Get a Grip!

Handgrip Strength as a Health Screening Tool

Molly Eckman, Chris Gigliotti, Staci Sutermaster, and Khanjan Mehta
Humanitarian Engineering and Social Entrepreneurship (HESE) Program
The Pennsylvania State University
University Park, USA
Correspondence: khanjan@engr.psu.edu

AbstractAn individuals handgrip strength (HGS),

measured by a hand dynamometer, has shown significant
correlations with clinical conditions such as malnutrition, type 2
diabetes, functional disability, and overall quality of
life. Existing studies have indicated that HGS testing is a
promising tool to screen for disease. This is of interest to
resource-constrained areas because barriers to healthcare have
created a large need for simple and effective medical screening
devices. Inexpensive, ruggedized dynamometers to measure HGS
already exist on the market. Despite these opportunities to use
HGS as a screening tool, the literature on HGS is incomplete and
not cohesive. This article provides a synthesis of the recognized
relationships and correlations between HGS and diverse clinical
conditions. Established statistically sound associations as well as
compelling gaps in the knowledge base are discussed. Pathways
to integrate HGS devices into the emerging Community Health
Worker (CHW) infrastructure as a health screening and incomegenerating tool in developing countries are described. The goal of
this article is to inform research and entrepreneurial initiatives
that can collectively leverage handgrip dynamometers as
effective and efficient health screening tools in low-resource
contexts.

dynamometer (Fig. 1). The simplicity, reliability, and

affordability of this test have led to a wide range of
applications in various settings. However, HGS is greatly
influenced by sex and age. The greatest grip strengths are
generally found in men between the ages of 24 and 39 [5], [6],
[10], [11], [12]. Men normally have a greater HGS in
comparison to their female counterparts [6], [10], [11], [12],
[13]. Factors such as exercise levels, overall health, nutrition,
BMI, hemoglobin levels, and residual glomerular filtration rate
have also been proven to impact HGS [2], [5]. Hand
dominance can affect HGS as well. Right-handed people can
see a difference of up to 10% in HGS between dominant and
non-dominant hands. However, left handed people do not
exhibit any strength differences between their dominant and
non-dominant hands [10], [13], [14].
Fig. 1. Handgrip Dynamometers, Courtesy of: http://www.topendsports.com,
http://prohealthcareproducts.com,
http://i01.i.aliimg.com/img/pb/523/204/834/834204523_440.jpg

Keywordshandgrip strength, health screening, community

health workers, developing world

I.

INTRODUCTION

Complicated, expensive medical equipment is difficult to

maintain in the developing world, rendering most common
screening and diagnostic devices useless. Using handgrip
strength (HGS) testing to screen for disease is a viable
alternative because HGS correlates strongly with general health
status [1], [2], [3], [4] but is easy and inexpensive to measure
[5], [6], [7], [8]. For HGS to be used as a screening tool,
reliable, quantitative relationships between HGS and clinical
conditions must be determined. There have already been
numerous studies over the past half-century relating HGS to
various health ailments.
However, varying subjects,
geographic locations, and methodologies make the research
scattered and inconclusive. In order to maximize the potential
of HGS testing as a screening method, the knowledge in this
particular field must be synthesized and localized for future
use.
HGS tests measure the amount of force produced by the
upper arm muscles that control the hand [9]. This metric is
obtained through the simple operation of a handgrip

