
Hulens and coworkers even reported that obese women exhibit
lower muscle strength of both upper and lower extremities when
compared to lean women, which might be explained by their lower
degree of activity.34
5. Changes of muscle morphology and function in
malnutrition
The alterations in muscle morphology found in malnutrition are
well described. Muscle biopsy specimens of untreated anorectics,35e37 of children with malnutrition38 and even of morbidly
obese patients after two weeks of starvation7 consistently show
myopathic changes with selective type II fibre (anaerobic, glycolytic, fast twitch) atrophy. Also, Z band degeneration is found in
malnutrition.7,39 These principal ultra structural changes in muscle
have been suggested to reflect loss of contractile elements.37
Changes in muscle function during malnutrition, assessed by
either voluntary hand grip strength or electrostimulation, are well
documented.28,40e42 Lopes et al. reported both increased muscle
fatigability and an altered pattern of muscle contraction and
K. Norman et al. / Clinical Nutrition 30 (2011) 135e142
137
Table 1
Cut off values and outcome prediction of hand grip strength in clinical and epidemiological studies.
Author
N
Setting/patients
Outcome prediction
Clinical studies
Klidjian et al.18
225
Major abdominal surgery
Webb et al.19
90
General surgery
Guo et al.46
127
Oral and maxillofacial cancer surgery
17
205
General surgery
Humphreys et al.16
Kerr et al.48
50
120
General surgery and internal medicine
Elderly patients (75e101 years)
Vecchiarino et al.49
213
Bohannon et al.50
153
Predominantly elderly patients
(72.5 16.5 years) with
community-acquired pneumonia
Elderly with community-acquired pneumonia
HGS <85% of standard value (derived from control group) predicted
complications in 48 of the 55 patients (87%) who developed them
HGS <85% standard for age and sex (derived from control group) predicted
74% of the complications
Patients with HGS< 85% of control value (derived from control group) developed
significantly more postoperative complications (48 vs. 18%, p < 0.05)
Patients with HGS< 85% of standard developed significantly more postoperative
complications (26 vs. 7%, p < 0.0001) and total as well as postoperative
LOS (p < 0.001)
Predictive of decline in functional status (b ¼ 0.448; p < 0.001)
Predictive of LOS: 1 kg increase in grip strength was associated with a 3% increase
in likelihood of discharge to usual residence (gender-adjusted hazard ratio, HR
per kg increase in grip strength: 1.03 (CI 1.001e07)
Grip strength 10 kg:
OR of discharge to home: 4.670 (CI 2.102e10.375)
OR death within 30 days of discharge: 0.370 (CI 0.149e0.992)
Predictive of death and/or readmission within one year of discharge. Grip strength
correctly classified 75.2% of patients relative to that outcome;
OR: 0.969 (CI 0.948 0.987)
Hunt et al.
Epidemiological studies
6089
Rantanen et al.85
45e68-year-old men healthy at baseline
56
Rantanen et al.
