Manual Therapy 15 (2010) 579e585

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Manual Therapy
journal homepage: www.elsevier.com/math

Original article

Predicting maximal grip strength using hand circumference

Ke Li a, b, David J. Hewson a, Jacques Duchne a, Jean-Yves Hogrel c, *
a

Institut Charles Delaunay, FRE CNRS 2848, Universit de Technologie de Troyes, Troyes, France School of Control Science and Engineering, Shandong University, 73 Jingshi Ave, 250062 Jinan, China c Institut de Myologie, Universit Paris 6 UMR S974, Inserm U974, CNRS UMR 7215, GH Piti-Salptrire, Paris, France
b

a r t i c l e i n f o
Article history: Received 16 October 2009 Received in revised form 23 June 2010 Accepted 28 June 2010 Keywords: Maximal grip strength Predictive model Outcome assessment Impairment

a b s t r a c t
The objective of this study was to analyze the correlations between anthropometric data and maximal grip strength (MGS) in order to establish a simple model to predict normal MGS. Randomized bilateral measurement of MGS was performed on a homogeneous population of 100 subjects. MGS was measured according to a standardized protocol with three dynamometers (Jamar, Myogrip and Martin Vigorimeter) for both dominant and non-dominant sides. Several anthropometric data were also measured: height; weight; hand, wrist and forearm circumference; hand and palm length. Among these data, hand circumference had the strongest correlation with MGS for all three dynamometers and for both hands (0.789 and 0.782 for Jamar; 0.829 and 0.824 for Myogrip; 0.663 and 0.730 for Vigorimeter). In addition, the only anthropometric variable systematically selected by a stepwise multiple linear regression analysis was also hand circumference. Based on this parameter alone, a predictive regression model presented good results (r2 0.624 for Jamar; r2 0.683 for Myogrip and r2 0.473 for Vigorimeter; all adjusted r2). Moreover a single equation was predictive of MGS for both men and women and for both non-dominant and dominant hands. Normal MGS can be predicted using hand circumference alone. 2010 Elsevier Ltd. All rights reserved.

1. Introduction There are a number of situations in which maximal hand-grip strength references are needed. Individual functional evaluation and follow-up can be considered, for example, within the frame of maturity or aging, injury and rehabilitation, disease and therapy, or medicolegal issues. Maximal grip strength (MGS) has also been shown to be a good indicator of overall upper-limb strength (Bohannon, 1998, 2004) or even of the whole neuromuscular system function (Avlund et al., 1994; Chan et al., 2008). Hand-grip strength is also known to be associated with ability to perform daily living activities (Nybo et al., 2001). MGS is thus implicitly linked to functional autonomy, hence quality of life. This relationship had already been attested in aging people (Sayer et al., 2006) and patients (Ansari et al., 2007). Frederiksen et al. (2002) concluded that grip strength is a suitable phenotype for identifying genetic variants of importance to mid- and late-life physical functioning. Most of the prediction regression models for MGS use gender, age, weight and/or height either in children, in adults or in aging people (Balogun et al., 1991; Crosby et al., 1994; Rauch et al., 2002;

* Corresponding author. Institut de Myologie, GH Piti-Salptrire, 75651 Paris Cedex 13, France. Tel.: 33 1 42 16 58 80; fax: 33 1 42 16 58 81. E-mail address: jy.hogrel@institut-myologie.org (J.-Y. Hogrel). 1356-689X/$ e see front matter 2010 Elsevier Ltd. All rights reserved. doi:10.1016/j.math.2010.06.010

