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What’s New in the Patient Safety World

July 2020

Getting a Grip on Things



We neurologists often take pride in being able to say we have completed half the neurological exam before the patient even sits down in our office. As the patient enters the room, we observe his stance and gait, gait speed, arm swing, any tremor or abnormal movements, and facial expression. As we introduce ourselves we get at least a glimpse of the patient’s speech articulation and prosody, if not a glimpse of a possible aphasia. And we usually shake hands with the patient (at least in the pre-COVID19 era!). The latter is, of course, a relatively subjective measure of grip strength. But, more and more, we have realized that formal measurement of grip strength provides a very powerful indicator of many patient vulnerabilities.


There are many parameters that have been used in various frailty indices (see our many columns on frailty listed below). Handgrip strength is one of those. In our June 2015 What's New in the Patient Safety World column “Get a Grip on It!” we noted that grip strength not only predicts surgical complications and outcomes but also predicts risk for stroke, MI, cardiovascular and all-cause death.


In an analysis of 351 consecutive patients undergoing major intra-abdominal operations Revenig and colleagues (Revenig 2015) found that “shrinking” and grip strength alone hold the same prognostic information as the full 5-component Fried Frailty Criteria for 30-day morbidity and mortality. When combined with American Society of Anesthesiologists (ASA) score and serum hemoglobin, they form a simple risk classification system with robust prognostic information.


Shortly after that publication, the results of the Prospective Urban-Rural Epidemiology (PURE) study were released (Leong 2015). This was a longitudinal population study done on approximately 140,000 subjects in 17 countries of diverse cultural and socioeconomic settings. Grip strength was measured with a dynamometer. Grip strength was inversely associated with all-cause mortality (16% increase for each 5 kg reduction in grip strength), cardiovascular mortality (17%), non-cardiovascular mortality (17%), myocardial infarction (7%), and stroke (9%). Grip strength was actually a stronger predictor of all-cause and cardiovascular mortality than systolic blood pressure.


In our May 16, 2017 Patient Safety Tip of the Week “Are Surgeons Finally Ready to Screen for Frailty?” we noted a study that looked at individual components of the Fried frailty phenotype measures (gait speed, hand-grip strength as measured by a dynamometer, and self-reported exhaustion, low physical activity, and unintended weight loss) in a primary care setting (Lee 2017). The researchers found that individual criteria all showed sensitivity and specificity of more than 80%, with the exception of weight loss. The positive predictive value of the single-item criteria in predicting the Fried frailty phenotype ranged from 12.5% to 52.5%. When gait speed and hand-grip strength were combined as a dual measure, the positive predictive value increased to 87.5%. They conclude that, while use of gait speed or grip strength alone was found to be sensitive and specific as a proxy for the Fried frailty phenotype, use of both measures together was found to be accurate, precise, specific, and more sensitive than other possible combinations and that assessing both measures is feasible within the primary care setting.


Analysis of data on over 500,000 patients in the UK (Celis-Morales 2018) found that reduced grip strength was associated with worse cardiovascular, respiratory, and cancer outcomes and all-cause mortality.


Probably the most extensive review of the literature on handgrip strength was done by Bohannon (Bohannon 2019). He concluded that there is adequate evidence to support the use of grip strength as an explanatory or predictive biomarker of specific outcomes such as generalized strength and function, bone mineral density, fractures, and falls, nutritional status, disease status and comorbidity load, cognition, depression, and sleep, hospital-related variables, and mortality. He suggested routine implementation of the measurement of grip strength for older adults in the community and healthcare settings.


Handgrip strength was a predictor of falls in the study by Xue (Xue 2011) and the review by Bohannon (Bohannon 2019). A recent article in Medscape (Millard 2020) discussed a study from Brazil that was scheduled to be presented at the recently cancelled American College of Sports Medicine (ACSM) 2020 Annual Meeting. The study of 204 elderly women found that the risk for falls was 2.73 times higher in women who had poor handgrip strength than in those who had normal handgrip strength. The risk was even greater in women with impaired balance.


