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ARTICLE IN PRESSHYST-740; No. of Pages 6

Physiotherapy xxx (2014) xxx–xxx

ormative data for hand grip strength in healthy children measured with abulb dynamometer: a cross-sectional study

Mariana Angélica de Souza, Cyntia Rogean de Jesus Alves de Baptista,Michele Mataruco Baranauskas Benedicto, Tatiana Maciel Pizzato,

Ana Cláudia Mattiello-Sverzut ∗Ribeirao Preto Medicine School, University of Sao Paulo, Ribeirao Preto, Sao Paulo, Brazil

bstract

bjective To present the normative hand grip strength values measured with a bulb dynamometer for children, by gender and age, and toorrelate the findings with weight, height, body composition and handedness.esign Cross-sectional study.articipants Data from 295 healthy children of both genders aged 6 to 13 years were analysed.ethods Weight, height, body composition (Biodynamics model 450 bioimpedance analyser), handedness (Edinburgh scale) and grip strengtheasured with a bulb dynamometer (North Coast) were obtained.esults Grip strength of both hands increased with age in the two genders. Grip strength was similar in boys and girls between 6 and 13 yearsf age. The dominant hand was stronger than the non-dominant hand [mean (standard deviation) 7.0 (2.3) psi vs 6.5 (2.1) psi], with a meanifference of 0.52 psi (95% confidence interval of the difference 0.46 to 0.58). Grip strength was positively correlated with fat-free mass andeight (r ≥ 0.75).onclusion This study provides normative values for hand grip strength measured with a bulb dynamometer in children aged 6 to 13 years.his dynamometer provides a simple method to measure grip strength, and the results of this study provide further evidence of its performance

n the measurement of grip strength. 2014 Chartered Society of Physiotherapy. Published by Elsevier Ltd. All rights reserved.

eywords: Adolescents; Children; Dynamometer; Grip strength

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ntroduction

In clinical practice, health professionals are faced with aariety of conditions that compromise upper limb strength1–3]. In this respect, the measurement of hand grip strengthontributes to the detection of deficits, therapeutic manage-ent and evaluation of treatment outcomes. The Jamar and

Please cite this article in press as: de Souza MA, et al. Normative datadynamometer: a cross-sectional study. Physiotherapy (2014), http://dx.d

and-held dynamometers are the most widely used instru-ents to measure muscle strength in children [4]. Other

evices used for the quantitative analysis of grip strength

∗ Corresponding author at: University of Sao Paulo, Ribeirao Pretoedicine School, Bandeirantes Av., 3900, Campus, 14049-900 Ribeirao

reto, Sao Paulo, Brazil. Tel.: +55 16 3602 0738; fax: +55 16 3602 4413.E-mail address: [email protected] (A.C. Mattiello-Sverzut).

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031-9406/$ – see front matter © 2014 Chartered Society of Physiotherapy. Publisttp://dx.doi.org/10.1016/j.physio.2013.11.004

nclude isokinetic [5], electrical [6–8], digital (Takei Ltd.)9–11] and electronic (Grippit) dynamometers (AB Detektor,öteborg, Sweden) [12,13].The Jamar (Lafayette Instrument, Lafayette, United

tates) dynamometer has been recommended by the Amer-can Society of Hand Therapists, and has been adopted in

any studies as an excellent instrument for the measurementf hand grip strength [14–17]. This dynamometer permitsdjustment of the handle in five different positions, includingcquisition of maximum isometric grip strength. However,he Jamar dynamometer showed low validity in the detec-ion of weakness in early stages of myopathic disorders [4].

for hand grip strength in healthy children measured with a bulboi.org/10.1016/j.physio.2013.11.004

ccording to Massy-Westropp et al. [18], low grip strengthalues can be detected with the Grippit dynamometer but notith the Jamar dynamometer. However, differences in the

hed by Elsevier Ltd. All rights reserved.

dx.doi.org/10.1016/j.physio.2013.11.004


mailto:[email protected]


ARTICLE IN PRESSPHYST-740; No. of Pages 6

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M.A. de Souza et al. / Ph

nstruments used, the type of handle and hand size impair theomparison of data generated in clinical studies [15].