Niempoog et al., 2007; Gunther et al., 2008). Measurements of the forearm and hand have already been described as better predictors of MGS than height and weight (Rice et al., 1998; Nicolay and Walker, 2005). Kallman et al. previously claimed that forearm circumference provides the most practical index of MGS (Kallman et al., 1990). However, Anakwe et al. recently found that forearm circumference was predictive of MGS for men but not for women (Anakwe et al., 2007). This could be explained by difference in forearm composition, implying that a gender effect could be eliminated as a factor in predicting MGS by using fat-free crosssectional area (CSA) (Bishop et al., 1987). Indeed, fat-free CSA was found to be highly correlated with MGS (r2 0.788) whatever the gender (Aghazadeh et al., 1993). Thus, many parameters have been used to establish predictive models for MGS and to provide clinicians with a means of computing the decit in strength or the residual strength of patients or elderly people. This is of particular importance for impairment quantication during aging, pathology, injury, rehabilitation or therapy. However many anthropological variables are difcult to assess such as fat-free mass (FFM), muscle CSA or even skin-fold measurements. Furthermore, the predictive models previously used tend to be either too general, mainly based on gender and age only, or too complicated, requiring many variables to be measured and calculated. The objective of the present study was to explore if a simple and practical predictive model of MGS

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could be obtained using a limited number of simple variables with an acceptable reliability. This was performed by using three types of dynamometers to ensure that the measurement device did not inuence the model. Moreover a homogeneous population of young healthy subjects was selected to ensure that age was not a factor in the model developed. 2. Methods 2.1. Subject selection One hundred undergraduate students participated in this study, which was conducted as part of practical work aiming to assess the relationship between some anthropometric data and muscle strength. Prior to any evaluation, each subject was given a detailed description of the objectives and requirements of the experiment. The protocol was approved by the university studies committee (CEVU), as part of the course structure. The idea was to get a homogeneous population of healthy subjects in order to obtain an optimal MGS that could be considered as independent of age (maturation and aging). People with any prior hand, wrist or forearm injury were not considered for the analyses in order to avoid any bias caused by a possible impairment of grip function. Accordingly, six subjects were not considered for subsequent data analysis. Of the remaining 94 subjects, none of them participated in sporting and tness activities more than four times a week. In addition, no subjects could be considered to be severely over- or under-weighted according to their body mass index (BMI). In order to assess the power of MGS prediction models, 29 additional healthy subjects were selected from a database of MGS using the same eligibility criteria and measured according to the same operating procedures, by another evaluator in another center. This study was approved by the local ethical committee (CPP Ile-de-France VI, Piti-Salptrire). 2.2. Data collection Subjects completed a questionnaire that provided information including gender, date of birth, and height. Weight was assessed by a conventional scale (0.1 kg precision). Anthropometric data were measured by the experimenter using a standard 1000-mm measurement tape. The circumference of the forearm was dened as the perimeter of the largest part of forearm, located over the bulk of the brachioradialis muscle, at about the proximal quarter of the whole forearm length depending on the subject morphology. The circumference of the wrist was measured at the joint of the radius and the ulna which corresponds to the perimeter of the thinnest part of the forearm. The circumference of the hand was measured as the perimeter of the middle part of hand, located over the two

