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Measurement of Grip Strength: Validity and

Reliability of the Sphygmomanometer and


Jamar Grip Dynamometer
George F. Hamilton, MS, PT, OCS'
Carolyn McDonald, BS, PT2
Thomas C. Chenier, PhD3
H
and grip strength is a
fundamental proce-
dur e used by thera-
pists and physicians
t o assess patient sta-
tus fbllowing injuries, surgical tech-
niques, and treatment procedures t o
t he hand and upper extremity. An
accurate, quantifiable assessment of
hand grip strength helps t he clinician
establish realistic treatment goals,
provides treatment outcome data,
and is frequently utilized during de-
termination of hand disability
ratings.
Over t he years, several instru-
ments and methods for measuring
hand grip strength have been devel-
oped. In t he 1950s. instruments such
as t he Sklar, Narrangansett, Geckler,
and Collins dynamometers were used
but were proven unsatisfactory for
standardized grip strength measure-
ment (5, 1 I).
In 1954, Bechtol introduced t he
Jamar dynamometer. It consisted of
a sealed hydraulic system with ad-
justable hand spacings that regis-
tered hand grip force in pounds per
square inch (PSI) (1). It became t he
most accepted instrument in Califor-
nia for quantitative measurement of
hand grip (5).
Brewer et al discussed two meth-
ods for hand grip strength measure-
ments. The Lansbury method, used
Quantitative measurement of grip strength is an important variable when plotting the prog-
ress of a hand-injured patient. When utilizing traditional commercially available apparatuses, obtain-
ing meaningful grip strength measurement in these subjects is frequently difficult due to severe
deformity, high tissue sensitivity, and low levels of force generated. The purpose of this study was to
measure hand grip strength using two instruments having different physical characteristics and units
of measurement to determine the reliability of repeated measures with each instrument. Addition-
ally, validity of the sphygmomanometer for strength measurement was established through compari-
son with the values obtained from measurements using the research-validated lamar dynamometer.
Twenty-nine right hand dominant female college-age subjects volunteered to perform hand grip
strength testing. Measurements were taken with a sphygmomanometer and a lamar dynamometer
while utilizing standardized measurement procedures. A Spearman Rho correlation coefficient test
utilized in measuring within-instrument reliability showed a high correlation for each instrument at
.85 for the sphygmomanometer and .82 for the lamar dynamometer. Construct validity testing
performed to determine validity of the measurements by the sphygmomanometer compared with
the lamar dynamometer produced a .75 correlation. A formula for conversion of the sphygmoma-
nometer scores into lamar units was developed to enhance reporting of sphygmomanometer scores
utilizing the lamar standard. The study showed that the sphygmomanometer and lamar dynamome-
ter exhibit good within-instrument reliability. Validity of the sphygmomanometer as a grip measure-
ment device i s acceptable and reportable using the conversion formula developed. Therefore, it can
be utilized with confidence as essentially equal to the lamar unit for grip strength measurement.
Key Words: grip strength, hand injury, reliability
Professor, Department of Physical Therapy, School of Allied Health Sciences, East Carolina Uniwrsity, Creen-
ville, NC 27858
Staff physical therapist, Department of Physical Therapy, Nash General Hospital, Rocky Mount, NC
'Assistant professor, Epidemiology and Statistics, School of Allied Health Sciences, East Carolina University,
Creenville. NC
prior t o 1958, consisted of a sphyg-
momanometer cuff folded twice and
inflated t o 20 mmHg. The Winthrop
torqueometer was a device used t o
measure hand grip and rotational
ability (2).
Kirkpatrick reported t he find-
ings of a California Commission that
examined grip strength measure-
ment instruments based upon pneu-
matic, spring, and hydraulic systems.