6040
45e68-year-old men healthy at baseline
Rantanen et al.51
567
Elderly (75-year-old) independent
in ADL at baseline
Rantanen et al.54
919
Moderately to severely disabled women
aged 65 to 101
Sasaki et al.55
4912
Men and women 35e74 years old healthy
at baseline
Newman et al.53
2292
Men and women 70e79 years
Gale et al.52
800
Men and women 65 years
Lowest tertile of HGS: increased risk of functional limitations and disability;
OR: 2.87 (CI 1.76e4.67) within 25 years
Lowest tertile of HGS: increased long-term mortality within 30 years independent
of BMI class:
OR: 1.36 (CI 1.14e1.63) for BMI group<20;
OR: 1.25 (CI 1.08e1.45 for BMI 20e24.9;
OR: 1.27 (CI 1.08e1.49) for BMI25
Lowest tertile of HGS had two to three times higher ADL dependence
within 25 years:
OR of walking speed of 0.4 m/s or slower:2.87 (CI 1.76e4.67);
OR of losing independence: 2.30 (CI 1.04e5.07)
Predictive of cause-specific and total mortality within 5 year follow-up:
RR of CVD mortality: 3.21 (CI 2.00e5.14)
RR of respiratory mortality: 2.38 (CI 1.09e5.20)
RR of other mortality: 2.59 (CI 1.59e4.20)
Multivariate-adjusted RR of all causes of death except external causes for
each 5-kg increment of grip strength:
RR: 0.89 (CI 0.86e0.92) for men,
RR: 0.87 (CI 0.83e0.92) for women
Predictive of mortality within 4.9 year follow-up; unadjusted HR
1.36 (CI 1.13e1.64) in men
1.84 (CI 1.28e2.65) in women
Predictive of mortality within 24 years of follow-up only in men
RR of all-cause mortality: 0.81 (CI 0.70e0.95),
RR of CVD mortality: 0.73 (CI 0.60e0.89),
RR of cancer mortality: 0.81 (CI 0.66e0.98)
HGS: hand grip strength; ADL: activities of daily living; CVD: cardiovascular disease, LOS: length of stay, CI: 95% confidence interval.
relaxation after electrical stimulation of the ulnar nerve in patients
with clinically apparent malnutrition. As a consequence of these
abnormalities, a decreased force of contraction at higher stimulation
frequencies with maintenance of force at lower frequencies was
shown.21 These findings have repeatedly been confirmed by
others.7,8,22
A variety of studies have described the impact of malnutrition
on muscle morphology as well as the impact on muscle function however, the pathogenesis of muscle dysfunction is not yet
understood in detail.
Although hand grip strength in general correlates with the
proportion of protein loss assessed by In-Vivo-Neutron-ActivationAnalysis (IVNAA),10,11 muscle function, interestingly, responds
earlier to both nutritional deprivation and nutritional repletion
than body composition parameters like muscle or body mass. Loss
of muscle mass does not appear to be exclusively responsible for
muscle dysfunction in malnutrition.
Short term starvation in obese, healthy women e.g., resulted in
significantly lower hand grip strength and altered adductor pollicis
muscle function, although no measurable change in anthropometric
indices occurred simultaneously.20 In one study, refeeding anorectic
patients restored maximal relaxation rate and muscle fatigability
within four weeks. All other muscle function parameters returned to
normal within eight weeks, whereas body nitrogen increased by
only 13% and total body potassium by only 32%.43 Also, 45 days of
refeeding improved physical performance in anorexia nervosa
patients without simultaneous normalization of fat free mass or
oxygen consumption.44 Functional changes in calf muscle have also
been reported to occur earlier during nutritional repletion in
malnourished elderly patients than changes in muscle mass.41
Moreover, Bissonnette et al. showed that muscle weight, size
and protein did not correlate with muscle function in fast and slow
twitch rat muscle during under e and subsequent refeeding.45
Further factors such as electrolyte status or energy rich
compounds appear to be more responsible for the early changes in
muscle function during malnutrition and refeeding than changes in
muscle mass. See Fig. 1 for current hypotheses on the pathogenesis
of muscle dysfunction in malnutrition.
138
K. Norman et al. / Clinical Nutrition 30 (2011) 135e142
Table 2
Hand grip strength as nutritional outcome variable in clinical studies.