major transverse palmar creases (heart line and head line). Palm length was dened as the distance from the midline of the distal wrist crease to the crease of the base of the middle nger. Hand length was dened as the distance from the midline of the distal wrist crease to the tip of the middle nger. All anthropometric data were measured to the nearest millimeter with the forearm and hand relaxed in a supinated position, while the elbow was supported on a table. A preliminary study has shown that the operating procedures for measuring these anthropometric variables were highly reliable (unpublished data). The dominant hand side was dened as the hand that the subject used to write with. 2.3. Test procedure Three dynamometers were used to assess MGS: the Jamar (Sammons & Preston, Bolingbrook, IL, USA), the Martin Vigorimeter (MartinMedizintechnik, Tuttlingen, Germany) and the Myogrip (ASICA, Saint-Malo, France) (Fig. 1.A). The Jamar is an isometric hydraulic dynamometer with an adjustable 5-position handle. It measures forces in kilograms (kg) from 6 to 90 kg with a resolution of 1 kg. The Jamar is considered as the reference tool by the American Society of Hand Therapists. The Martin Vigorimeter is a pseudo-dynamic dynamometer that measures the pressure when subjects press a rubber bulb connected by a tube to a manometer. Three sizes of bulbs are available. The Vigorimeter measures pressures in kiloPascal (kPa) and has been shown to be highly correlated to grip strength (Desrosiers et al., 1995). The Myogrip dynamometer is an isometric electronic device specically developed for measuring grip strength in weak patients, but which can also be used in healthy subjects. The Myogrip can directly display the strength of the subjects or be connected to a computer either by radio-frequency, RS232 or BNC connections. Handle size is adjustable in a continuous way. It measures forces in decaNewtons (daN) from 0 to 89 daN with a resolution of 0.01 daN. The measurement sessions took place in a quiet laboratory at a controlled temperature of 22  C. Tests using the Jamar were performed with the handle in the second position, while the large bulb of the Vigorimeter was used. All tests with the Myogrip used a handle position of 1.5, which corresponds to the second position of the Jamar. No subjects reported any problems with the handle size chosen. Test mode by RS232 connection was used for all recordings from the Myogrip. Both Jamar and Myogrip were calibrated before the recording periods. During the evaluation, subjects were seated on a chair, with their feet at on the oor, their shoulders adducted, and their testing arm close to their body, with their elbow extended to 180 along the vertical axis and their wrists in slight extension (Li et al., 2009). The distal part of the forearm was maintained by the evaluator in order to avoid any

Fig. 1. Materials and standardized positions. A. Picture of the three dynamometers used in the study. 1. Jamar; 2. MyoGrip; 3. Martin Vigorimeter. B. Position of the subject during the evaluation. C. Position of the evaluator.

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compensatory movements (Fig. 1.C). Subjects were continuously given standardized verbal encouragements before and during all trials in order to motivate them to exert their MGS. Each subject was tested for both right and left hands, and for all three dynamometers. The order in which each device and the two sides were tested was randomized in order to prevent for any warm-up or fatigue effects. MGS for each dynamometer was measured twice for each hand, alternating between hands, with 15 s between trials (Li et al., 2009). Maximal grip contractions were performed until the values measured from two trials were within 10% (Nevill and Holder, 2000). The MGS was taken as the largest force from these two values. Subjects changed dynamometers after completing all measurements for both left and right hands. Subjects were given a 2-min rest between dynamometers. 2.4. Data analysis All statistical analyses were performed using the Statistical Package for Social Sciences (V16, SPSS Inc., Chicago, IL, USA). Data were assessed for normality using the KolmogoroveSmirnov test. An independent-samples t-test was used to compare grip strength between genders. Paired-samples t-tests were used to analyze the inuence of hand dominance. Pearsons correlation analysis was used to compare the inuence of anthropometric data and dynamometers on MGS. A stepwise multiple linear regression analysis with an entry probability of 0.05 and a removal probability of 0.10 was applied to determine the importance of anthropometric data and to establish a predictive regression-based model. Pearsons correlation analysis and PeP plot were used for residue analysis for the initial population as well as for the additional population. Intraclass correlation coefcients (ICC(2,1)) were computed for the additional population in order to assess the agreement between the values calculated by the prediction models and the true measurements. All coefcients of determination are adjusted r2. All statistical test results were considered as statistically signicant for p values less than 0.05. The correlations were characterized according to Hopkins scale whereby correlations can be considered to be moderate from 0.3 to 0.5, large from 0.5 to 0.7, very large from 0.7 to 0.9 and nearly perfect from 0.9 to 1 (Hopkins, 2000).
Table 1 Characteristics and anthropometric data of the subjects. Men (n 67) Mean (SD) Age (y) Height (cm) Weight (kg) BMI (kg/m2) Forearm circumference (mm)* Wrist circumference (mm) Hand circumference (mm)* Palm length (mm) Hand length (mm) Dominance Right handed Left handed D: dominant side; ND: non-dominant side. *Signicantly different between sides (p < 0.0001). D ND D ND D ND D ND D ND 20.5 178.6 71.1 22.3 (0.9) (5.7) (8.7) (2.2)

