Sensitivity of the Jamar Dynamometer in detecting submaximal grip effort

Multidisciplinary Management Strategies for Long COVID: A Narrative Review

Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) has caused millions of infections to date and has led to a worldwide pandemic. Most patients had a complete recovery from the acute infection, however, a large number of the affected individuals experienced symptoms that persisted more than 3 months after diagnosis. These symptoms most commonly include fatigue, memory difficulties, brain fog, dyspnea, cough, and other less common ones such as headache, chest pain, paresthesias, mood changes, muscle pain, and weakness, skin rashes, and cardiac, endocrine, renal and hepatic manifestations. The treatment of this syndrome remains challenging. A multidisciplinary approach to address combinations of symptoms affecting multiple organ systems has been widely adopted. This narrative review aims to bridge the gap surrounding the broad treatment approaches by providing an overview of multidisciplinary management strategies for the most common long COVID conditions.

Characterization of Musculoskeletal Injury Risk in Dungeness Crab Fishing

OBJECTIVES

Commercial Dungeness crab fishermen's manual crab pot handling activities can be done in harsh outdoor working environments at sea and can pose well-known physical risk factors associated with musculoskeletal injury including forceful exertion, repetition and awkward posture. The nonfatal injury rate in this fishing fleet is 3.4 per 1,000 full-time equivalent workers. Two-thirds of self-reported injuries in the fleet were musculoskeletal sprains and strains. To date, no objective biomechanical assessment of musculoskeletal disorder (MSD) risk has been conducted due to the challenging work environment.

METHODS

The aim of this study was to determine the feasibility of collecting objective biomechanical assessments (i.e., posture and repetition) using inertial measurement unit (IMU) sensors placed on the arms and torso of professional deckhands (n = 7) while at sea, harvesting Dungeness crab. Based on the IMU-measured posture data, fishermen's anthropometry, and crab pot weights, biomechanical loading of the low back and both shoulders was estimated.

RESULTS

The IMU sensor data showed that commercial Dungeness crab fishing is highly repetitive and poses awkward postures in the shoulders and back. The estimated static low back compression, shear force, and flexion moment about the shoulders and low back (L5/S1) indicate potential injury risk associated with harvesting crab.

CONCLUSION

The results indicate that objective biomechanical assessment using the IMU sensors is feasible in the commercial fishing environment.

Rationale and design of an ancillary study evaluating the effects of the cocoa flavanol and/or multivitamin interventions on falls and physical performance outcomes in the COcoa Supplement and Multivitamin Outcomes Study (COSMOS)

BACKGROUND

Falls and decreased physical function increase markedly with age and result in injury, hospitalization, and premature death. Emerging studies show potential benefits of supplemental cocoa extract on physical performance, including grip strength and walking speed in older adults. However, there are no large, long-term randomized controlled trials of effects of supplemental cocoa extract on falls, muscle performance, and/or fall-related injuries.

METHODS

The COcoa Supplement and Multivitamin Outcomes Study (COSMOS) is a double-blind, placebo-controlled, 2 × 2 factorial trial investigating effects of supplementation with cocoa extract (500 mg/d, including 80 mg (-)-epicatechin) and/or a multivitamin on prevention of cardiovascular disease and cancer in 21,442 women (≥65 years) and men (≥60 years).

COSMOS

Effects on Falls and Physical Performance is an ancillary study to COSMOS that will clarify effects of cocoa extract and/or multivitamin supplementation on falls, physical performance, and incident fracture outcomes in older adults. Injurious fall(s) resulting in healthcare utilization and recurrent falls were regularly assessed by follow-up questionnaires in the overall cohort. Incident fractures were also assessed by annual questionnaires. Circumstances surrounding falls and any fall-related injuries will be confirmed by medical record review. Effects of the interventions on 2-year changes in physical performance measures (grip strength, walking speed, and the Short Physical Performance Battery) will be tested in a clinic sub-cohort (n = 603).

CONCLUSION

Results from this ancillary study will determine whether supplemental cocoa extract slows age-related declines in physical performance and decrease injurious and recurrent falls and fall-related injuries and fractures that are major public health problems in older adults.

Comparing Statistics and Machine Learning to Detect Insincere Grip Force Testing Using Manugraphy

Background Currently, there are no tests that have been proven to be capable of rating an individual's grip force measurement as sincere or insincere. However, different parameters have been found to vary in grip force testing for maximal versus submaximal effort. A novel data analysis and processing approach might be key to improving these measurements. This study explores the use of a machine learning (ML) algorithm as a means to more accurately determine the sincerity or insincerity of grip force testing. The ML algorithm compares the hand's load distribution pattern with the information generated using conventional statistical methods. Methodology This study uses manugraphy data collected as part of a previous investigation that analyzed load distribution patterns of the right and left hands of 54 healthy subjects. The subjects underwent grip force testing using maximal or submaximal effort, and the percentage contributions of each of the seven defined anatomical areas of the hand were calculated with respect to the total load applied. The predictions based on the load distribution and its use for rating individual grip force measurements as sincere or insincere were compared with the results of conventional statistical methods (thresholds for a bi-manual area-to-area comparison) and an ML algorithm. Results Based on an area-to-area comparison, our method achieved a sensitivity of 54% and a specificity of 78% to detect insincere effort. A predictive ML model developed using these data was capable of recognizing submaximal effort based on the hand's load distribution pattern, determining a sensitivity of 94% and a specificity of 99%. Conclusions Compared to conventional methods, the use of an ML algorithm considerably improved the validity of manugraphy results in discerning the sincerity or insincerity of grip effort.

Sex Differences in Recovery Across Multiple Domains Among Older Adults With Hip Fracture

BACKGROUND

Hip fractures are a public health problem among older adults, but most research on recovery after hip fracture has been limited to females. With growing numbers of hip fractures among males, it is important to determine how recovery outcomes may differ between the sexes.