978-1-4799-7193-0/14/$31.00 2014 IEEE

242

IEEE 2014 Global Humanitarian Technology Conference

Occupation and the participation in certain hobbies can also

affect HGS enough to supersede other influential factors [10],
[14], [15]. In addition to environmental and lifestyle factors,
individuals can be genetically predisposed to a certain HGS
[2], [16], [17], [18], [19]. Despite the multitude of factors
affecting HGS, it is possible to develop accurate predictions of
HGS for an individual using only age, weight, height, gender,
and sometimes occupation [10], [11], thus allowing abnormal
HGS values to be identified. Because the factors influencing
HGS are universal, general HGS correlations are applicable to
different populations and races [20]. This is possible even
though the average HGS can vary between demographic
groups [18].
The literature on handgrip strength is extensive but
inconclusive. Cross-sectional studies and studies using narrow
demographics often limit the utility of findings. However,
relationships between HGS and general health, nutrition levels,
postoperative complications, disability, morbidity, protein loss,
muscle mass, and diabetes have been found [6]. HGS has
been strongly correlated with the strength of other muscle
groups, making it a good marker for overall strength [1], [2]. It
also has been linked to physical activity levels [1], [2]. Since
functional ability is related to physical activity levels and
overall muscle strength, HGS can be used to predict disabilities
later in life [1], [2], [21]. In addition, HGS has been proven to
provide comparable or even better predictive results than
laboratory and clinical measurements for other health ailments
[21]. While the mechanisms of these relationships are not fully
understood, studies suggest that HGS is reflective of causal
variables for diseases rather than the diseases themselves [21].
By synthesizing these findings, this article discusses the
feasibility of using handgrip strength as a clinical indicator of
underlying health conditions. All existing literature is reviewed
and compelling conclusions are discussed. Potential
applications for handgrip strength testing as a sustainable social
entrepreneurship venture the developing world are explored.
In this context, handgrip dynamometers have the potential
improve livelihoods and provide prognostic health information
II.

HANDGRIP STRENGTH ASSOCIATIONS

A. Malnutrition
Low HGS is highly correlated with malnutrition [5], [12],
[15], [21], [22], [23]. Patients with a HGS 85% below the
mean are considered malnourished [24]. HGS is strongly
linked to nutrition indices [12] such as body protein loss [5],
BMI [12], [15], arm muscle area [15], skeletal muscle function
[25] and lean muscle mass [5]. In fact, HGS is a more sensitive
indicator of nutritional status than other markers such as weight
loss, BMI, skinfold thickness, arm muscle circumference and
plasma protein makeup [5], [25]. Because of these associations,
HGS can be used to monitor nutritional status. It has already
been used as a nutrition indicator in hemodialysis patients [26]
and can be used in conjunction with serum albumin
concentration to monitor nutrition in peritoneal dialysis
patients [5]. HGS testing has the benefits of being much easier
and cheaper than current laboratory tests [24] while still
providing independent prognostic information [5]. It is also not
affected by hydration status or inflammation like serum
albumin concentration, a common nutrition metric [5]. HGS

also indirectly predicts mortality by identifying life-threatening

nutrition states. Poor early-life nutritional status may lead to an
increase in late-life mortality [27], and protein-energy
malnutrition, a frequent complication in patients with end-stage
renal disease, is predictive of dialysis patient mortality [5]. In
addition, malnutrition can cause reduced immunocompetence
and wound healing abilities, which are closely correlated with
morbidity and mortality [24].
B. Chronic Conditions
Low HGS suggests a risk of subclinical disease that may
lead to chronic disease and disability [1], [18]. A steep
decrease in strength of 1.5% or greater per year is correlated
with an increased risk of stroke, diabetes, arthritis, and chronic
obstructive pulmonary disease [20]. One study conducted on
older disabled women associated low HGS with a higher risk
of mortality from chronic conditions such as cardiovascular
disease (CVD) and respiratory disease [27].
1) Stroke
After a stroke, muscles weaken as a result of impaired
neurological function [20]. Reduced HGS can indicate the
weakness of a patients arm and therefore the patients ability
to complete motor tasks. During functional recovery, muscle
weakness and the ability to perform complex motor tasks can
improve. However, it has been shown that if grip strength does
not increase during recovery, patients risk low functional
outcome [28]. HGS is an approved, sensitive indicator of
stroke recovery and can indicate the impact of physiotherapy
[28].
2) Diabetes
Patients who have type 2 diabetes and are over the age of
30 tend to have a lower HGS score [14]. Adults diagnosed
with diabetes for more than 6 years exhibit a significant decline
in the upper limb muscle quality due to diabetic neuropathy
[20], a condition that causes muscle weakness and atrophy
[29]. Because HGS is linked to overall strength, this decrease
in muscle quality causes a decline in HGS. HGS values for
diabetics could be important in determining hand function after
hand surgery [14].
3) Hypertension
Hypertension and atherosclerotic vascular disease,
(specifically ischemic heart disease, angina, myocardial
infarction, coronary artery bypass surgery, angioplasty,
cerebrovascular events, transient ischemic attacks, or
peripheral vascular disease), are also correlated with steep
strength decline [5]. These associations could be explained
through relationships between higher body weight,
hypertension risk, and HGS [20].
4) Renal Disease
In patients with end-stage renal disease, HGS is used as a
reliable method to determine nutritional status because it is a
direct marker of lean body mass. Patients with long-lasting
renal function have higher HGS scores and lack
malnourishment. Protein-energy malnutrition, a complication
of end-stage renal disease, is related to cardiac comorbidity and
inflammation [5]. Since HGS is a marker for the bodys protein
loss [23], it can serve as a predictor of these conditions as well.
HGS is also independently associated with cardiovascular