3. Results A nal number of 94 subjects was retained for analysis, with characteristics of these subjects given in Table 1. Pearsons correlation coefcients between grip strength and anthropometric data are provided in Table 2. The largest correlations were observed for hand, forearm, and wrist circumference, then for hand and palm length, followed by weight and height. Men were signicantly stronger than women by similar ratios for the three dynamometers (Jamar: 1.50; Myogrip: 1.55; Vigorimeter: 1.50). The dominant side was signicantly stronger than the non-dominant side by similar ratios for the three dynamometers (Jamar: 1.09 0.11; Myogrip: 1.08 0.11; Vigorimeter: 1.06 0.13). In addition, hand and forearm circumferences were signicantly larger at the dominant side compared with the nondominant side (ratio for the forearm: 1.025 0.025; ratio for the hand: 1.035 0.027). There was a trend toward a larger wrist circumference (p 0.0981) and a smaller hand length (p 0.0796) at the dominant side compared with the non-dominant side. The correlation matrix for the anthropometric data is given in Table 3. It should be noted that the correlation between BMI and forearm circumference is very large, whereas the correlation between BMI and hand circumference is only moderate (Hopkins, 2000). Stepwise multiple linear regression analysis was used to establish predictive models for MGS for each dynamometer. Table 4 provides the successive parameters entering the regression model in the order dened by the stepwise method. For the three dynamometers, on the dominant or non-dominant sides taken separately or together, the only anthropometric parameter systematically included in the regression model was hand circumference. Thus three regression functions were established based on hand circumference only, one for each device (Table 5). A single equation was used for both hands and both genders after verifying that the 95% condence intervals of the parameters of the models computed separately for each gender and side overlapped. Adjusted r2 demonstrates that these regression functions have a good capacity to predict MGS when considering hand circumference alone (Fig. 1). The coefcients of determination (r2) of these correlations were 0.626, 0.685 and 0.481 for Jamar, Myogrip and Vigorimeter, respectively (all p < 0.001).

Women (n 27) Range 19e24 169e192 57e92 17.0e26.6 224e302 234e302 147e186 147e187 191e249 185e237 96e122 97e123 171e215 174e215 Mean (SD) 20.2 166.7 57.3 20.6 (1.1) (5.4) (8.1) (2.3) Range 19e24 152e176 43e81 17.0e26.2 200e282 199e276 133e174 133e170 168e213 163e206 89e116 86e114 154e201 154e194

270.9 (16.6) 264.5 (15.7) 168.0 (8.8) 167.6 (8.8) 215.6 (11.0) 208.4 (10.6) 111.9 (5.9) 111.8 (5.4) 194.3 (9.8) 195.4 (9.1) 61 (91.0%) 6 (9.0%)

238.7 (18.1) 232.3 (17.1) 154.2 (9.8) 153.0 (8.3) 190.2 (11.0) 183.8 (9.5) 103.2 (6.9) 103.4 (7.0) 179.7 (10.8) 179.7 (9.9) 25 (92.6%) 2 (7.4%)

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K. Li et al. / Manual Therapy 15 (2010) 579e585 Table 3 Correlation matrix between the anthropometric variables. All correlations are signicant at p < 0.0001. BMI: Body Mass Index; C: circumference; L: length. Height Weight BMI Height 1.000 Weight 0.766 BMI 0.327 Forearm C 0.641 Wrist C 0.637 Hand C 0.690 Palm L 0.741 Hand L 0.772 1.000 0.855 0.853 0.801 0.710 0.615 0.676 Forearm C Wrist C Hand C Palm L Hand L