METHODS

168 males and 171 females were enrolled within 15 days of hospitalization with follow-up visits at 2, 6, and 12 months postadmission to assess changes in disability, physical performance, cognition, depressive symptoms, body composition, and strength, and all-cause mortality. Generalized estimating equations examined whether males and females followed identical outcome recovery assessed by the change in each outcome.

RESULTS

The mean age at fracture was similar for males (80.4) and females (81.4), and males had more comorbidities (2.5 vs 1.6) than females. Males were significantly more likely to die over 12 months (hazard ratio 2.89, 95% confidence interval: 1.56-5.34). Changes in outcomes were significantly different between males and females for disability, gait speed, and depressive symptoms (p < .05). Both sexes improved from baseline to 6 months for these measures, but only males continued to improve between 6 and 12 months. There were baseline differences for most body composition measures and strength; however, there were no significant differences in change by sex.

CONCLUSIONS

Findings confirm that males have higher mortality but suggest that male survivors have continued functional recovery over the 12 months compared to females. Research is needed to determine the underlying causes of these sex differences for developing future prognostic information and rehabilitative interventions.

Respiratory and peripheral muscle involvement in patients with pulmonary arterial hypertension due to congenital heart diseases

Skeletal and respiratory muscle dysfunction has been previously described in patients with other etiologic subgroups of pulmonary arterial hypertension (PAH) but has never been investigated in patients with PAH due to congenital heart diseases (CHD). This study aims to show the involvement of skeletal and respiratory muscles in these patients. This cross-sectional study included patients with PAH due to CHD and healthy controls. Patients' demographic properties, six-minute walk tests; shoulder abduction, handgrip, knee extension, and ankle dorsiflexion muscle strength, maximum inspiratory (MIP) and expiratory pressures (MEP) were measured. Deltoid, flexor digitorum superficialis, and profundus, tibialis anterior and rectus femoris muscles were visualized with ultrasonography and their cross-sectional areas (CSA) were also measured in both groups. 12 patients and 12 controls were included. Mean MIP was 104.22±32.57 cm H2O for healthy participants while 61.33±29.74 cm H2O for patients (p<0.001). For mean MEP, it was 100.08±26.05 cm H2O in healthy participants and 69.75±39.79 cmH2O in controls (p=0.004). When the strength of skeletal muscles was compared, there were significant differences between the groups in all measurements except for bilateral grip strength. In the correlation analysis, MIP and MEP values showed no significant correlations with clinical parameters. They showed significant moderate correlations with skeletal muscle strength. When CSAs of the muscles were compared, there were significant differences in all measurements except for left FDS and FDP and bilateral rectus femoris. This study showed that in patients with pulmonary arterial hypertension due to CHD, respiratory muscle strength is significantly worse than healthy participants. Patients had also significantly worse skeletal muscle strength except for grip strength.

Effects of Deep Dry Needling on Tremor Severity and Functionality in Stroke: A Case Report

This study aimed to determine the effect of one session of dry needling on the severity of tremor, motor function and skills, and quality of life of a 39-year-old woman with post-stroke tremor. Myofascial trigger points (MTrP) of the following muscles were treated: extensor digitorum, flexor digitorum superficialis and profundus, brachioradialis, short head of biceps brachii, long head of triceps brachii, mid deltoid, infraspinatus, teres minor, upper trapezius, and supraspinatus. Outcomes were assessed via (i) clinical scales (activity of daily living (ADL-T24), a visual analog scale (VAS), and the Archimedes spiral), (ii) a functional test (9-Hole Peg test), and (iii) biomechanical and neurophysiological measurements (inertial sensors, electromyography (EMG), and dynamometry). The subject showed a decrease in the severity of tremor during postural (72.7%) and functional (54%) tasks after treatment. EMG activity decreased after the session and returned to basal levels 4 days after. There was an improvement post-intervention (27.84 s) and 4 days after (32.43 s) in functionality and manual dexterity of the affected limb, measured with the 9-Hole Peg test, as well as in the patient's hand and lateral pinch strength after the treatment (26.9% and 5%, respectively), that was maintained 4 days later (15.4% and 16.7%, respectively).

Frailty among institutionalized older people: a cross-sectional study in Natal (Brazil)

Objective:

Verify the prevalence of frailty and its associated factors in institutionalized older people.

Methods:

Cross-sectional study carried out in 10 nursing homes in Natal (Brazil), between October/2013 and January/2014. All institutionalized older people 60+ that were not hospitalized, in terminal state, coma or under palliative care were included in the study. The dependent variable of the study was the presence/absence of frailty, classified according to the following criteria: severe cognitive decline and/or impossibility of independent walking or being bedridden. The 5 criteria (muscular weakness, unintentional weight loss, low physical activity level, slowness and exhaustion) of Fried et al. were considered for those with preserved cognitive and walking capacity. The chi-square test or Fisher’s test and logistic regression were used for bivariate and multiple analysis, respectively. Sociodemographic, institution-related and health-related variables were also included.

Results:

Of the 321 participating older people, 80.1% were considered frail, 16.8% pre-frail and 3.1% non-frail. The final model demonstrated association of frailty with age (OR=2.67; 95%CI 1.39-5.14; p=0.003), presence of chronic diseases (OR=10.27; 95%CI 3.42-30.90; p<0.001), systemic arterial hypertension (OR=0.11; 95%CI 0.05-0.27; p<0.001) and institutionalization due to lack of caregiver (OR=2.55; 95%CI 1.36-4.76; p=0.003) adjusted by sex and type of institution.

Discussion:

Frailty was highly prevalent in institutionalized older people and its association with multi-factor aspects suggested that action of health services and government representations could aid in the prevention or delay of frailty onset, improving the life quality of older people.