Author
N
Setting
Intervention
Impact of nutritional intervention
on grip strength
Christie and Hill73
41
Malnourished IBD patients
14 day TPN
Paton et al.74
36
Malnourished tuberculosis patients
Oral nutritional supplements for 6 weeks
Norman et al.75
80
Malnourished patients with benign
gastrointestinal disease
Oral nutritional supplements for 3 months
Beattie et al.76
101
Malnourished surgical patients
Oral nutritional supplements for 10 weeks
Keele et al.86
86
Malnourished patients undergoing
major abdominal surgery
Oral nutritional supplements during hospital
stay (phase I of the study)
Ha et al.77
124
Malnourished stroke patients
Individualized, nutritional support for
three months
Price et al.78
76
Malnourished elderly
Oral nutritional supplements for 8 weeks
Edington et al.79
82
Malnourished elderly
Oral nutritional supplements for 8 weeks
HGS increased by 15% within the first week
whereas total body protein did not change
during therapy but during convalescence
(200 days)
Greater increase in lean body mass and HGS
(2.79 3.11 compared with 0.65 4.48 kg,
P ¼ 0.016) in intervention patients than controls
Improvement in HGS and QoL only in
intervention patients, significantly correlated to
Physical Function (r ¼ 0.30, p ¼ 0.009), and
Role Physical (r ¼ 0.26, p ¼ 0.023)
Postoperative HGS reduction in intervention
patients was less marked, with significantly
improved values at 10 weeks when compared
with controls ( 0.82 v 1.93 kg/m2; p < 0.001)
Control patients showed a significant reduction
in HGS during their hospital stay (p < 0.01). In
the intervention patients, grip strength dropped
at study day 3, but returned to preoperative
levels by discharge
The intervention patients had a significantly
higher increase in QoL score (P ¼ 0.009) and
in HGS (difference between groups: 2.6 kg
(CI 1.0e4.2); p ¼ 0.002
HGS increased more in the intervention
patients (13.9%) than in the control group
(7.2%) (p ¼ 0.055)
HGS improved significantly in the intervention
group during supplementation, and was
significantly different from control group
at week 8, but it decreased thereafter, and
at week 24 there was no significant difference
in HGS or QoL between groups
HGS: hand grip strength; IBD: inflammatory bowel disease; TPN: total parenteral nutrition; QoL: Quality of life; CI: 95% confidence interval.
6. Outcome associated with impaired muscle function
The predictive power of muscle function, and hand grip strength
in particular, has been demonstrated in numerous clinical as well as
epidemiological studies (see Table 1).
In disease, reduced muscle function has severe consequences for
functional status, recovery from disease and clinical outcome,
particularly as several further factors may also interact.
Reduced hand grip strength was early shown to be strongly
correlated with postoperative complications18,19,46 and has also
been reported to be both predictive of length of hospital stay47,48
and loss of functional status16,48 as well as short term survival49
in hospitalized patients. Even death within one year of hospitalization was correlated with hand grip strength in a study of elderly
patients admitted for pneumonia. In these patients, hand grip
strength was a more powerful predictor than pneumonia severity,
age or number of comorbidities.50
Regarding long-term outcome, hand grip strength has been
shown to predict onset of dependency in the activities of daily living
(ADL) within the subsequent five years in elderly and even old age
disability in at baseline healthy middle aged men. This suggests that
higher strength might provide greater physiologic and functional
reserve that protects against mortality and morbidity.51
Hand grip or quadriceps strength but not muscle mass or
parameters of body composition is moreover related to all-cause
mortality in middle aged and elderly subjects.50,52e55 In healthy
middle aged men, baseline hand grip strength has even shown to
be associated with mortality risk in the subsequent 30 years.56
In the elderly in particular, hand grip strength has been
demonstrated to be a superior outcome predictor both in healthy
and sick individuals. A systematic review from 2008 demonstrated
that low grip strength was consistently associated with greater
probability of premature mortality, earlier onset of disability, and
increased risk of complications or prolonged length of stay after
hospitalization or surgery.47
7. Hand grip strength as predictor of bone mass
There is a known site specific effect between muscle mass and
strength and bone mineral density (BMD) as the torque placed on
bone by muscle contraction strengthens the bone.57,58 This is
clinically relevant in the case of knee extension strength and total
hip BMD e.g. since muscle weakness is a possible contributing risk
factor for falls59,60 and low BMD a clinical predictor for increased
risk of fracture in falls.