Electrical dynamometers provide recordings of strengths a function of time that are easy to interpret and can betored [6]. However, the cost of these instruments is highnd transportation is difficult. The Grippit dynamometer haseen shown to be a reliable instrument for the measure-ent of hand grip strength in children [13]. Molenaar et al.

7] compared the reliability of a Jamar-like dynamometerLode BV, Groningen, The Netherlands) and the Martin Vig-rimeter (Elmed, Addison, United States) (bulb design) forhe measurement of grip strength in children. As expected,maller children needed a wider grip to use the Jamar-likeynamometer. However, both instruments showed good toxcellent reliability, but the intraclass correlation coefficientsndicated better results for the Jamar-like dynamometer.

Factors that influence force generation are handle [19],ge, gender, height, weight, body composition, hand anthro-ometric measures and handedness [2,9,12,20]. The bulbynamometer is smaller and lighter than instruments fre-uently cited in the literature; a fact facilitating the recordingf isometric strength and its use by children. Link et al. [21]stablished normative data for hand grip strength in childrenged 3 to 6 years using a Martin Vigorimeter, which is similaro a bulb dynamometer. Therefore, more complete referenceata of hand grip strength in healthy children measured withhe bulb dynamometer are necessary to permit the use of thisnstrument in clinical practice.

As marked differences in strength are observed betweenenders at the onset of puberty, the aim of the present studyas to present normative hand grip strength values mea-

ured with a bulb dynamometer for children, by gender andge, and to correlate the findings with weight, height, bodyomposition and handedness.

ethods

articipants

In total, 313 healthy children and adolescents from public


chools, ranging in age from 6 to 13 years, participated inhe study. The participants were divided by age as shownn Table 1. Exclusion criteria were: confirmed history of

able 1umber of participants by gender and age.

ge (years) Boys Girls Total

6 15 11 267 21 16 378 15 21 369 21 28 49

10 17 23 4011 17 23 4012 18 19 3713 12 18 30

Total 136 159 295

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eurological, orthopaedic and metabolic diseases; handnjuries or previous hand surgery; complaints of weakness orain; and continuous use of medications during the 6 monthsreceding the study. Eighteen children were excluded andhe final sample consisted of 295 participants. The schoolsere selected after authorisation by the Regional Board ofducation of Ribeirao Preto, Brazil. The parents or legaluardians of the children/adolescents agreed to their partici-ation by signing an informed consent form. The study waspproved by the Ethics Committee of HCFMRP-USP (Ref.o. 6990/2007).

nstrument and test procedure

Personal data of the participants were collected fromhe parents/legal guardians using a questionnaire, includingssues that could interfere with grip strength (e.g. use of drugs,rauma). Handedness was evaluated using the Edinburghcale and was confirmed by the parent/legal guardian. Weight,eight, body composition, handedness and grip strength wereeasured at school. Body composition was determined with

tetrapolar electrical bioimpedance device Biodynamics 450Biodynamics, Shoreline, United States) according to theanufacturer’s instructions.A North Coast bulb dynamometer (NC 70154)-North

oast, California, United States was used for grip strengthests. This bulb dynamometer is composed of soft rubber, has

circumference of 13 cm, and was calibrated every 6 months.ifferent bulb sizes are not available. The dynamometer was

alibrated by positioning the red pointer at the zero markefore each trial.