Comparison of the effectiveness of orthotic intervention, kinesiotaping, and paraffin treatments in patients with carpal tunnel syndrome: A single-blind and randomized controlled study

PURPOSE

The aim of the study was to compare different conservative treatments in patients with carpal tunnel syndrome (CTS).

STUDY DESIGN

A single-blind randomized controlled study.

METHODS

Patients (n = 169) diagnosed with mild or moderate CTS were screened; 110 met study requirements. The patients were randomized into 3 groups. The control (CON) comparison provided to all patients was a fabricated night orthotic which held the wrist in a neutral position. The second group received adjunctive kinesiotaping (KIN) and the third group received paraffin (PARA). All patients were evaluated clinically, electrophysiologically, and ultrasonographically before treatment and at 3 weeks, 3 months, and 6 months.

RESULTS

There were 36 patients in CON, 37 in KIN, and 37 in PARA. Pain reduction in KIN was better than the other groups at 3 weeks (mean difference [MD] in CON 2.4 ± 2.5, KIN 3.7 ± 2.0, PARA 2.7 ± 2.3; P < .01) and 6 months (MD in CON 3.4 ± 3.0, KIN 4.9 ± 3.1, PARA 3.7 ± 2.9; P < .05). KIN pain reduction was better than CON at 3 months (MD in CON 3.8 ± 2.8, KIN 5.0 ± 2.5; P < .05). Reduction of the cross-sectional area of median nerve at the level of radioulnar joint was greater for KIN than CON at 3 weeks (MD in CON 0.0 ± 0.5, KIN 0.3 ± 0.7; P < .01) than PARA at 3 months (MD in KIN 0.3 ± 0.8, PARA 0.0 ± 0.8; P < .05) and both groups at 6 months (MD in CON 0.1 ± 0.8, KIN 0.5 ± 0.9, PARA 0.0 ± 1.0 P < .05).

CONCLUSION

Adding KIN to night use of an orthotic was more effective in achieving symptomatic and structural improvements than either the orthotic alone or adjunctive use of paraffin in patients with mild and moderate CTS.

Examining Differences in Recovery Outcomes between Male and Female Hip Fracture Patients: Design and Baseline Results of a Prospective Cohort Study from the Baltimore Hip Studies

BACKGROUND

Incidence of hip fractures in men is expected to increase, yet little is known about consequences of hip fracture in men compared to women. It is important to investigate differences at time of fracture using the newest technologies and methodology regarding metabolic, physiologic, neuromuscular, functional, and clinical outcomes, with attention to design issues for recruiting frail older adults across numerous settings.

OBJECTIVES

To determine whether at least moderately-sized sex differences exist across several key outcomes after a hip fracture.

DESIGN, SETTING, AND PARTICIPANTS

This prospective cohort study (Baltimore Hip Studies 7th cohort [BHS-7]) was designed to include equal numbers of male and female hip fracture patients to assess sex differences across various outcomes post-hip fracture. Participants were recruited from eight hospitals in the Baltimore metropolitan area within 15 days of admission and were assessed at baseline, 2, 6 and 12 months post-admission.

MEASUREMENTS

Assessments included questionnaire, functional performance evaluation, cognitive testing, measures of body composition, and phlebotomy.

RESULTS

Of 1709 hip fracture patients screened from May 2006 through June 2011, 917 (54%) were eligible and 39% (n=362) provided informed consent. The final analytic sample was 339 (168 men and 171 women). At time of fracture, men were sicker (mean Charlson score= 2.4 vs. 1.6; p<0.001) and had worse cognition (3MS score= 82.3 vs. 86.2; p<0.05), and prior to fracture were less likely to be on bisphosphonates (8% vs. 39%; p<0.001) and less physically active (2426 kilocalories/week vs. 3625; p<0.001).

CONCLUSIONS

This paper provides the study design and methodology for recruiting and assessing hip fracture patients and evidence of baseline and pre-injury sex differences which may affect eventual recovery one year later.

Genotype, resilience and function and physical activity post hip fracture

BACKGROUND

Individuals who are resilient are more likely to engage in functional tasks and exercise post hip fracture. There may be a genetic predisposition to being resilient.

OBJECTIVES

This study tested the direct and indirect association of 10 candidate genes, age, cognition, gender, comorbidities, pain and social activity on resilience, function and exercise post hip fracture.

METHOD

This was a descriptive study including 172 community dwelling older adults. Measures included: age, gender, cognition (Modified Mini Mental Status Exam), comorbidities, social activities (self-report), DNA (GRM1, NTRK1, NTRK2, GNB3, NPY, SLC6A15. SLC6A4, BDNF, CR1TR1, FKBP5), pain (areas of pain and Numeric Rating Scale), function (Physical and Instrumental Activities of Daily Living; Lower Extremity Gains Score; Short Physical Performance Battery; Grip Strength) and exercise (Yale Physical Activity Scale).

RESULTS

The majority of participants were Caucasian (93%), 50% were women and the average age was 81.09 (SD = 7.42). There were significant associations between resilience and single nucleotide polymorphisms from GRM1, NTRK1, NTRK2, GNB3, NPY and SLC6A15. Resilience, age, cognition, social activity, pain and genetic variability were directly and/or indirectly associated with exercise and/or function.

DISCUSSION

This study highlights the importance of resilience for engagement in exercise and function after hip fracture and provides preliminary evidence for a genetic role for resilience.

Influence of Maximal or Submaximal Effort on the Load Distribution of the Hand Analyzed by Manugraphy

PURPOSE

This study aims to investigate if the hands' load-distribution pattern differs during maximal and submaximal grip.