Similarly, hand grip strength functions as indicator of hand BMD
in adults,61e67 but also to some extent as predictor of BMD at
distant skeletal sites in adolescents,68 as well as postmenopausal
women in particular.61,69 A large population based study in 1380
women over the age of 50 demonstrated a clear association
between low grip strength and impaired spine and hip BMD as well
increased risk of vertebral fracture.70 Maintenance of muscle
strength is also associated with lower loss of bone mass during the
perimenopausal period and is also suggested to maybe even
counteract weight loss related postmenopausal bone loss71 as
results from 10-year prospective follow-up studies in 971 and 587
women respectively have shown. Hand grip strength even predicts
15-year fracture free survival in perimenopausal women with
normal BMD at baseline, while DEXA measurements performed in
5 year intervals did not.72
K. Norman et al. / Clinical Nutrition 30 (2011) 135e142
139
Fig. 2. Reference values generated in healthy populations. A: men (dominant or right hand). B: men (non-dominant or left hand) C: women (dominant or right hand) D: women
(non-dominant or left hand) References 1: Schlüssel et al., 2008. 2: Budziareck et al., 2008. 3: Massy-Westropp et al., 2004. 4: Günther et al., 2008. 5: Goldhahn et al., 2008. 6: Crosby
et al., 1994.
140
K. Norman et al. / Clinical Nutrition 30 (2011) 135e142
8. Hand grip strength as nutritional outcome variable
Since muscle function reacts earlier to nutritional deprivation as
well as restoration than muscle mass, as described above, it is
obviously very tempting to employ hand grip strength as target
variable for detecting and monitoring changes in nutritional status
(see Table 2). Christie and coworkers demonstrated rapid
improvement of various muscle function tests including voluntary
hand grip strength in 41 severely malnourished IBD patients
undergoing a 14 day intervention with total parenteral nutrition,
while total body protein measured by IVNAA did not improve
significantly during the intervention period.73 This distinction is
obviously only seen in short term nutritional therapy, while longterm nutritional therapy usually restores both mass and function.
Paton et al. e.g. reported significant increase in fat free mass and
hand grip strength in malnourished tuberculosis patients after six
week intervention with sip feeds.74 Improvement in muscle function is usually accompanied by improved functional status and thus
increased quality of life. We studied the effect of three month post
hospital intervention with sip feeds on body composition, muscle
function and quality of life in malnourished patients with benign
gastrointestinal disease. Whereas the effect on body cell mass was
comparable between intervention and control group, both hand
grip strength and expiratory peak flow improved significantly only
in the intervention group and these changes were paralleled by
a similar improvement in physical aspect of quality of life.75
Comparable results are also known from intervention with sip
feeds in malnourished surgical patients. While progressive postoperative reduction in grip strength occurred in all patients up to
four weeks after surgery, the reduction was less marked in the
intervention group and significantly improved grip strength values
were observed at ten weeks in comparison with the control
patients. These changes were again accompanied by similar
increases in the physical aspect of quality of life.76 In stroke patients
at nutritional risk, individual nutritional support also improved
hand grip strength and quality of life scores mobility, self care and
usual activities whereas control patients experienced a worsening
of hand grip strength.77
In the elderly, findings on changes in hand grip strength during
nutritional therapy are not as consistent. Price et al. investigated
the impact of two month nutritional therapy on hand grip
strength in geriatric patients (>75 years) following hospital stay.
The per-protocol analysis revealed a significant increase of hand
grip strength in the intervention patients, whereas the intentionto-treat analysis showed no difference between intervention and
control group.78 In a comparable trial by Edington et al. in
malnourished elderly patients (>65 years), eight week supplementation resulted in significant improvement in hand grip
strength which, however, appeared to be linked to the intake of
sip feeds. After six months, hand grip strength values of the
intervention patients approached the values of the control
group.79 We studied the effect of two month protein and energy
supplementation on elderly nursing home residents and found no
improvement in hand grip strength, Barthel Index or quality of life
despite an increase of BMI and mini nutritional assessment
score.80
Furthermore, the meta-analysis by Milne et al found no positive
effect of nutritional intervention on hand grip strength in a pooled
analysis of ten studies. It is therefore tempting to conclude that
muscle function is more closely related to general frailty in older
age than to nutritional status.81 This is in accordance with the fact
that reduced skeletal muscle mass is a common finding in the
elderly as shown in the large cross-sectional survey using data form
the Third National Health and Nutrition Examination Survey
(NHANES III).82 However, there appears to be a gender-related
Table 3
Reference values for hand grip strength derived from studies with >200 healthy
participants.