The test was performed in the standardised position rec-mmended by the American Society of Hand Therapists [22]i.e. sitting in a straight-backed chair with feet supported onhe floor, shoulder in adduction and neutral rotation, elbowexed at 90◦, forearm in neutral position, and wrist between◦ and 30◦ of extension and between 0◦ and 15◦ of ulnareviation). The participants were verbally encouraged to useaximal grip strength using the word ‘strength’ four times:

strength, strength, strength, strength’. The dynamometeras supported slightly by the examiner to prevent any acci-ental falls. Three measurements were obtained, alternatingetween dominant and non-dominant hands. All tests wereerformed by the same examiner.

tatistical analysis

The sample size was calculated in accordance with Roys-on [23]. Exploratory analysis of the data was performedsing the PROC MEANS procedure from SAS Version 9.2.

linear regression model with mixed (random and fixed)ffects was used to compare grip strength between domi-


ant and non-dominant hands, and to determine differencesn dominant and non-dominant grip strength between gen-ers and ages. The association of grip strength with weight,eight, body mass index, fat-free mass and fat mass was



M.A. de Souza et al. / Physiotherapy xxx (2014) xxx–xxx 3

Table 2General characteristics of the participants including height, weight, body mass index, fat-free mass, fat mass, and grip strength of dominant and non-dominanthands.

Age (years) No. of par-ticipants

Height (cm) Weight (kg) Body massindex(kg/m2)

Fat-freemass (kg)

Fat mass(kg)

DominantHGS (psi)

Non-dominantHGS (psi)

Boys6 15 122.0 (5.0) 23.8 (3.7) 15.9 (1.7) 19.7 (2.8) 4.7 (3.2) 4.3 (0.9)a 4.0 (0.9)7 21 128.9 (7.9) 30.7 (9.4) 18.1 (3.9) 23.3 (5.2) 7.4 (4.5) 5.4 (1.3) 5.2 (1.5)8 15 133.8 (5.0) 33.2 (6.2) 18.4 (2.7) 25.7 (3.5) 7.5 (3.3) 6.3 (1.0)a 5.9 (1.2)9 21 139.6 (6.7) 34.6 (9.7) 17.5 (3.6) 27.0 (5.3) 7.6 (5.0) 6.1 (1.3)a 5.8 (1.2)10 17 141.9 (6.0) 39.4 (11.8) 19.3 (4.6) 28.9 (6.2) 10.5 (6.5) 6.9 (1.4)a 6.5 (1.2)11 17 147.4 (5.8) 43.6 (11.6) 19.7 (4.5) 33.3 (7.4) 10.1 (6.1) 7.9 (1.7)a 7.3 (1.9)12 18 154.4 (8.6) 46.4 (13.0) 19.2 (4.3) 36.2 (7.5) 10.2 (6.8) 9.2 (2.2)a 8.6 (2.1)13 12 163.8 (10.0) 50.0 (12.5) 18.4 (3.6) 41.0 (8.4) 8.9 (5.9) 10.7 (2.6)a 10.0 (2.3)

Girls6 11 121.4 (5.6) 23.9 (3.7) 16.1 (2.1) 19.1 (2.4) 4.7 (1.9) 4.6 (0.9)a 4.1 (0.8)7 16 124.6 (4.2) 25.6 (4.2) 16.4 (2.1) 19.7 (2.5) 5.8 (2.2) 4.8 (1.0)a 4.3 (0.9)8 21 132.7 (6.6) 30.4 (9.5) 17.0 (3.9) 23.0 (4.9) 8.7 (6.8) 5.5 (1.3)a 5.1 (1.1)9 28 139.0 (7.6) 37.2 (11.7) 18.6 (4.8) 27.5 (7.5) 9.5 (5.1) 6.6 (1.4)a 6.0 (1.4)10 23 144.5 (6.4) 36.2 (7.1) 17.1 (2.8) 27.9 (5.1) 7.9 (3.1) 7.0 (1.3)a 6.2 (1.2)11 23 149.7 (4.4) 42.1 (7.4) 18.7 (3.4) 32.3 (5.1) 11.0 (6.7) 8.1 (1.4)a 7.3 (1.2)12 19 154.2 (7.9) 42.0 (8.9) 17.6 (2.7) 32.5 (5.4) 9.5 (4.4) 8.4 (2.0)a 7.8 (1.8)13 18 158.4 (5.3) 50.6 (10.8) 20.1 (3.9) 37.2 (5.5) 13.4 (6.9) 10.0 (2.3)a 9.5 (1.9)Total (295) 295 141.3 (13.4) 37.1(12.1) 18.1 (3.8) 28.4 (8.1) 8.8 (5.6) 7.0 (2.3)a 6.5 (2.1)

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Table 3Correlation (r) between grip strength and weight, height, body mass index,fat-free mass and fat mass for dominant and non-dominant hands.