METHODS

Fifty-four healthy subjects used the 200-mm Manugraphy cylinder to assess the load-distribution pattern of both hands. On 2 testing days, the subjects performed grip-force testing: 1 hand with maximal effort and the other with submaximal effort. Sides changed for the second testing day. The whole contact area of the hand was sectioned into 7 anatomical areas, and the percent contribution of each area, in relation to the total load applied, was calculated. Maximal and submaximal efforts were compared across the 7 areas in terms of load contributions.

RESULTS

Comparing maximum effort of the left and right hand, the load distribution was very similar without statistically significant differences between the corresponding areas. Comparing the maximal and the submaximal effort for each hand, 4 (left) and 5 (right) of the 7 corresponding areas showed statistically significant differences. Comparing the right hand, performing with maximal effort, with the left hand, performing with submaximal effort, 5 areas varied significantly. With the right hand performing submaximal effort, all 7 anatomical areas were significantly different.

CONCLUSIONS

The load distribution of a healthy hand is different when performing with submaximal effort compared with maximal effort. To analyze a hand's load-distribution pattern, the opposite hand can be used as a reference.

CLINICAL RELEVANCE

The hand's load-distribution pattern may be a useful indication of submaximal effort during grip-force testing.

The Takei Handheld Dynamometer: An Effective Clinical Outcome Measure Tool for Hand and Wrist Function in Boxing

BACKGROUND

The aim of this article was to explore retrospectively the Takei dynamometer as a valid and reliable outcome measure tool for hand and wrist pathology in the Great Britain amateur boxing squad between 2010 and 2014.

METHODS

Longitudinal retrospective injury surveillance of the Great Britain boxing squad was performed from 2010 to 2014. The location, region affected, description, and duration of each injury were recorded by the team doctor and team physiotherapists. For each significant injury, we recorded hand grip scores using the Takei handheld dynamometer and compared the scores with baseline measures.

RESULTS

At the hand, fractures and dislocations were highly detected with an average difference of 40.2% ( P < .05) when comparing postinjury to baseline measures. At the wrist, carpometacarpal and carpal joint injuries were highly detected with an average difference of 32.6% ( P < .05). Other injuries provided varied results. In the absence of pathology, up to 15% difference between left and right scores can be considered normal with a predominance observed below 10%. A difference of 20% can be indicative of a form of pathology, although pathologies can also be present with lower difference or no apparent changes. A difference of >20% should be highly considered for significant pathology.

CONCLUSIONS

The Takei dynamometer is a valid and reliable outcome measure tool for hand and wrist pathologies in boxing. Our study highlights the importance of appropriate clinical tools to guide injury management in this sport.

Baseline characteristics of participants in the VITamin D and OmegA-3 TriaL (VITAL): Effects on Bone Structure and Architecture

Vitamin D supplements are often used to benefit skeletal health, although data on effects of daily high-dose vitamin D alone on bone density and structure are lacking. The ongoing VITamin D and OmegA-3 TriaL (VITAL) is a double-blind, randomized, placebo-controlled trial testing effects of high-dose supplemental vitamin D3 (cholecalciferol; 2000 IU/day) and/or omega-3 fatty acids (FAs; 1 g/day) for the primary prevention of cancer and cardiovascular disease. The study has a mean treatment period of 5 years among 25,874 U.S. men ≥50 years and women ≥55 years old from all 50 states. The ancillary study, VITAL: Effects on Bone Structure and Architecture, is testing effects of vitamin D3 and/or omega-3 FAs on musculoskeletal outcomes and body composition in a subcohort of 771 participants. At in-person visits at the Harvard Catalyst Clinical and Translational Science Center (CTSC), participants completed bone density/architecture, body composition, and physical performance assessments at baseline and two-year follow-up. Baseline characteristics were evenly distributed among treatment groups, suggesting that any uninvestigated confounders will be evenly distributed; sex differences were also analyzed. Future analyses of the two-year follow-up visits will elucidate whether daily high-dose, supplemental vitamin D3 and/or omega-3 FAs improve musculoskeletal outcomes, helping to advance clinical and public health recommendations.

CLINICAL TRIAL REGISTRATION NUMBER

NCT01747447.

The impact of body composition, pain and resilience on physical activity, physical function and physical performance at 2 months post hip fracture

The purpose of this study was to test a model of the factors influencing physical activity, physical function and physical performance at 2 months post hip fracture and compare model fit between men and women. Age, cognitive status, comorbidities, pain, resilience, bone mineral density, total body lean mass, total body fat and grip strength were hypothesized to be directly and/or indirectly related to physical activity, physical function and physical performance. This analysis used data from the seventh Baltimore Hip Studies (BHS-7), a prospective cohort study that included 258 community-dwelling participants, 125 (48%) men and 133 (52%) women, hospitalized for treatment of a hip fracture; survey and objective data were obtained at 2 months post hip fracture. In addition to age, sex and comorbidities (modified Charlson scale), data collection included body composition from dual-energy x-ray absorptiometry (DXA) scans, grip strength, and physical activity, function and performance based on the Yale Physical Activity Survey, the Short Physical Performance Battery and the Lower Extremity Gain Scale. Age, cognition, and comorbidities were not significantly associated with resilience; and, resilience was not associated with pain. In addition, bone mineral density was not associated with physical activity, physical performance or physical function. Total lean body mass, resilience and pain were associated with physical activity, physical function and physical performance in women, but were not consistently associated with physical and functional outcomes in men. Future research should consider evaluation of muscle quality and additional psychosocial factors (e.g., depression, social supports) in model testing.

[Grip strength measurement : Significance and boundaries]

BACKGROUND

Grip strength measurement is a widely used method for clinical as well as scientific purposes. In hand surgery, it is an essential component in the diagnosis of disease, treatment sequences and assessment. In epidemiological studies, it is a good predictor of healthy ageing or disease progression.