Author (country)
N (m/f)
214 (105/109)
Crosby et al.87 (USA)
540 (254/286)
Massy-Westropp et al.88
(Australia)
Luna-Heredia et al.89 (Spain) 517 (229/267)
Age
Hand Device
16e63
18e97
l/r
l/r
17e97
l/r
Schlüssel et al.84 (Brazil)
Budziareck et al.25 (Brazil)
Günther et al.90 (Germany)
3050 (1122/1928) 20-70þ l/r
300 (150/150)
18e90 l/r
769 (366/403)
20e95 l/r
Werle et al.91 (Switzerland)
1023 (516/507)
18e96
l/r
Jamar
Jamar and
Grippit
BASELINE
and GRIP-D
Jamar
Jamar
BASELINE
digital
Jamar
Abbreviation: l ¼ left; r ¼ right.
difference, as a study of a small non-random sample of 67 older
men and women (mean age 59.7 years) revealed that whereas men
appear to lose more hand grip strength and body cell mass per
decade, loss of isokinetic force of lower leg muscle (knee extension)
is more prominent in women.83
In younger adults, however, hand grip strength appears to be an
attractive easy-to-use instrument for monitoring of nutritional
intervention. Short term effects of nutritional therapy as e.g.
refeeding of acute malnutrition are seen earlier by muscle function
than by changes in body composition. Long-term nutritional
therapy should result in both changes of body composition and
muscle function, which should be paralleled by improvements of
physical status.
For the evaluation of single measurements, however, reference
values must be consulted. Fig. 2 and Table 3 give an overview
over current reference values generated in healthy populations;
the largest database with age- and gender-specific percentiles
comes from Brazil (3050 healthy adults aged 20 years).84
Whether they can be transferred to European populations,
however, and which percentile proves to be clinically relevant,
remains to be seen.
9. Limitations and controversies related to hand grip strength
Some limitations related to the measurement of hand grip
strength must also be addressed. There is still e.g. no consensus on
measurement protocols.92 The American Society of Hand therapists93 proposes assessment of grip strength with the elbow flexed
at 90 with the subject in the sitting position, with their shoulders
adducted, their elbows flexed 90 , and their forearms in neutral,
a methodology which is associated with high intra-test and intertest reliability.94 Consistency in measuring hand grip strength is
crucial, since posture, arm side or handle position of the dynamometer easily alter maximum grip strength.13,92,94e96
It must also be kept in mind that hand grip strength is an indicator
of upper limb strength only and despite its predictive potential
cannot replace evaluation of assessment of activities of daily living
(ADL), lower extremity strength or walking speed in fragile populations such as the elderly or patients with neuromuscular disease.
Mortality prediction of hand grip strength also depends on which
further parameters are included in the regression models. As recently
shown by our group, hand grip strength predicted 6 month mortality
in cancer patients, but lost significance when bioelectrical phase
angle was introduced in the model.97 This may apply to other populations as well.
Nevertheless, hand grip strength is a simple bed side parameter
which provides valuable information in addition to assessment of
nutritional and/or functional status. In order to identify patients at
risk, reliable cut off values still have to be proposed and validated.
K. Norman et al. / Clinical Nutrition 30 (2011) 135e142
Conflict of interest statement
The authors have no disclosure of interest regarding this review
article.
Acknowledgements
KN, NS and MP: concept, literature research and writing of the
article. KN and MCG: concept of figures. MCG and JDS: critical
revision. All authors have actively contributed, read and approved
the final manuscript. No writing assistance was needed.
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