They concluded that grip is a force
rather than a pressure and that it
should be measured in force units
such as Ibs or gms; they recom-
mended use of t he Jamar dynamom-
JOSPT Volume 16 Number 5 November 1992
R E S E A R C H S T U D Y
et er (5). Most of t he recent studies of
grip strength measurement have re-
ported t he Jamar dynamometer t o
be t he most reliable and accurate de-
vice for measurement of hand grip
strength (6-9). However, Solgaard et
al tested three units utilized in grip
strength measurement; two were
steel spring force dynamometers
("Collins" and "My-Gripper") and
one was pneumatic ("Martin Vigori-
meter"). Accuracy of t he units was
tested by placing each instrument be-
tween two compressible plates of a
machine that yielded force and de-
flection information. Machine test
results demonstrated near linearity
of all units, with the pneumatic unit
performing the best. Th e instru-
ments were also subjected t o a clini-
cal test of measured grip strength in
100 normal men and women sub-
jects. Th e pneumatic unit demon-
strated t he highest precision and was
deemed t o be t he superior instru-
ment for grip strength measurement
by those investigators (1 2). Due t o
problems of discomfort conformity
and convenience in hand-injured pa-
tients, many clinicians continue t o
utilize the soft cuff of t he Sphygmo-
manometer t o measure grip strength.
Th e purpose of this study was t o
determine t he repeated measures re-
liability of t he sphygmomanometer
under well-controlled test conditions,
t o compare those reliability out-
comes t o values obtained for t he re-
search-validated Jamar dynamome-
ter, and t o test for construct validity
of t he sphygmomanometer's meas-
urement scale (mmHg) by compari-
son with t he Jamar (PSI) unit. If t he
sphygmomanometer proved t o be
valid and reliable, then clinicians
might use this instrument with
greater confidence when obtaining
hand grip measurements.
METHODS
Subjects
Twenty-nine normal healthy fe-
male college-age subjects with no
known history of orthopaedic disor-
ders of their dominant hand volun-
teered t o participate in this study.
Descriptive characteristics of the sub-
jects ar e listed in Table 1.
Apparatus
Apparatuses used in this experi-
ment were an Aneroid type adult
sphygmomanometer U.A. Preston,
Inc., 60 Page Road, Clifton, New
Jersey, 270 12) (Figure 1). which
measures force in units of mmHg,
and a Jamar dynamometer (Item
3363, G.E. Miller, Inc., 484 Broad-
way, Yonkers, New York, 10705)
(Figure 2). which measures in units
of PSI.
Many dinicians
continue to utilize the
soff cuff of the
sphygmomanometer
to measure grip
strength.
The sphygmomanometer cuff
was evenly rolled, forming a circum-
ference of approximately 7 in t o
conform with a normal functional
hand position for grip.A rubber
band was placed around each end of
t he cuff t o hold it in position. Th e
cuff was inflated t o 20 mmHg, which
was t he starting position for meas-
urement of each subject. Th e Jamar
dynamometer was set at t he third
handle space, which is reported t o be
t he most commonly used position for
measurement (1). Additionally, it
provided t he closest hand grip di-
mension t o the rolled up sphygmo-
manometer cuff.
The Jamar dynamometer was
calibrated by suspending a range of
weights, comparable t o anticipated
study values, from t he handle of the
FIGURE 1. The sphygmomanometer.
FIGURE 2. The lamar dynamometer.
Factor Units Total Mean SD
Age (yean) 29 23.8 4.9
Height (in) 29 66.1 2.2
Weight (Ibd 29 131.9 26.3
TABLE 1. Subject characteristics.
Volume 16 Number 5 November 1992 JOSPT
R E S E A R C H S T U D Y
fixated instrument. Dial readings ob-
tained were identical t o those of t he
suspended weights, thus, confirming
the validity of t he Jamar dynamome-
ter with which t he sphygmomanome-
ter would be compared.
Design
Under the direction of the same
operator, 29 subjects performed
hand grip strength testing for each
instrument. A mean score was calcu-
lated from three measurements per
instrument, obtained at each of
three independent measurement ses-
sions occurring approximately 1
week apart.