PROBLEM

Measurement results and their interpretation can be influenced by many factors. The historical development of dynamometry, measurement technology and the standard values in various population groups are presented. Comparisons with standard values should only be made using current tables because the grip strength has changed in recent decades. Assessment of the voluntarily submaximal grip strength remains problematic. Proposals are made for how to assess grip strength during the evaluation.

Why averaging multiple MUNIX measures in the longitudinal assessment of patients with ALS?

OBJECTIVE

To assess the impact of averaging multiple MUNIX trials on the follow-up of patients with amyotrophic lateral sclerosis (ALS).

METHODS

We determined the percent relative change (%RC) of MUNIX, in healthy subjects and patients with ALS, by subtracting the MUNIX value in the second visit from the first. Both the mean of a set of three MUNIX (mean-MUNIX) and the first MUNIX sample (single-MUNIX) were evaluated. Then, we studied the sensitivity to detect relative changes over time and the statistical dispersion of the %RC from these two parameters.

RESULTS

We found that the mean-MUNIX %RC has lower mean coefficient of variation than the single-MUNIX %RC in all muscles. The mean-MUNIX also resulted in more ALS patients with significant %RC, i.e., outside reference limits.

CONCLUSION

The mean-MUNIX resulted in less dispersed values of %RC in patients with ALS and thus, increased the precision of the technique. The mean-MUNIX resulted also in an increase in the sensitivity to track changes over time in these patients.

SIGNIFICANCE

The mean-MUNIX should be considered in any ALS follow-up study as a more reliable approach and as a way of potentially reducing the sample size needed for the study.

Determining Sincerity of Effort Based on Grip Strength Test in Three Wrist Positions

Background

Several grip strength tests are commonly used for detecting sincerity of effort. However, there is still no widely accepted standardized sincerity of effort test. Therefore, this study aimed to examine whether grip strength test in three wrist positions could distinguish between maximal and submaximal efforts.

Methods

Twenty healthy individuals (10 men and 10 women) with a mean age of 26.7 ± 3.92 years participated in this study. All participants completed two test conditions (maximal and submaximal efforts) in three wrist positions (neutral, flexion, and extension) using both hands. Each participant exerted 100% effort in the maximal effort condition and 50% effort in the submaximal effort condition. The participants performed three repetitions of the grip strength test for each session.

Results

The results showed that there is a significant main effect of the type of effort (p < 0.001), wrist position (p < 0.001), and hand (p = 0.028). There were also significant types of effort and wrist position interactions (p < 0.001) and effort and hand interactions (p < 0.028). The results also showed that grip strength was highest at the wrist in neutral position in both the maximal and the submaximal effort condition. Grip strength values of the three wrist positions in the maximal effort condition were noticeably greater than those in the submaximal effort condition.

Conclusion

The findings of this study suggest that grip strength test in three wrist positions can differentiate a maximal effort from a submaximal effort. Thus, this test could potentially be used to detect sincerity of effort in clinical setting.

Fragment-Specific Fixation Versus Volar Locking Plates in Primarily Nonreducible or Secondarily Redisplaced Distal Radius Fractures: A Randomized Controlled Study

PURPOSE

To compare the patient-reported, clinical, and radiographic outcome of 2 methods of internal fixation in distal radius fractures.

METHODS

Fifty patients, mean age 56 years (range, 21-69 years) with primarily nonreducible or secondarily redisplaced distal radius fractures were randomized to open reduction internal fixation using volar locking plates (n = 25) or fragment-specific fixation (n = 25). The patients were assessed on grip strength, range of motion, patient-reported outcome (Quick Disabilities of the Arm, Shoulder, and Hand), pain (visual analog scale), health-related quality of life (Short Form-12 [SF-12]), and radiographic evaluation. Grip strength at 12 months was the primary outcome measure.

RESULTS

At 12 months, no difference was found in grip strength, which was 90% of the uninjured side in the volar plate group and 87% in the fragment-specific fixation group. No differences were found in range of motion and the median Quick Disabilities of the Arm, Shoulder, and Hand score was 5 in both groups. The overall complication rate was significant, 21% in the volar locking plate group, compared with 52% in the fragment-specific group.

CONCLUSIONS

In treatment of primarily nonreducible or secondarily redisplaced distal radius fractures, volar locking plates and fragment-specific fixation both achieve good and similar patient-reported outcomes, although more complications were recorded in the fragment-specific group.

TYPE OF STUDY/LEVEL OF EVIDENCE

Therapeutic II.

Assessment following Hand Trauma: A Review of some Commonly Employed Methods

Accurate assessment strategies underpin appropriate implementation and review of surgical and therapeutic intervention. This paper explores some of the commonly described assessment methods used following hand injury, including measures of range of motion (ROM), strength, sensation, hand function and patient self-evaluation. The strengths and limitations of some methods are discussed. It is suggested that accurate assessment tools and standardised approaches to assessment will promote effective evaluation of intervention. In addition long-term review and comparative studies may be facilitated by such an approach.

What can Handgrip Strength tell the Therapist about Hand Function?

Power handgrip strength is recorded by clinicians as a quick and viable measure of hand impairment and function that can serve as a useful evaluation of hand status and treatment progress. This paper explores the procedure and reliability of measuring handgrip using different equipment. The extent of usefulness of grip strength as an indicator of structural impairment and ability measures in patient populations is questioned and the relevance of recording grip strength as part of a clinical assessment is summarised.

Measurement of Function Post Hip Fracture: Testing a Comprehensive Measurement Model of Physical Function

BACKGROUND

Measurement of physical function post hip fracture has been conceptualized using multiple different measures.

PURPOSE

This study tested a comprehensive measurement model of physical function.