Table 2 Pearson correlation coefcients between anthropometric data and grip-strength scores obtained for the three dynamometers. Jamar Hand circumference Forearm circumference Wrist circumference Hand length Palm length Weight Height Age D ND D ND D ND D ND D ND D ND D ND D ND 0.789 0.782 0.739 0.803 0.702 0.711 0.657 0.630 0.600 0.592 0.671 0.667 0.642 0.611 0.156 (p 0.133) 0.250 (p 0.015) Myogrip 0.829 0.824 0.764 0.805 0.730 0.764 0.718 0.737 0.664 0.678 0.703 0.730 0.693 0.684 0.152 (p 0.145) 0.138 (p 0.186) Vigorimeter 0.663 0.730 0.614 0.729 0.604 0.652 0.617 0.630 0.542 0.581 0.525 0.582 0.559 0.591 0.170 (p 0.101) 0.253 (p 0.014)

1.000 0.747 0.668 0.497 0.321 0.386

1.000 0.884 0.849 0.566 0.621

1.000 0.803 0.553 0.628

1.000 0.618 0.697

1.000 0.935

1.000

D: dominant side; ND: non-dominant side. All p < 0.001 except when mentioned.

In order to verify these models and to illustrate their ability to predict MGS, 29 additional subjects were tested. Their characteristics are given in Table 6. Fig. 2 shows the results obtained for the Myogrip. Correlation analysis showed that the predicted and observed values were signicantly correlated (r2 0.635; p < 0.0001). The ICC(2,1) between predicted and measured values was 0.795. The residuals were normally distributed (Fig. 3). 4. Discussion The main result of this study shows that MGS can be suitably predicted using hand circumference alone, indicating that this measurement is a relevant body-size dimension associated to grip strength. Moreover a single equation can be used for both genders and both hands provided that men have larger hands than women and the dominant hand is signicantly larger than the non-dominant hand. The coefcients of determination can be interpreted as large for the Martin Vigorimeter and very large for both the Jamar and the Myogrip dynamometers (Hopkins, 2000). Thus, hand circumference is a convenient and practical variable for routinely predicting MGS since its measurement is easy to perform. The model developed in the current study was constructed using a homogeneous young adult population. Such a choice of

population was performed specically to ensure that the subjects had not begun the aging process. The resulting model was thus independent of age. In addition, a single model can be used for both genders and hand sides. The use of a single model was conrmed by comparing separate models for hand dominance and gender. The resulting single model will enable simple calculations of expected grip strength to be performed. It is clear that additional investigations are needed using both young and elderly populations to conrm this nding. Normative data for MGS have been produced for several populations (Hager-Ross and Rosblad, 2002; Rauch et al., 2002; Kunelius et al., 2007; Gunther et al., 2008; Mitsionis et al., 2009). These normative data depict what is supposed to be a normal grip performance mainly with respect to gender and age. Hence they can be used to describe the possible loss of functional status during aging (Robertson et al., 1996) or disease (Chin et al., 1999; Visser et al., 2003) in terms of decit or residual strength. Normal grip strength may be also dened as the maximal MGS observed in the life of a standard individual, i.e. without any effect of age (maturation and aging), illness, injury, training or obesity. Age and gender are mainly considered as two main factors inuencing MGS. For both genders, MGS presents a curvilinear relationship to age (Hinson and Gench, 1989), which results in a peak of MGS in the third decade and a decline at an accelerating rate after age 40 (Kallman et al., 1990; Sinaki et al., 2001; Mitsionis et al., 2009). However, a large study conducted by Hanten et al. concluded that age correlated weakly to grip strength, with the exception of people between 50 and 64 years (Hanten et al., 1999). A poor correlation between age and MGS was also found by MacDermid et al. (2002). Regardless of age, men have signicantly higher values than women (Hanten et al., 1999). However, when related to muscle CSA or one of its surrogates (forearm circumference for instance), strength differences between men and women become considerably reduced (Hanten et al., 1999) or even absent (Bishop et al., 1987; Sartorio et al., 2002).