Grip strength Weight Height BMI Fat-free mass Fat mass

Dominant 0.72 0.79 0.42 0.80 0.39N

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GS, hand grip strength.alues are mean (standard deviation).a P < 0.05 compared with the non-dominant hand.

nalysed using Pearson’s correlation coefficient (r), adopting level of significance of 5%.

esults

Intrarater reliability was assessed by determining thenterclass correlation coefficient (ICC). Agreement betweenepetitions was observed in each assessment (ICC > 0.91)nd between assessments (ICC ≥ 0.87). In addition, measure-ent agreement was analysed using Bland and Altman plots

Fig. 1) and the ICC, considering both hands. The best mea-urement agreement was observed between Measures 2 and

for both dominant (ICC = 0.93) and non-dominant handsICC = 0.57).

The general characteristics of the sample studied arehown in Table 2. There was a predominance of right han-ers (93%), and none of the participants were ambidextrous.nalysis of the whole sample revealed no significant dif-

erence in grip strength between boys (n = 136) and girlsn = 159), regardless of whether dominant or non-dominantands were tested (P > 0.05). The dominant hand was signifi-antly stronger than the non-dominant hand [mean (standardeviation) 7.0 (2.3) psi vs 6.5 (2.1) psi], with a mean differ-nce of 0.52 psi (95% confidence interval of the difference


.46 to 0.58) (Table 2).Table 3 shows the correlation between dominant and

on-dominant grip strength and the variables analysed forhe whole sample. Grip strength was positively correlated

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on-dominant 0.72 0.79 0.40 0.80 0.38

MI, body mass index.

ith fat-free mass, height and weight (r = 0.80, r = 0.79 and = 0.72, respectively).

Analysis of the sample by gender and age showed a sig-ificant difference in grip strength between dominant andon-dominant hands in all groups (P < 0.05), except for-year-old boys (Table 2). Grip strength of both handsncreased with age in girls and boys. Fig. 2 shows the averagerip strength growth curves of dominant and non-dominantands for boys and girls.

iscussion

The data obtained for the 295 children enabled the authorso establish gender-specific reference values of hand griptrength measured with a bulb dynamometer, and to cor-elate these values with weight, height, body compositionnd handedness during the period between 6 and 13 yearsf age. Different devices have been used in previous stud-


es that established reference values of hand grip strength2,8,9]. However, considering the differences in the shapef the handle and the recording device, comparison of grip



4 M.A. de Souza et al. / Physiotherapy xxx (2014) xxx–xxx

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ig. 1. Intra-observer reliability assessed by Bland and Altman plots, comparands (D, E, F).

trength measured with the bulb dynamometer and normative


alues obtained with other instruments is not recommended8,10,11]. To the authors’ knowledge, the influence of bulbize on grip strength in children has not been investigated.

piv

n grip strength between repetitions for dominant (A, B, C) and non-dominant

his is an issue for further research as the purpose of the


resent study was not to investigate this question. Also, it ismportant to note that the bulb dynamometer has not beenalidated in the international scientific literature.



M.A. de Souza et al. / Physiotherapy xxx (2014) xxx–xxx 5

F r girls (

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ig. 2. Grip strength growth curve of dominant and non-dominant hands fo

Normative data for grip strength are usually presented inable format or as growth curves as a function of age [9,11].he latter approach was chosen in the present study to illus-

rate grip strength development at different ages. Hand griptrength was measured according to the suggestions raised byias et al. [24], which would permit excellent performance of

he participants. With respect to participant grouping, sometudies established broad age groups [17], whereas otherseported grip strengths for specific ages [8,12].

