SAMT DEEL 68 12 OKTOBER 1985 585 Nutritional assessment by hand grip dynamometry 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 D. A. K. W ATIERS, CH.M. F.R.CS. men with carcinoma of the oesophagus (who were starvation- A. A. HAFFEJEE, F.R.CS. 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 TABLE I. HAND GRIP STRENGTH MEASURED BY DYNAMOMETRY IN NORMALLY NOURISHED AND MALNOURISHED SUBJECTS Men Women Malnutrition 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 (kg/m') 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=0.176. .... 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 . ", E o c was a significant correlation between right- and left-hand • c values in females and the correlation was of similar magnitude "'20 o (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. TABLE 11. CORRELATION OF NUTRITIONAL PARAMETERS WITH RIGHT-HAND GRIP STRENGTH 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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