Nutritional assessment by hand grip dynamometry by tqo12217


									                                                                                         SAMT    DEEL 68   12 OKTOBER 1985      585

Nutritional assessment by hand grip
D. A. K. WATTERS,                   A. A. HAFFEJEE,       I. B. ANGORN,          K. J. DUFFY

                                                                   carcinoma of the oesophagus comprised a starvation-adapted
                                                                   group while 16 patients were in a catabolic phase, suffering
   Summary                                                         from intestinal fistula, prolonged postoperative ileus,2 amoebic
   Hand grip dynamometry was studied in 109 normally               colitis/ pancreatic fistula,2 or abdominal tuberculosis. I All
   nourished and 26 malnourished patients. The grip                malnourished women were in a catabolic phase. Patients with
   strength was 37,5 ± 9,9 kg/m 2 in normal men, 30,5              minor compliants, such as skin lacerations, attending the
   ± 14,4 kgl m 2 in men with carcinoma of the                     outpatient department, Church of Scotland Hospital, Tugela
   oesophagus (starvation-adapted) and 22,0 ± 9,2                  Ferry, comprised the normally nourished group. These patients
   kg/m 2 in catabolic men (P < 0,001). Normal women               were shown to be normally nourished by standard nutritional
   had a grip strength of 31,6 ± 7,5 kg/m 2 compared               tests 3 and to have similar nutritional parameters to healthy
   with 22,3 ± 7,0 in catabolic women (P = 0,083).                 subjects in Durban. 3
   Hand grip dynamometry fell with age (r = 0,69 men; r               The height, weight, mid-arm and mid-forearm circumference
   = 0,57 women), aithough the correlation was only                and skinfold thickness on both sides were measured. Mid-arm
   statistically significant in women (P < 0,05). There            and forearm muscle circumferences were then calculated
   was a strong correlation between right and left hand            according to the following formula: mid-arm circumference
   grip (r = 0,84 men; r = 0,86 women), but hand grip              (cm) minus mid-arm skinfold thickness (mm) multiplied by
   did not correlate well with other indices of nutritional        0,314.
   status. Although hand grip dynamometry is a quiCk,                 The serum albumin level, TIBC, total lymphocyte count
   easy and reproducible test, and grip strength is                and haemoglobin concentration were measured. These standard
   reduced in malnutrition, it cannot replace other tests          nutritional parameters gave a nutritional profile of each patient.
   of nutritional status.                                          Protein-energy malnutrition was defined as a serum albumin
                                                                   level of less than 35 gll, weight loss of more than 9 kg and
   S Air Med J 1985; 68: 585-587.                                  decreased food intake for more than 2 weeks. 4 All patients
                                                                   from the Church of Scotland Hospital, Tugela Ferry, were
                                                                   normally nourished, while all patients referred for parenteral
                                                                   nutrition were malnourished.
                                                                      Hand grip dynamometry was performed after demonstrating
In order to assess the nutritional status of a patient a wide      the technique to the patient. The patient was encouraged to
range of tests are usually made. These include the measurement     squeeze the dynamometer as hard as possible and the best of
of height, weight, arm muscle circumference, triceps skinfold      three readings was recorded. Both hands were tested. If the
thickness, serum albumin and pre-albumin levels, serum total       patients referred for parenteral nutrition were receiving intra-
iron-binding capacity (TIBC), total lymphocyre count, serum        venous infusion via a hand vein, hand grip dynamometry was
transferrin levels and serum retinol-binding protein values as     performed only on the non-utilized limb since the presence of
well as delayed hypersensitivity skin testing.' The wide range     an infusion reduces hand grip strength.
of tests available suggests that no single test is sufficiently       Results were computerized and simple regressions were
reliable to be the sole measure of nutritional status. Hand grip   plotted for each nutritional test against hand grip measured by
dynamometry has been proposed as a quick, simple, cheap and        dynamometry on both sides. Hand grip was also plotted as a
reproducible predictor of postoperative complications. 2 This      simple regression against age. Means and standard deviations
study was undertaken to: (I) assess the value of hand grip         for hand grip in age bands 16 - 30 years, 31 - 50 years, 51 - 60
dynamometry as a measure of nutritional status; (ii) determine     years, and 61 years and over were calculated, and simple
the correlation of dynamometry with other tests; (iil) define      regression equations calculated both for normally nourished
normal values; and (iv) determine whether it is necessary to       and malnourished patients. The hand grip values in normally
measure grip by dynamometry in both hands.                         nourished and malnourished patients were compared using
                                                                   Student's [-test.
Patients and methods
Twenty-six malnourished (22 male, 4 female) and 109 normally       Results
nourished (41 male, 68 female) adult patients were studied.
The malnourished patients were those referred to the parenteral    Hand grip strength in normally nourished and malnourished
nutrition unit, King Edward VIII Hospital. Ten men with            patients of both sexes is shown in Table 1. Men in the
                                                                   catabolic malnourished group who were under severe metabolic
                                                                   stress showed a significantly reduced hand grip strength (P <
                                                                   0,001). There were only 4 women in the malnourished group
Departments of Surgery and Computer Services, University           who also showed reduced strength, but the reduction just
of Natal and King Edward VllI Hospital, Durban                     failed to achieve statistical significance at the 5% level. Ten
                                                                   men with carcinoma of the oesophagus (who were starvation-
1. B. ANGORN, F.R.CS. (EDIN.), F.R.CS. (ENG.)                      adapted) showed reduced hand grip strength. Their grip
K. J. DUFFY, B.SC HONS                                             strength did not differ significantly from that of normal men
                                                                   in the 50+ age groups (P = 0,17).
586       SAMJ VOLUME 68              12 OCTOBER 1985