DESIGN

This was a descriptive secondary data analysis including 168 men and 171 women post hip fracture.

METHODS

Using structural equation modeling, a measurement model of physical function which included grip strength, activities of daily living, instrumental activities of daily living, and performance was tested for fit at 2 and 12 months post hip fracture, and among male and female participants. Validity of the measurement model of physical function was evaluated based on how well the model explained physical activity, exercise, and social activities post hip fracture.

FINDINGS

The measurement model of physical function fit the data. The amount of variance the model or individual factors of the model explained varied depending on the activity.

CONCLUSION

Decisions about the ideal way in which to measure physical function should be based on outcomes considered and participants.

CLINICAL RELEVANCE

The measurement model of physical function is a reliable and valid method to comprehensively measure physical function across the hip fracture recovery trajectory.

A study of grip strength among 20–49-year-old British adults and comparison to existing norms

Introduction

Hand grip strength is frequently assessed to evaluate interventions or guide treatment. When using calibrated equipment in a standardised method, hand-held dynamometry is a reliable measure for hand grip strength and can be compared to normative data. However, existing British grip strength normative data were published 20 years ago.

Methods

A non-experimental quantitative study was carried out to establish if existing UK hand grip norms and consolidated multinational norms were representative of today’s 20–49-year-old British adult population. The methodology used was modelled on a previous British study using the mean Jamar dynamometer maximal grip strengths and reported within age bands.

Results

A total of 135 healthy British citizens of various ethnicities between 20 and 49 years were recruited. Grip strength is decreased in comparison to the existing British normative data for both males and females in all age bands. A significant difference exists ( p < 0.05) for male right hand aged 40–44 years and right and left hands for women 25–29 years and 45–49 years, respectively. Significant differences were also noted in 5 and 8 of the 12 multinational means for men and women respectively.

Conclusions

Due to small sample size, the ability of this study to demonstrate a significant difference in mean grip strength to the earlier British norms is low. However, a small increase in sample size may have resulted in further significant differences with both studies. A larger study, taking into consideration ethnicity, is recommended to ensure valid and reliable grip strength norms are used in practice.

Grip strength measured by high precision dynamometry in healthy subjects from 5 to 80 years

BACKGROUND

Grip strength is a variable which may be important to measure and follow in various populations. A new dynamometer with high accuracy and sensitivity has recently been developed to assess grip strength. The objectives of this work were to provide norms of maximal isometric grip strength measured with this new dynamometer (the MyoGrip device), to assess the reliability of measurements, to compare the measurements obtained with MyoGrip and Jamar dynamometers and finally to establish predictive equations from a population of healthy subjects (children and adults).

METHODS

Measurements of maximal isometric grip strength using the MyoGrip and the Jamar (which is considered as the gold-standard) were performed on 346 healthy subjects aged from 5 to 80 years. Test-retest reliability for both devices was assessed on 77 subjects. Predictive equations were computed on subjects younger than 60 years of age in order to avoid the effects of aging on strength.

RESULTS

This study provides norms for isometric grip strength for health subjects from 5 to 80 years. Reliability of the MyoGrip device was excellent (intraclass correlation coefficient: 0.967). Despite good correlation between devices, the Jamar tended to overestimate maximal grip strength by about 14 %. A single predictive equation for men and women, adults and children incorporating hand circumference only can be used to compute the predicted theoretical maximal grip strength.

CONCLUSIONS

The MyoGrip device is a reliable tool for measuring isometric grip strength. Owing to its unique metrological features, it can be used in very weak patients or in any situation where high precision and accuracy are required.

Psychotropic medication use and association with physical and psychosocial outcomes in nursing home residents

Psychotropic medications are commonly prescribed for older adults living in long-term care settings. Use of these medications has been associated with negative functional outcomes. The purpose of this study was to describe the prevalence of psychotropic medication use among nursing home residents, and to explore the relationship of psychotropic medication use on physical and psychosocial outcomes. A secondary data analysis was done using baseline measures from the Res-Care Intervention Study. The sample included 419 residents from 12 nursing homes. There were 288 participants (69%) who were prescribed at least one psychotropic medication, with 81 participants (19%) receiving antipsychotics, 248 (59%) receiving antidepressants, 50 (12%) receiving anxiolytics and 37 (9%) receiving sedative/hypnotics. Controlling for gender, age and cognition, physical outcomes were significantly lower in residents receiving psychotropic medications (F= 3.2, P= 0.01) compared to those not receiving psychotropic medications. Psychosocial outcomes were significantly lower in those residents receiving psychotropic mediations (F= 2.0, P= 0.04). The findings from this study provide additional support for the prevalence of psychotropic medication use among nursing home residents and suggest that residents receiving psychotropic medications may be less likely to engage in functional activities and experience decreased quality of life.

Identifying sincerity of effort based on the combined predictive ability of multiple grip strength tests

STUDY DESIGN

Retrospective Cohort.

INTRODUCTION

Detecting sincerity of effort (SOE) of grip strength remains a frustrating and elusive task for hand therapists because there are no valid, reliable, or widely accepted assessments for identifying feigned effort. Some therapists use various combinations of different SOE tests in an attempt to identify feigned effort, but there is lack of evidence to support this practice.

PURPOSE

The present study examined the ability of a combination of three grip strength tests commonly used in the clinic to detect SOE: the five rung grip test, rapid exchange grip test, and coefficient of variation. A secondary purpose was to compare the predictive ability between the logistic and linear regression models.

METHODS

Healthy participants (n=146) performed the three SOE tests exerting both maximal and submaximal efforts. We compared the ability of two regression models, the logistic and linear models, to predict sincere versus insincere efforts.

RESULTS

Combining the three tests predicted SOE better than each test alone. Yet, the full logistic model, which was the best predictor of SOE, explained only 42% of variance and correctly classified only 58% of the efforts.