Table 4 Variables selected for the stepwise multiple linear regression model and corresponding adjusted coefcient of determination. Jamar Non-dominant Forearm circumference Hand circumference Hand circumference Palm length Forearm circumference Hand circumference Forearm circumference Gender Palm length r2 0.641 r2 0.673 r2 0.618 r2 0.639 r2 0.651 r2 0.624 r2 0.661 r2 0.673 r2 0.679 Myogrip Hand circumference Forearm circumference Hand length Hand circumference Palm length Gender Hand circumference Palm length Forearm circumference Gender r2 0.675 r2 0.712 r2 0.744 r2 0.683 r2 0.723 r2 0.738 r2 0.683 r2 0.720 r2 0.739 r2 0.750 Vigorimeter Hand circumference Forearm circumference Hand circumference Hand length Hand circumference Hand length Forearm circumference Weight Age r2 0.527 r2 0.565 r2 0.433 r2 0.473 r2 0.478 r2 0.511 r2 0.530 r2 0.540 r2 0.549

Dominant

Total

All p < 0.0001.

K. Li et al. / Manual Therapy 15 (2010) 579e585 Table 5 Regression prediction functions by stepwise multiple linear model for three dynamometers based on hand circumference (in mm). Dynamometer Jamar (kg) Myogrip (kg) Vigorimeter (kpa) All p < 0.0001. Regression prediction equation MGS 65.477 0.524 Hand circumference MGS 67.895 0.523 Hand circumference MGS 147.433 1.200 Hand circumference r 0.791 0.827 0.694 Adjusted r 0.624 0.683 0.478
2

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80 70 60 MGS (kg) 50 40 30 20 10 0 150

Jamar R = 0.626

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Besides age and gender, the correlation between several anthropometric variables and MGS has been explored in several populations of children and adults in various countries. Signicant correlations were found between MGS and height, weight (Hanten et al., 1999; Hager-Ross and Rosblad, 2002; Schreuders et al., 2003; Gunther et al., 2008; Mitsionis et al., 2009), FFM (Aghazadeh et al., 1993; Innes, 1999; Almuzaini, 2007), forearm volume or circumference (Harries, 1985; Fraser et al., 1999; Vaz et al., 2002; Gunther et al., 2008), as well as hand volume, width, circumference or length (Fraser et al., 1999; MacDermid et al., 2002; Kunelius et al., 2007; Gunther et al., 2008). The effect of hand dominance is still a subject of debate regarding whether there is a consistent difference in grip strength between dominant and non-dominant hands (Innes, 1999; Mitsionis et al., 2009). Height and weight are two important anthropometric factors for predicting MGS. However, they are too global to describe grip strength with a good reliability. Their importance is evidently less than local anthropometric data such as hand, wrist and forearm circumference, or hand and palm length (see Table 2). Among all the parameters highly correlated with MGS, the strongest correlated one was hand circumference. Consistent results were found (see Table 4) when the stepwise multiple linear regression was applied. The only parameter that was systematically selected was hand circumference, which was then chosen as the sole parameter to establish the nal predictive models (see Table 5). This nding was the same for both dominant and non-dominant hands. Although grip strength for the dominant hand was signicantly higher than for the non-dominant hand, hand circumferences were also larger for dominant hands. Thus a single predictive equation was able to be used for both hands. Our results are similar to those of Nicolay and Walker who found a correlation of 0.826 between palm width and MGS (to be compared to 0.789 for the Jamar and 0.829 for the MyoGrip in the present study) (Nicolay and Walker, 2005). Desrosiers et al. (1995) found also strong correlations between strength and hand circumference, with stronger correlations observed for the Jamar than for the Vigorimeter. The initial interpretation of selection of hand circumference as the preferred variable seems counterintuitive since the muscles used to produce grip force are predominantly located in the

MyoGrip 70 60 MGS (kg) 50 40 30 20 10 0 150 160 170 180 190 200 210 220 230 240 250 260 Hand circumference (mm) Vigorimeter 180 160 140 120 100 80 60 40 20 0 150

R = 0.685

R = 0.481

MGS (kPa)

Women Men

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Fig. 2. Correlation between hand circumference and MGS measured by three dynamometers: A. Jamar; B. Myogrip; C. Vigorimeter.