mortality. It is used as a valid predictor of all-cause mortality in

dialysis patients [5].
C. Disability and Quality of Life
HGS has been found to serve as a good marker of overall
quality of life due to its relationships with functional disability
and mortality [18], [22]. HGS is a strong indicator of overall
muscle strength [6], [19], [27], [30], [31] which can be further
linked to health-related quality of life [4], [6], hand function
[10], [13], and terminal illness [18], [22], [27]. HGS can
predict cause-specific and total mortality in older women [5],
[22], [27], activities of daily life (ADL) disability in elderly
men and women [1], [2], [3], [6], [12], sarcopenia and general
frailty [4], [5], [32], and incident disability in older men [34].
HGS has also been found to be an identifier for gene variants
that are important to physical function late in life [2]. A higher
HGS and overall strength are indicative of a reserve capacity
that helps prevent disease and functional limitations later in
life [1], [18]. For example, in younger, midlife populations,
HGS can predict future disability up to 25 years in advance
[1], [2], [27], [34]. The associations that make HGS such a
good predictor of functional disability and mortality are not
entirely explained through the relationships between HGS and
age or gender, making HGS an independent indicator of
overall quality of life in elderly populations [3], [4], [27]. As
such, HGS may serve as an inexpensive screening tool to track
patients deterioration of health by taking regular HGS
readings and checking for significant decreases [27].
D. Post-operative Conditions
HGS is an excellent predictor of postoperative
complications [5]. About 74% of postoperative complications
can be predicted by a HGS below 85% of the standard for a
certain age and gender [24], [25]. Below this standard of 85%,
a patient can be deemed high risk for postoperative
complications and is advised to seek nutritional help [25]. HGS
testing for these conditions is highly sensitive, which lowers
the false-negative rate [23]. Out of 21 patients receiving
gastric, pancreatic, or colonic operations, 95% of those who
experienced complications also had a low grip strength [23].
HGS testing has been used as a noninvasive tool to assess
skeletal muscle function, which is used to indicate malnutrition
in surgical patients [24], [25], and has successfully predicted
postoperative complications in the USA and UK [25].
However, HGS testing is not valid for postoperative
complications in the elderly [25].
E. Weight Loss
Weight loss has a strong positive correlation with a decline
in HGS [15], [20]. Because weight loss includes the loss of
muscle tissue, especially in the elderly [47], it is a major
determinant of overall muscle strength, which has already been
linked to HGS [24]. It has also been shown that thinner people
have poorer strength, more illness, and greater mortality [24].
While strength can vary widely at distinct levels of body
weight [24], weight loss has similar negative effects on HGS
regardless of initial weight [2].