CONCLUSIONS

Our findings do not support the clinical practice of combining these three tests to detect SOE.

LEVEL OF EVIDENCE

Not applicable.

RELATIONSHIP OF IMPAIRMENT, DISABILITY AND WORKING STATUS AFTER RECONSTRUCTIVE SURGERY OF THE WRIST

The aim was to study the relationship between impairment (function) and disability (participation) in wrist surgery, according to the WHO definitions.

The outcome of 205 wrist operations were studied. The impairment was expressed as range of motion (ROM) and gripping force, the disability as the DASH score.

There was a significant correlation between DASH and gripping force (R = 0.47). The correlation between ROM and DASH was weaker (R = 0.24).

In manual workers, shorter temporary disability periods were significantly associated with lower DASH score.

In (reconstructive) wrist surgery, impairment, disability and working status are significantly correlated. Gripping force measurement is a reliable tool for evaluation and gives a good impression of the disability. Preservation of some mobility is important, however the amount of ROM is not essential for the disability.

Teste de força de preensão manual: análise metodológica e dados normativos em atletas

INTRODUÇÃO: Diferentes modalidades esportivas utilizam as mãos como importante seguimento corporal envolvido para o desempenho. Entre essas modalidades destacam-se judô, tênis, vela, remo, boxe, levantamento de peso e outras. A força de preensão manual é exigida nessas modalidades específicas, em que o nível de força gerado pode ser o diferencial no desempenho final. A dinamometria manual é um valioso instrumento a ser utilizado na detecção do talento esportivo, no controle do treinamento e na avaliação de recuperação de lesão. OBJETIVOS: O objetivo deste estudo é fazer uma revisão sobre os principais aspectos metodológicos envolvidos na mensuração da força de preensão manual, utilizando o dinamômetro Jamar®, identificando os aspectos relacionados à validade, confiabilidade, precisão, posição para realização do teste, posição da alça, instruções, número de medidas, período de descanso entre as tentativas, duração do tempo de contração, aquecimento pré-teste. MATERIAIS E MÉTODOS: Foi realizado um levantamento para compor uma base de dados de diferentes modalidades olímpicas: coletivas e individuais. Foi realizada uma pesquisa eletrônica da literatura utilizando as bases de dados MEDLINE, SciELO e LILACS, sendo utilizados os seguintes descritores: força de preensão manual, dinamometria manual e, em inglês, hand, grip, strength, dynamometer, Jamar, norms e reference values. CONCLUSÃO: Os valores de força de preensão manual apresentados pelos atletas diferem de acordo com a modalidade, sexo, peso corporal, nível do atleta, idade e tipo de treinamento. A força de preensão manual deve estar presente nas baterias de testes para identificação de possíveis talentos esportivos.

The Impact of Anemia on Nursing Home Residents

The purpose of this secondary data analysis was to describe the prevalence and treatment of anemia and test the impact of anemia on physical and psychosocial outcomes at baseline and following restorative care interventions. A total of 451 residents from 12 nursing homes participated in this study. The average age of the participants was 83.74 ( SD = 8.24), the majority were female (79%), White (66%), and unmarried (90%). A total of 245 (54%) residents were anemic, and 66% were treated with at least one medication. Physical performance was worse in those with anemia, and those with anemia associated with chronic kidney disease had lower self-efficacy and outcome expectations for functional activities than those without anemia. There was no time by treatment interaction between those with and without anemia. The findings provide some additional support for the prevalence of anemia and suggest that those with anemia associated with chronic kidney disease are less motivated to engage in functional activities.

Nursing home resident outcomes from the Res-Care intervention

OBJECTIVES

To test the effectiveness of a restorative care (Res-Care) intervention on function, muscle strength, contractures, and quality of life of nursing home residents, with secondary aims focused on strengthening self-efficacy and outcome expectations.

DESIGN

A randomized controlled repeated-measure design was used, and generalized estimating equations were used to evaluate status at baseline and 4 and 12 months after initiation of the Res-Care intervention.

SETTING

Twelve nursing homes in Maryland.

PARTICIPANTS

Four hundred eighty-seven residents consented and were eligible: 256 from treatment sites and 231 from control sites. The majority were female (389, 80.1%) and white (325, 66.8%); 85 (17.4%) were married and the remaining widowed, single, or divorced/separated. Mean age was 83.8 +/- 8.2, and mean Mini-Mental State Examination score was 20.4 +/- 5.3.

INTERVENTION

Res-Care was a two-tiered self-efficacy-based intervention focused on motivating nursing assistants and residents to engage in functional and physical activities.

MEASUREMENTS

Barthel Index, Tinetti Gait and Balance, grip strength, Dementia Quality-of-Life Scale, self-efficacy, and Outcome Expectations Scales for Function.

RESULTS

Significant treatment-by-time interactions (P<.05) were found for the Tinetti Mobility Score and its gait and balance subscores and for walking, bathing, and stair climbing.

CONCLUSION

The findings provide some evidence for the utility and safety of a Res-Care intervention in terms of improving function in NH residents.

Ultrasound evaluation in combination with finger extension force measurements of the forearm musculus extensor digitorum communis in healthy subjects

Background

The aim of this study was to evaluate the usefulness of an ultrasound-based method of examining extensor muscle architecture, especially the parameters important for force development. This paper presents the combination of two non-invasive methods for studying the extensor muscle architecture using ultrasound simultaneously with finger extension force measurements.

Methods

M. extensor digitorum communis (EDC) was examined in 40 healthy subjects, 20 women and 20 men, aged 35–73 years. Ultrasound measurements were made in a relaxed position of the hand as well as in full contraction. Muscle cross-sectional area (CSA), pennation angle and contraction patterns were measured with ultrasound, and muscle volume and fascicle length were also estimated. Finger extension force was measured using a newly developed finger force measurement device.