Table 6 Characteristics and anthropometric data for the additional subject group. Men (n 17) Mean (SD) Age (y) Height (cm) Weight (kg) BMI (kg/m2) Hand circumference (mm)* 21.5 179.0 71.8 22.4 213.8 207.9 (1.8) (5.8) (8.3) (1.9) (8.3) (8.0) Range 19e24 170e190 60e92 19.4e25.8 201e233 195e220 Women (n 12) Mean (SD) 21.5 165.8 59.9 21.8 187.8 189.7 (1.7) (6.3) (7.0) (2.1) (7.8) (8.4) Range 19e24 153e175 50e70 18.4e25.1 170e205 170e202

D ND

D: dominant side; ND: non-dominant side. *Signicantly different between sides (p < 0.0001).

forearm (Rice et al., 1998). However, the forearm volume, in addition to the FFM, is also heavily inuenced by the amount of fat. Such a relationship can be seen in the very large correlation found in the present study between forearm circumference and BMI (r 0.747). In contrast, hand volume is less related to the amount of fat as shown by the moderate correlation between BMI and hand circumference (r 0.497). In addition, the anatomical landmarks for hand circumference (palm creases) are easier to standardize than those of the forearm (largest diameter of the proximal quarter of the forearm). The population used in the present study was selected in order to be as homogeneous as possible to eliminate the possible effects of age, physical activity levels, injuries, and issues related to underor over-weight. No subjects had prior hand or forearm injuries, while no subjects performed physical activity more than four times per week. The BMI of subjects fell within 17 and 27 kg/m2. In such a population, hand and forearm circumferences are strongly correlated (r 0.849) and may be seen as a redundant information if both are used. However, when the subjects are involved in a situation in which the forearm volume is prone to be changed (muscle atrophy or obesity for instance), the relationship between hand and forearm circumferences may be modied.

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70 60 Measured MGS (kg) 50 40 30 20 10 0 0

A
y = 1.016x R=0.683

that has been shown to be correlated with global neuromuscular functioning (Nybo et al., 2001; Chan et al., 2008). Indeed, regular measurement of MGS should be performed, preferably at home using a convenient setup, in order to get a robust way of following MGS changes over time, as it can be done for body weight or blood pressure. As suggested by Kerr et al. (2006) and Bohannon (2006), grip strength should be measured routinely alongside the measurement of blood pressure. The main result of this study is particularly important as it shows that grip strength is directly proportional to morphological development and muscle trophicity. In other words, specic grip-strength capacities, prior to the onset of aging and sarcopenia, are independent of gender, dominance or age. Further analyses in children and elderly people obviously need to be performed to support the use of hand circumference alone to predict grip strength. Acknowledgements The authors would like to thank the China Scholarship Council (CSC) for the nancial support for Ke Li and all the subjects for their participation in the experiments. This study was partly supported by the Association Franaise contre les Myopathies (AFM). References