F. Aging
Handgrip strength has been found to decrease with age
[11], [20] in a nonlinear fashion such that HGS peaks around
age 30 [11], [16], [34], [35], and decreases with accelerated
speed thereafter [11], [34], [35]. This loss of strength may be
attributed to muscle mass loss due to either motor neuron death
[35] or muscle cell shrinkage due to inactivity [36]. It may also
be caused by illness or alterations in muscle fiber composition
or quantity [12]. Midlife HGS can predict strength in old age
[1].
G. Sexual Behavior
In men only, an increase in HGS can be related to a greater
number of sexual partners, sexual intercourse at a younger age,
increased aggression, and broader shoulders [6]. Aggressive
behaviors including verbal and physical abuse in the adolescent
years were observed in males with higher HGS [6]. This
relationship may have important implications with the recent
efforts to limit bullying in adolescent settings. HGS may be
interpreted as a metric of natural selection [6]. The stronger,
more developed males who are producing more testosterone
and therefore a greater muscle mass have an advantage when
preforming specific tasks [6], [17]. The influence of
testosterone is one potential reason why women do not portray
equivalent trends when comparing HGS to sexual behavior [6].
H. Proven Unrelated Factors
Although HGS has been correlated with chronic conditions,
it is not associated with all diseases. HGS is not associated
with cognitive function [34], and in females, maximum HGS is
not correlated with sexual behavior [16]. HGS is not capable
of predicting depression in the elderly as they age because of
psychological adaptation [3]. A normal grip strength in the
elderly does not reduce risk of postoperative complication [25].
In a Japanese population, aged 65 years or older, HGS is not
correlated with disability on the instrumental activities of daily
living (IADL) scale [3]. Additionally, cancer mortality was not
associated with HGS [27].
I. Further Research
The current research on HGS is scattered and not cohesive,
though HGS has been identified as a promising candidate as a
screening tool for malnutrition, disability, and disease for
which correlations with HGS are very strong [20], [22], [27],
[34]. However, there is a general need for longitudinal studies
in order to determine the effectiveness and reliability of HGS
as a screening tool; currently, most longitudinal studies focus
on elderly populations. The notable exception is the 25 year
study published in 1999 by Rantanen, et. al. which showed
midlife HGS to be highly predictive of old age disability [1].
Specifically, a deeper analysis must be conducted concerning
the potential relationship between a low HGS and
immunodeficiency [22] and type 2 diabetes [14], [37], [38].
Regarding type 2 diabetes, it is debatable whether a low HGS
is caused by the loss of muscle mass or quality of muscle loss
[38] and further explanation is needed to understand the
relationship between HGS and neuropathy [14]. Future HGS
research is also needed among a wider range of populations
[38]. HGS studies up to this point have used very focused,
narrow demographics as samples. However, in order to
translate HGS into a useful tool for resource-constrained areas,

more generalized research or research focused on those

specific areas must be conducted. Specific areas that would

Disease Factor

benefit from additional attention are regions in Africa because

of high occurrences of malnutrition [12].

Table 1: Summary of HGS Associations

Correlation
Indicator

Predictor

Nutrition
Nutritional Status
Functional Recovery after Stroke

+
+

Chronic Conditions
Diabetes
Hypertension
Nutritional Status in Patients with Renal Disease
Mortality in Patients with Renal Disease

+
-

Disability
Hand function
Sarcopenia
Incident Disability in Older Men
Activities of Daily Life (ADL) disability in elderly
men and women
Instrumental Activities of Daily Living (IADL) Scale

None

Quality of Life
Cancer Mortality
Elderly Japanese
Muscle Strength
Terminal Illness

None
None

Total Mortality in Elderly Women

Post-operative Conditions
Post-operative Complication in the Elderly
Weight Loss
Aging

None

Strength in Old Age

Behavior
Sexual Behavior
Aggressive Behavior

+
+

Cognitive Function
None
Sexual Behavior in Females
None
Depression in the Elderly
None
Legend: + = positive correlation, - = negative correlation, = association exists
III. OPPORTUNITES FOR THE DEVELOPING WORLD
A. Problems in the Developing World
One of the Millennium Development Goals set by the
United Nations is to combat HIV/AIDS, malaria, and other
diseases. Despite efforts towards meeting this goal,

however, many developing regions have seen drastic

increases in non-communicable diseases such as
cardiovascular disease and diabetes [40]. Due in part to the
adoption of many Western practices such as sedentary
behavior and poor dietary choices [41], deaths from
cardiovascular disease have jumped almost 30% worldwide
between 1990 and 2010 [42]. Diabetes cases are predicted to