Spearman Rho correlation coef-
ficient tests were administered t o de-
termine relationships within and be-
tween the instruments. Repeated
measures reliability was obtained by
calculating correlation coefficients
between sessions 1 and 2, sessions 1
and 3, and sessions 2 and 3 for each
instrument. The relationship be-
tween the two instruments was ob-
tained by applying a Spearman Rho
correlation coefficient test utilizing
t he mean value of all observations
from each instrument and by plot-
ting a simple linear regression t o as-
sess construct validity of t he sphyg-
momanometer for measurement of
hand grip strength.
Procedure
All subjects signed a personal
consent form, after which we re-
corded their ID number, age,
height, and weight. The American
Society of Hand Therapists' stand-
ardized arm position for hand
strength testing was utilized (4).
Each subject was positioned in a
straight back chair with both feet flat
on t he floor. Arm positioning was
demonstrated by t he operator, then
each subject was instructed t o place
her left hand on her right thigh and
assume a position of adducted and
neutrally rotated shoulders. For the
arm t o be tested, the elbow was
flexed t o 90". t he forearm and wrist
were in neutral positions, and the
fingers were flexed as needed for a
maximal contraction (Figure 3).
Fach subject was instructed t o
breathe in through her nose and
blow out through pursed lips as a
maxinlum grip effort was made. At
this time, a verbal command of
"Squeeze! Harder! Harder! Relax!"
was given by the examiner. Demon-
stration of maximum hand grip per-
formance was given prior t o t he first
session, and re-instruction was given
prior t o t he ot her two sessions as
needed. The instrument t o be tested
first was assigned by random order
t o each subject. Four minutes o r
Results demonstrated
high within-instrument
repeated measures
reliability and an
acceptable correlation
between
sphygmomanometer
and lamar
dynamometer
measurements.
greater were allowed between each
grip measurement. Th e mean score
among three trials of each instru-
ment was recorded for data calcula-
tions. The second and third sessions
for hand grip measurements were
repeated approximately 1 week apart
using each instrument.
Extraneous variables were con-
trolled by using t he same room with
an average temperature of 74" F,
subjects of t he same gender, right
hand dominance, and approximately
t he same age group, and approxi-
mately the same time of day. The
FIGURE 3. Positioning of a subject while performing
hand grip strength measurements using the
sphygmomanometer and the lamar dynamometer.
same instructions were given t o each
subject regarding position of the u p
per extremity, hand grip strength
performance, and breathing tech-
nique. Each subject was encouraged
not t o do any strenuous activity with
t he dominant upper extremity dur-
ing the study.
RESULTS
Mean and standard deviation
grip strength scores for each instru-
ment at each of t he three sessions
ar e presented in Table 2. Spearman
Rho correlation coefficient test out-
comes for each possible pair of Ja-
mar and sphygmonianometer read-
ings collected over all sessions are
presented in Table 3. The average r
value for t he three observational pe-
riods was .85 for the sphygmoma-
nometer and .8 1 for the Jamar (Ta-
ble 3A), each with a statistically sig-
nificant relationship (/I < .OO 1) for
scores obtained between the three
test intervals.
Sphygnionianometer vs Jamar
mean scores for all observational pe-
riods produced a correlation coeffi-
cient of .75 (Table 3C).
Using the inverse regression
technique (3). we calculated an in-
JOSPT * Volume 16 * Number 5 * November 1992
R E S E A R C H S T U D Y
Sessions 1 2 3 Mean
Sphygmomanometer (mmHg)
Mean 205.96 200.17 199.83 203.12
SD 22.53 21.53 14.85 21.10
jamar dynamometer (PSI)
Mean 63.09 69.21 66.23 64.83
SD 9.43 8.08 10.50 9.07
TABLE 2. Mean and standard deviation for three grip strength sessions using the sphygmomanometer and the
lamar dynamometer, plus the mean and standard deviation values for all grip sessions.