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Aghazadeh F, Lee K, Waikar A. Impact of anthropomatric and personal variables on grip strength. J Hum Ergol 1993;22:75e81. Almuzaini KS. Muscle function in Saudi children and adolescents: relationship to anthropometric characteristics during growth. Pediatr Exerc Sci 2007;19 (3):319e33. Anakwe RE, Huntley JS, McEachan JE. Grip strength and forearm circumference in a healthy population. J Hand Surg Eur 2007;2:203e9. Ansari K, Shamssain M, Keaney NP, Burns G, Farrow M. Predictors of quality of life in chronic obstructive pulmonary disease patients with different frequency of exacerbations. Pak J Med Sci 2007;23(4):490e6. Avlund K, Schroll M, Davidsen M, Lvborg B, Rantanen T. Maximal isometric muscle strength and functional ability in daily activities among 75-year-old men and women. Scand J Med Sci Sports 1994;4:32e40. Balogun JA, Akinloye AA, Adenlola SA. Grip strength as a function of age, height, body weight and Quetelet index. Physiother Theory Pract 1991;7:111e9. Bishop P, Cureton K, Collins M. Sex difference in muscular strength in equallytrained men and women. Ergonomics 1987;30(4):675e87. Bohannon RW. Hand-grip dynamometry provides a valid indication of upper extremity strength impairment in home care patients. J Hand Ther 1998;11 (4):258e60. Bohannon RW. Adequacy of simple measures for characterizing impairment in upper limb strength following stroke. Percept Mot Skills 2004;99(3 Pt 1):813e7. Bohannon RW. Grip strength predicts outcome. Age Ageing 2006;35:320. Chan DC, Lee WT, Lo DH, Leung JC, Kwok AW, Leung PC. Relationship between grip strength and bone mineral density in healthy Hong Kong adolescents. Osteoporos Int 2008;19(10):1485e95. Chin APMJ, Dekker JM, Feskens EJ, Schouten EG, Kromhout D. How to select a frail elderly population? A comparison of three working denitions. J Clin Epidemiol 1999;52(11):1015e21. Crosby CA, Wehbe MA, Mawr B. Hand strength: normative values. J Hand Ther 1994;19(4):665e70. Desrosiers J, Hebert R, Bravo G, Dutil E. Comparison of the Jamar dynamometer and the Martin vigorimeter for grip strength measurements in a healthy elderly population. Scand J Rehab Med 1995;27(3):137e43. Fraser A, Vallow J, Preston A, Cooper RG. Predicting normal grip strength for rheumatoid arthritis patients. Rheumatology 1999;38(6):521e8. Frederiksen H, Gaist D, Petersen HC, Hjelmborg J, McGue M, Vaupel JW, et al. Hand grip strength: a phenotype suitable for identifying genetic variants affecting mid- and late-life physical functioning. Genet Epidemiol 2002;23(2):110e22. Gunther CM, Burger A, Rickert M, Crispin A, Schulz CU. Grip strength in healthy Caucasian adults: reference values. J Hand Surg Am 2008;33(4):558e65. Hager-Ross C, Rosblad B. Norms for grip strength in children aged 4e16 years. Acta Paediatr 2002;91(6):617e25. Hanten WP, Chen WY, Austin AA, Brooks RE, Carter HC, Law CA, et al. Maximum grip strength in normal subjects from 20 to 64 years of age. J Hand Ther 1999;12 (3):193e200. Harries AD. A comparison of hand-grip dynamometry and arm muscle size amongst Africans in North-East Nigeria. Hum Nutr Clin Nutr 1985;39(4):309e13. Hinson M, Gench BE. The curvilinear relationship of grip strength to age. Occup Ther J Res 1989;9:53e60. Hopkins WG. A new view on statistics. Available from: http://www.sportsci.org/ resource/stats/; 2000.

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0 0 0.2 0.4 0.6 0.8 Observed cumulative probability 1

20 15 Residual MGS (kg) 10 5 0 20 -5 -10 -15 -20

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Fig. 3. Results on a population of 29 additional subjects for the Myogrip dynamometer. A. Relation between measured and predicted MGS. B. Residual cumulative probability. C. Relation between residuals and predicted MGS.

Hand circumference is obviously not the sole determinant of grip strength. Many genotypic and phenotypic parameters, as well as psychological, methodological, environmental variables may inuence physical performance. This is the reason why betweenand even within-individual variabilities are large. Predictive models are designed to get a statistical picture of the MGS of an individual but allow impairment detection and follow-up. Maximal strength is only one aspect of neuromuscular function, but this is a variable

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