                                             AND MALNOURISHED SUBJECTS
                                                                              Men                                                       Women
                                                       Normal            Starvation-                                        Normal               Malnutrition
                                                       nutrition          adapted                  Catabolic                nutrition            (catabolic)
                    No. of subjects                      41                       10                     12                       68                    4
                    Mean age (yrs)                     39 ± 16          56    ± 12*                 36   ± 13                41   ± 17            31    ± 17
                    Grip strength
                      Right                           37,5   ± 9,9     30,5 ± 14,4***            22,0    ± 9,2**           31,6   ± 7,5       22,3    ± 7,0****
                      Left                            36,6   ± 8,1        Not done               21,4    ± 8,0**           29,6   ± 6,9       18,6    ± 4,9*****
                    'P< 0,01 .
                    •• p< O.OOl.
                    .... P=0.083.
                    • .... P=0.067.

   The correlations of simple linear regressions for right-hand
grip strength including both normally nourished and mal-                                                                                            ,- O,S2
nourished patients are shown in Table 11. In women there was                                      40                                               1J··O,21
a significant positive correlation between right-hand grip                                                                                           p<O,05

strength and height (P < 0,01) and mid-forearm circumference
(P < 0,05). Correlations with serum albumin level and forearm
muscle circumference just failed to reach statistical significance.
  one of the correlations in the male group were statistically
significant although similar trends were evident except for
correlations with height and with serum albumin level. There

was a significant correlation between right- and left-hand                                  •
values in females and the correlation was of similar magnitude                              "'20
(0,84) in males but just failed to achieve significance (P < 0,1).
   A simple regression analysis between age and hand grip
strength showed a strong correlation between the two on each
side. Hand grip strength fell with increasing age. The corre-                                     O-'-~--~---~--~--~-----,~--~--                                                        ....
                                                                                                         20         30            40          50      60           70          80
lations were similar in both sexes although they only reached                                                                                 Age (yu,e)