A Sphyg 1 vs Sphyg 2 Rho = .8426 p < .001
Sphyg 1 vs Sphyg 3 Rho = .8616 p < .001
Sphyg 2 vs Sphyg 3 Rho = ,8401 p < .001
Jamar 1 vs Jamar 2 Rho = ,8764 p < .001
Jamar 1 vs Jamar 3 Rho = .8049 p < .001
Jamar 2 vs Jamar 3 Rho = .7844 p < .001
B Sphyg 1 vs Jamar 1 Rho = .6079 p < .001
Sphyg 2 vs Jamar 2 Rho = .7455 p < .001
Sphyg 3 vs Jamar 3 Rho = .5723 p = .001
C Mean scores of Sphyg vs mean scores of jamar
Rho = .7497 p < .001
- - - -
TABLE 3. Spearman Rho correlation coefficient values showing within (A) and between (6) instrument
rekability in hand grip strength measurement for the sphygmomanometer and the lamar dynamometer.
FIGURE 4. Inverse regression prediction line
showmg the relationship between
sphygmomanometer (mmHg) and lamar (PSI)
readings and the formulas for conversion of
sphygmomanometer to lamar scores.
reliability and an acceptable correla-
tion between sphygmomanometer
and Jamar dynamometer measure-
ments. Although statements ar e
available in the literature expressing
the inadequacy of pressure-related
instrumentation for grip strength
measurement (5. 8). test results from
Solgaard et al demonstrated that a
pneumatic-based (Martin Vigorime-
ter) ball type unit provided highly
linear and reliable data for grip
strength measurement ( 1 2). Robert-
son and Deitz have advocated t he
use of t he Martin Vigorimeter for
measuring grip strength in preschool
children due t o its ability t o accu-
rately measure spherical grip
verse regression line showing the re-
strength, which they indicated was a
lationship between Jamar and
more effective indicator of hand
monianometer scores and a formula
function in the child ( 1 0).
t o convert sphygmomanometer
. ,
Our scores for s ~h v ~mo ma n o m-
1 , <7
scores t o equivalent Jamar values
et er and Jamar grip strength testing
(Figure 4). The formula is Jamar =
were similar, each yielding correla-
.!j4 s~h~gnl Onl anOmet er - 45.12.
tion values of .80 o r greater. These
< I
findings conform with t he previous
DISCUSSION work of Mathiowetz et al, who re-
ported a high correlation (.80 o r
Results demonstrated high greater) in hand grip strength using
within-instrument repeated measures t he Jamar dynamometer (8).
Data obtained from the two in-
struments were used t o construct a
formula Uamar = .54 x Sphygmo-
manometer - 45.12) by which meas-
urements on the sphygmomanome-
t er (mmHg) could be converted into
t he corresponding Jamar (PSI) meas-
urements. An inverse regression
technique was used t o make these
conversions (3). For these data, it
would be inappropriate t o apply the
usual regresson analysis. One of the
assumptions of t he usual regression
analysis is that t he predictor variable
is measured without error, o r that
the error of t he predictor varible is
small relative t o the error of the re-
sponse variable. When a regression
line is fit t o data where the predictor
variable is measured with error, the
resulting estimate of the slope of the
regression line is biased. In this in-
stance, measurements associated with
t he sphygmomanometer that are
subject t o error are being used t o
predict t he values obtained from the
Jamar.
When measuring grip strength
in the hand-disabled subject, there
are multiple advantages of the
Sphygmomanometer over t he Jamar
unit: I) ready availability of a sphyg-
momanometer in most clinics, 2) a
soft compliant surface that may pro-
duce less discomfort t o t he injured
hand during testing, and 3) a scale
with smaller increments than the Ja-
mar and, therefore, greater sensitiv-
ity t o small changes in strength.
The outcome of this study dem-
onstrates t he ability of t he sphygmo-
manometer t o provide acceptable
levels of repeated measures reliabil-
ity in the normal population. How-
ever, further studies ar e needed
within the hand-injured population
t o fully validate its application. JOSPT
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Volume 16 Number 5 November 1992 JOSPT
R E S E A R C H S T U D Y
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JOSPT Volume 16 Number 5 November 1992