In the present study, hand grip strength was analysed byge. The grip strength of both hands increased with age inoys and girls, in agreement with previous studies [8,9,12].imilar findings were reported by Cohen et al. [10] for 7147nglish children aged 10 to 16 years; however, Cohen et al.sed the Takei hand grip dynamometer. Considering gendernd age, the present results showed similar grip strength inoys and girls between the ages of 6 and 13 years when domi-ant or non-dominant hands were tested. Differences betweenenders in grip strength measured with a digital dynamome-er (Takei Ltd.) became apparent by 12 years of age in a studynvolving 2125 children and adolescents (6 to 18 years of age)9]. Häger-Ross and Rösblad [12] studied 530 children (267oys and 263 girls) aged 4 to 16 years and found no differencen grip strength between genders until 10 years of age. There-fter, grip strength was higher in boys than girls. Similarly, aeview by Moura et al. [25] concluded that boys are strongerhan girls, particularly after 11 years of age. In contrast, some


tudies reported greater grip strength for boys at all ages, suchs Carreira et al. [16] who studied 195 Portuguese childrenged 11 to 14 years using the Jamar dynamometer. Cohen

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top panel) and boys (bottom panel) aged 6 to 13 years.

t al. [10] found that boys are stronger than girls at all ages,nd that the age-related increase in grip strength was moreronounced in boys. According to Molenaar et al. [8], the dif-erence in grip strength between boys and girls does not seemo be the same for each age, and boys are always stronger.

The onset of puberty, the period characterised by heightain and alterations in body composition, occurs 2 years ear-ier in girls. The body composition of boys and girls is similarefore this period. During puberty, adipose deposition pre-ominates in girls, whereas muscle mass increases in boys26]. This divergence may explain the differences in handrip strength between genders after puberty. This hypothesiss supported by the fact that fat-free mass was one of the vari-bles that had the greatest influence on grip strength in theresent study.

The dominant hand was found to be stronger than the non-ominant hand for the whole sample; a fact also reported inhe literature [8,17,27]. Sartorio et al. [27] found that griptrength of the dominant hand was 10% greater comparedith the non-dominant hand in both genders and for all ages.

n the present study, analysis of the participants by gender andge showed a difference in grip strength between dominantnd non-dominant hands for all ages, except for 7-year-oldoys. Furthermore, grip strength was positively correlatedith height and fat-free mass. Similar results have been

eported by Jürimäea et al. [20], who studied 64 prepubertal8 to 11 years of age) children. The authors demonstrated


hat fat-free mass, body mass index and height had the great-st influence on hand grip strength. Carreira et al. [16],auch et al. [2] and Moura et al. [25] also demonstrated



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M.A. de Souza et al. / Ph

positive correlation between grip strength and height andeight.In conclusion, the normative values for hand grip strength

n children measured with a bulb dynamometer were similaro those obtained with other instruments (i.e. higher valuesere observed for older ages and for the dominant hand). Fat-

ree mass and height were the main variables influencing griptrength. Bulb dynamometers can be handled easily by chil-ren aged 6 to 13 years, and may be a useful tool for paediatricvaluation by health professionals. In addition, age-specificalues provided by grip strength growth curves permit obser-ation of the development of children, and evaluation of theffects of therapeutic interventions.

cknowledgements

The authors wish to thank the State and Municipal Sec-etary of Education, the Regional Board of Education ofibeirão Preto, and the school directors for their permission

or data collection. The authors also wish to thank Prof. Paula. Chiarello from the Internal Medicine Department for pro-iding the bioimpedance equipment, CEMEQ for statisticalnalysis, and the physiotherapy students of the Faculty ofedicine of Ribeirao Preto (FMRP-USP) – Andréia Abud daosta, Maria Laura Pucciarelli, Francine Bertolais de Souzand Vanessa Ramalho – for technical assistance.

thical approval: Ethics Committee of HCFMRP-USP (Ref.o. 6990/2007).

unding: Conselho Nacional de Desenvolvimento Científico Tecnológico.

onflicts of interest: None declared.

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