                                                                                            Fig. 1. Left-hand grip strength plotted against age in women.
                                          Men                        Women
                                                                                                 TABLE Ill. LEFT-HAND GRIP STRENGTH IN NORMALLY
 Nutritional test                     r          F                            F
                                                                                                                  NOURISHED ADULTS
  Haemoglobin                   0,39            0,56           0,08     0,08
                                                                                                                         No. of                          No. of
 Totallymphocyte                                                                                    Age (yrs)            men              kg/m'          women            kg/m'
 count                          0,21            0,13           0,15     0,30
 Serum albumin level            0,11            0,04           0,49     4,2
                                                                                                       16 - 30            17           38,4   ± 7,9         23          33,0   ± 5,6
 TIBC                           0,46            0,81           0,08     0,09
                                                                                                       31 - 50            14           38,9   ± 6,3         25          30,6   ± 5,6
 Weight                         0,31            0,31           0,40     2,50
                                                                                                       51 - 60             3           30,0   ± 6,4         11          25,2   ± 5,3
                                                                                                       61. and
 Height                         0,37            0,48           0,78    19,92**
 Right arm circum-
                                                                                                        over               7           29,5   ± 8,8            9        23,1   ± 6,5
 ference                        0,53            1,29           0,17     0,38                     Correlation left-hand grip strength against age was for males 0,69. for females 0.57
                                                                                                 (P < 0.05 in females).
 Right arm muscle
 circumference                  0,58            1,5           0,03      0,01
 Right arm skinfold             0,18            0,10          0,20      0,52
 Right forearm                                                                              significance (P < 0,05) in the female group. The plot is shown
 circumference                  0,41            0,60          0,52      4,91*               in Fig. 1. The normal values for the well-nourishe~ patients
 Right forearm muscle                                                                       are shown by age band in Table Ill.
 circumference                  0,39            0,54          0,47      3,7
 Right forearm skin-
 fold                           0,54            1,2           0,37      2,1
 Left hand grip                                                                              Discussion
 strength                       0,84            7,5           0,86      35,4***
 .p< 0.05.                                                                                  The functioning nutritional unit of the body is the lean body
 "P<O.01.                                                                                   mass, of which muscle is a major component. Hand grip
 "·P<0.05.                                                                                  dynamometry has been proposed as a test of skeletal muscle
                                                                                            function and thus a means of detecting malnutrition. 2 Our
                                                                                                   SAMT     DE EL 68   12 OKTOBER 1985            587