nearly triple in the next fifteen years [43]. While these

diseases can often be mitigated by lifestyle changes, most
people lack the health knowledge to properly identify and
treat their symptoms. In developing countries, numerous
barriers, such as a shortage of trained physicians and the
prohibitively high cost of transportation and care, make
healthcare (especially primary or preventative healthcare)
extremely hard to access. Consequently, people do not seek
treatment for illness or injury until the ailment is dangerously
severe. This has created the need for a different, more locally
based health care system.
Currently, many regions in the developing world have
adopted Community Health Worker (CHW) programs to
bridge the gap between communities and proper healthcare.
CHWs are generally volunteers trained to provide preprimary healthcare and basic health information to rural
communities which otherwise do not have access to trained
health care professionals. CHWs hold unique positions as
trusted community leaders, mentors, and educators dedicated
to improving the health of their communities [44]. While in
many ways CHWs have been able to significantly improve
community health [45], their abilities remain limited by a
lack of tools and devices, preventing them from effectively
screening for and diagnosing disease. However, in order for a
biomedical device to succeed in a resource-constrained
setting, it must be inexpensive, ruggedized, and easy to use.
Unfortunately, very few devices fit those standards.
B. Relevance of HGS
HGS testing has the potential to be a valuable screening
tool for CHWs in resource-constrained areas. Inexpensive,
durable hand dynamometers exist on the market already,
which makes HGS testing financially accessible to both
health workers and their customers. The automatic
calibration and digital readout of these dynamometers make
HGS simple to use even for CHWs who lack extensive
medical training. HGS testing avoids health hazards caused
by dangerous chemicals or bodily fluids often used in
diagnostic tests. These benefits allow the health information
provided by HGS to be utilized in the developing world.
C. Application of HGS
HGS testing can be introduced into the developing world
by integrating it into existing CHW services. By providing a
HGS-based screening test for a fee, CHWs can develop HGS
testing into a sustainable business. In this scenario, HGS
testing provides financial value to the CHW and important
disease risk assessments to the customer. To validate this
concept, HGS testing was implemented and evaluated in
three different locations in Kenya.
1) Case Study 1: Nyeri Marketplace
HGS testing was provided for free in conjunction with
blood pressure, height, and weight measurements in order to
evaluate general public interest in the service as well as
feasibility. The novelty of the device attracted many
participants, most of them finding the test to be humorous.
However, people were much more concerned with their
blood pressure as it is widely known to be an important
health indicator. In one instance, a participant declined to

have their handgrip strength tested after receiving a blood

pressure reading.
2) Case Study 2: Othaya District Hospital
Handgrip strength testing was introduced to employees of
the Othaya District Hospital, a small rural hospital, in order
to gauge the reactions of health professionals. The general
response was positive and hinged mainly on the potential for
handgrip strength testing to act as a clinical indicator of
common non-communicable diseases such as diabetes,
especially as traditional urinalysis testing is too expensive for
most patients. The need for more non-communicable
disease-focused outreach programs was also emphasized,
highlighting another potential use for handgrip strength
testing.
3) Case Study 3: Karatina
Handgrip dynamometers were provided to three
specially-trained CHWs in the town of Karatina, Kenya.
These CHWs already successfully provide blood pressure
and BMI measurements to the community for a fee. HGS
testing was added to their repertoire of services. Because no
clinical information could be inferred from the HGS data, the
CHWs were given a chart (Fig .2) that assigned labels of
weak, normal, strong, and very strong, based on the
customers age, gender, and HGS. These labels were also
linked with a culturally appropriate animal to add a fun
factor and increase interest.
Figure 2: Example chart that converts age, gender and HGS into a fun
animal ranking. Separate charts were provided for men and women.

Initial community reception was very positive, despite

the fact that this HGS testing did not provide any additional
insights. Each CHW was able to sell around 30 HGS tests in
a 3 hour period. Many people found the animal scale
humorous, even those who were ranked weak. Each test
was provided for a fee of Ksh 20 (about $0.22), earning the
CHWs an income of about Ksh 600 (about $6.74). More
people expressed interest in the test, though they declined to
pay because no further health information was provided. This
reaction promises greater success for HGS testing once it is
quantitatively linked to diseases such as diabetes and
malnutrition.
It should be noted that some of the interest in the test
could be attributed to the presence of foreign researchers. To
determine if the service would be sustainable without foreign
involvement, handgrip dynamometers were sold to the
CHWs participating in the study for continued use in their
day-to-day services. Four weeks after research team
departure, the CHWs reported continued sales of HGS
testing. The success of this service has been maintained
despite customer and CHW inquiries into the clinical
relevance of the test. This again highlights the potential
benefits of determining quantitative, clinically important
correlations.
D. Conclusion and Further Directions
Further research, including longitudinal clinical trials, is
required before HGS can reliably screen for disease. While
many HGS studies have established quantitative
relationships between HGS and several diseases, other
studies have shown that normative HGS values may vary
from population to population due to genetic or lifestyle
differences [12]. Therefore, in order for this screening
service to succeed, context-specific and quantitative
relationships must be established between relevant diseases
and HGS.
Additionally, the success of the handgrip dynamometer in
capturing the attention of the general public may be further
exploited to improve health education and awareness. This
device may be incorporated into simple games that both
engage the participant and impart valuable health
information on important issues such as nutrition and
maternal health. In this scenario, the HGS test itself is not
clinically important, but instead serves as a means by which
to focus public attention on previously neglected health
issues. Further studies are needed to explore this use and
develop culturally appropriate games and health lessons.
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