But there are 2 additional important parameters on grip strength that we need to take into consideration:


The Women's Health and Aging Study (Xue 2011) found that a decline in grip strength over time is a stronger predictor of a greater variety of subsequent adverse outcomes compared with a single observation of grip strength, Outcomes included falls, walking speed slower than 0.4 m/s, the WHAS frailty phenotype, and difficulty in 1 or more task of the Activities of Daily Living (ADL) and Instrumental Activities of Daily Living (IADL) scales. Independent of baseline grip strength, a greater rate of decline in grip strength over time, was significantly associated with higher risk for all outcomes except ADL disability. The risk of developing an IADL disability was 1.32 times higher for every 0.5-SD unit increase in the rate of decline in grip strength. The associations were independent of age, disease burden, lifestyle, nutritional status, inflammation, and mental well-being. That led the authors to suggest that “becoming weaker” is important in addition to “being weak.”


A new study evaluated both grip strength (HGS) and asymmetry of grip strength in relation to cognitive function (McGrath 2020). McGrath and colleagues used a dynamometer to measure grip strength in elderly patients. Asymmetry was considered as any difference of more than 10% between sides. They found that weakness of grip strength and asymmetry of grip strength (even without weakness) were both predictive of lower cognitive function. Relative to those with symmetric HGS and no weakness, each HGS asymmetry and weakness group had greater odds for lower cognitive functioning: 1.15 for any HGS asymmetry alone, 1.64 for weakness alone, and 1.95 for any HGS asymmetry and weakness. Each HGS asymmetry dominance and weakness group also had greater odds for lower cognitive functioning: 1.12 for asymmetric dominant HGS alone, 1.27 for asymmetric nondominant HGS alone, 1.64 for weakness alone, 1.89 for weakness and asymmetric dominant HGS, and 2.10 for weakness and asymmetric nondominant HGS.


Measurement of handgrip strength is a simple, inexpensive way to identify patients who are at risk for frailty and a variety of adverse health outcomes. Reduced grip strength (and also asymmetric handgrip strength or worsening handgrip strength over time) is a marker for patients having multiple comorbidities that collectively reduce their physiologic reserve and make them more vulnerable to adverse outcomes. It can be used to predict increased risk for complications in patients undergoing surgery, predict patients at risk for falls, and many other conditions.



Some of our prior columns on preoperative assessment and frailty:






Revenig LM, Canter DJ, Kim S, et al. Report of a Simplified Frailty Score Predictive of Short-Term Postoperative Morbidity and Mortality. J Am Coll Surg 2015; 220(5): 904-911



Leong DP, Teo KT, Rangarajan S, et al. Prognostic value of grip strength: Findings from the Prospective Urban Rural Epidemiology (PURE) study. Lancet 2015; 386(9990): 266-273, July 18, 2015



Lee L, Patel T, Costa A, Bryce E, Hillier LM, Slonim K, et al. Screening for frailty in primary care. Accuracy of gait speed and hand-grip strength. Can Fam Physician 2017; 63: e51-7



Celis-Morales Carlos A, Welsh Paul, Lyall Donald M, Steell Lewis, Petermann Fanny, Anderson Jana et al. Associations of grip strength with cardiovascular, respiratory, and cancer outcomes and all cause mortality: prospective cohort study of half a million UK Biobank participants BMJ 2018; 361 :k1651



Bohannon R. W. (2019). Grip Strength: An Indispensable Biomarker For Older Adults. Clinical Interventions in Aging 2019; 14: 1681-1691



Xue Q, Walston JD, Fried LP, Beamer BA. Prediction of Risk of Falling, Physical Disability, and Frailty by Rate of Decline in Grip Strength: The Women's Health and Aging Study. Arch Intern Med 2011; 171(12): 1119-1121



Millard E. Handgrip Strength Could Be a Simple Way to Predict Fall Risk. Medscape Medical News 2020; June 10, 2020



McGrath R, Cawthon PM, Cesari M, et al. Handgrip Strength Asymmetry and Weakness Are Associated with Lower Cognitive Function: A Panel Study. J Am Geriatr Soc 2020; first published 30 May 2020





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