results suggest that hand grip strength so measured is reduced           following the infusion may also reduce grip strength. Although
in malnutrition, values being lower in metabolically stressed            it seems preferable to test the non-dominant hand to avoid
patients than in those malnourished by starvation alone.                 misleading results due to a very strong dominant hand, this
   Klidjian er al. 2 proposed dynamometry as a good predictor            does not seem important because of the good correlation
of postoperative complications, as were arm muscle and forearm           between right and left hands.
muscle circumference. The attraction of dynamometry is that                 Inevitably dynamometry is a difficult test to interpret when
it is quick, inexpensive, easy to use and repeatable as often as         one has little idea of normal performance. However, a man
required. We therefore hoped that results of dynamometry                 should have a grip strength greater than 30 kg/m 2 and a
would show a strong correlation with other nutritional para-             women should have a strength of 25 kg/m 2; over the age of 60
meters, and thus its use could reduce the number of monitoring           years it is slightly lower in each sex. These figures are similar
tests required in nutritional assessment. This hope was not              to unpublished dynamometric values in Edinburgh Hospital
fulfilled since dynamometry correlated poorly with most                  staff and patients. The tendency of grip strength to fall with
nutritional tests studied.                                               age merely states the obvious. A single value for dynamometry
   In women height correlated well with hand grip strength,              is less valuable than a series of readings. Once a baseline has
but this was not so in men. The reason for this sex difference           been established for a particular patient. an improvement in
is unclear.                                                              nutritional and metabolic state would be expected to be
   Measures of arm and forearm muscle circumference did not              reflected in a stronger hand grip.
correlate with hand grip strength; perhaps because muscle
efficiency may be more important than muscle mass. This is
one reason why there has been recent interest in studying                   We wish to thank Dr J. McCutcheon, previous superintendent
muscle at the cellular level in malnutrition. 5 Dynamometry              of the Church of Scotland Hospital, Tugela Ferry, for permission
results may correlate better with muscle metabolism.                     to study patients' nutritional status, and Dr R. Arbuckle for
   Irving6 recently suggested that serum albumin and haemo-              statistical advice.
globin levels are the most important blood indices for predicting
a good clinical outcome in surgery for Crohn's disease. The
fact that these correlated poorly with results of dynamometry,           REFERE TCES
as did TIBC and total lymphocyte count, suggests that dyna-               I. Grant JP. A Handbook 01 Pareneerat Nutr;c;oll. Philadelphia: WB Saunders,
mometry measures something different. It is not a substitute                1980.
                                                                         2. Klidjian AM, Foster KJ, Kammerling RM, Cooper A, Karran SJ. Relation
for nutritional tests but rather another of an already long list            of anthropometric and dynamometric variables IO serious post-operative
of nutritional measurements. The poor correlation with these                complications. Br Med] 1980; 281: 899-901.
nutritional parameters precludes its use as a single test.               3. Waners OAK, Haffejee AA, Angorn IB, Ouffy KJ. Nurritional parameters
                                                                            in urban and rural Zulus. S Air Med] 1985; 68: 582-584 (this issue).
   The method of performing hand grip dynamometry is                     4. Law OK, Oudrick SJ, Abdou NI. Immunocompetence of patients with
important, and the patient needs to be taught the technique.                protein-calorie malnutrition. Ann lneem Med 1973; 79: 545-550.
                                                                         5. Larsson J, Schildt B, Symreng T. Relations between anthropometric
The more ill the patient, the more time this takes. If the                  variables, visceral proteins and muscle metabolism in severe malnutrition
patient is receiving an intravenous infusion into a limb the                (abstract 0.11). Proceedings of 5th Congress of European Society of Enteral
                                                                            and Parenteral Nutrition, Brussels, 12-14 September 1983.
ability to squeeze the dynamometer is markedly reduced                   6. Irving M. Assessment and management of external fistulas in Crohn's
compared with the opposite side. Painful thrombophlebitis                   disease. Br] Surg 1983; 70: 233-236.

Nuus en Kommentaar/News and Comment
Osteoporosis and oestrogen                                               Heel-drop jarring and appendicitis
Fractures in elderly postmenopausal women are common and                 It has been said that if you get the diagnosis of acute appendi-
can be disastrous, particularly fractures of the neck of the             citis right 7 times out of 10, you are not doing too badly, 6 out
femur, which can pose considerable therapeutic dilemmas.                 of 10 and you should re-examine your diagnostic criteria, 5 out
Other common fractures are those of the ribs, wrist, tibia and           of 10 and you should seriously consider taking up farming.
fibula, and vertebrae. More information on the protective                Jokes aside, no clinician needs to be told that acute appendicitis
effect of oestrogen replacement has now been provided by a               can be very difficult to diagnose, particularly if the appendix is
trial in which a retrospective study was done oompating the occurrence   not in its usual place. A simple clinical test has been described
of fractures in 245 long-term oestrogen users and the same               which can help in solving these diagnostic dilemmas (Markle,
number of case-matched controls followed for 17,6 years.                 Arch Surg 1985; 120: 243). The heel-drop jarring test is
Bone mineral assessments were also carried out. (Ettinger er             performed by asking the patient to stand on tip-toe and
al., Ann Intern Med 1985; 102: 319). The results quite unequi-           suddenly to drop down on the heels with an audible thump. If
vocally showed the value of oestrogen replacement in that the            there is intraperitoneal inflammation, the patient may feel a
incidence of fractures was 50% lower in the treated group and            definite pain and can usually point to its specific location. In
that bone mineralization was greater. However, not all parts of          patients too sick to stand, the same test can be performed by
the skeleton were equally well protected, the spinal column              lifting the legs 12 cm off the bed and striking the heels with
being better protected than the appendicular skeleton so that            the forearm. It appears to be superior to the rebound test,
the greatest reduction was in spinal compression fractures and           does not depend on linguistic or intellectual skills on the part
the least in wrist fractures.                                            of the patient, and is helpful in reducing diagnostic errors.

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