Results

The following muscle parameters were determined: CSA, circumference, thickness, pennation angles and changes in shape of the muscle CSA. The mean EDC volume in men was 28.3 cm³ and in women 16.6 cm³. The mean CSA was 2.54 cm² for men and 1.84 cm² for women. The mean pennation angle for men was 6.5° and for women 5.5°. The mean muscle thickness for men was 1.2 cm and for women 0.76 cm. The mean fascicle length for men was 7.3 cm and for women 5.0 cm. Significant differences were found between men and women regarding EDC volume (p < 0.001), CSA (p < 0.001), pennation angle (p < 0.05), muscle thickness (p < 0.001), fascicle length (p < 0.001) and finger force (p < 0.001). Changes in the shape of muscle architecture during contraction were more pronounced in men than women (p < 0.01). The mean finger extension force for men was 96.7 N and for women 39.6 N. Muscle parameters related to the extension force differed between men and women. For men the muscle volume and muscle CSA were related to extension force, while for women muscle thickness was related to the extension force.

Conclusion

Ultrasound is a useful tool for studying muscle architectures in EDC. Muscle parameters of importance for force development were identified. Knowledge concerning the correlation between muscle dynamics and force is of importance for the development of new hand training programmes and rehabilitation after surgery.

Evaluation of the torque-velocity test of the BTE-Primus as a measure of sincerity of effort of grip strength

An inverse linear relationship exists between torque and velocity in the mid-ranges of an isotonic maximal contraction in a single joint movement (such as the elbow and knee). We hypothesized that submaximal effort does not produce a linear torque-velocity relationship because replicating a submaximal isotonic contraction requires an enormous amount of proprioceptive feedback and the nervous system may not be able to accurately replicate both force and speed of contraction. If this hypothesis is true, the torque-velocity test of the BTE-Primus would be an effective method for assessing sincerity of effort. The purpose of this study was to examine if differences exist in the linear torque-velocity relationship between maximal and submaximal grip strength effort. Due to the fact that a test is not valid unless it is reliable, an additional purpose was to calculate the test-retest reliability of velocity during isotonic contraction using the torque-velocity test of the BTE-Primus' grip tool. Participants included 32 healthy, right-hand dominant (16 male, 16 female) persons, aged 20-50 years (mean age 25+/-8.0), with no history of upper-extremity injury. The subjects participated in two days of grip-strength testing (approximately two weeks apart) and were instructed to exert maximal effort with both hands on one day, and to feign injury with one hand on the other day. Each day included two sessions of testing, which consisted of performing the "torque-velocity test" on the BTE-Primus grip attachment (#162). We randomly assigned the feigning hand (dominant vs. nondominant) and the effort (maximal vs. submaximal). The test administrator was blinded to the level of effort. On each day, four isotonic grip-strength tests were performed at loads of 20%, 30%, 40%, and 50% of isometric test scores. Three repeated isotonic grip strength trials were performed at each load and the average was plotted. One plot was generated for the maximal effort and another for the submaximal efforts. Average torque was plotted against the average velocity at each of the four loads and for each level of effort (maximal vs. submaximal). The linear relationship of the torque-velocity curve was examined by performing regression analysis, calculating the intercept, slope, correlation coefficient (r), and the coefficient of determination (r(2)) for each curve. Paired t-tests were used to compare the intercept, slope, and r(2) between maximal and submaximal efforts. Bonferroni correction set the alpha level at 0.0167. Sensitivity and specificity values were calculated for linearity (r(2)) and a Receiver Operator Characteristic (ROC) curve was constructed to obtain the optimal sensitivity and specificity combination. In addition, test-retest reliability was determined for velocity of maximal isotonic effort using Intraclass Correlation Coefficient. Significant differences between maximal and submaximal efforts were found for the intercept (t=5.069; p<0.001) and for linearity as expressed by r(2) (t=5.414; p<0.001). Mean r(2) was 0.89 for maximal effort and 0.53 for submaximal effort. The slopes of maximal and submaximal efforts were not significantly different (t=0.14; p=0.888). The ROC curve revealed the optimal combination of sensitivity (0.69) and specificity (0.72) values. Test-retest reliability of maximal isotonic grip effort for velocity was r=0.843. The differences in intercepts suggested that velocity was greater during maximal effort. Greater r(2) values indicated greater linearity for maximal efforts than submaximal efforts. These findings suggest that the torque-velocity test of the BTE-Primus can distinguish between maximal and submaximal efforts during grip-strength testing. However, the test misclassified 31% of submaximal effort and 28% of maximal error, for a total error of 59%. Therefore, this test does not possess adequate sensitivity and specificity values to justify its use in the clinic.

Using the force-time curve to detect maximal grip strength effort

Currently, there are no universally accepted assessment methods for detecting insincere effort during grip strength testing. We examined the validity of the slopes of the force-time curve (during force-generation and force-decay phases) as indicative of sincerity of effort. Thirty healthy subjects performed both maximal and submaximal grip strength trials. The test administrator was blinded as to the nature of the effort. A force-time curve was generated for each individual trial. The slopes of the force-generation phase and the force-decay phase were calculated. Both slopes were significantly steeper for the maximal than the submaximal efforts (p</=0.0001). Sensitivity and specificity analyses revealed that the slope of the force-generation phase was a more effective assessment of sincerity of effort for women, whereas the slope of the force-decay phase was a more effective assessment for men. The most notable finding was that for the force-decay phase, for slope cutoff values of -0.75 and -1.0, none of the men who exerted maximal effort were mistakenly identified as exerting a submaximal effort, whereas only 7% of the men who exerted submaximal effort were incorrectly identified as exerting a maximal effort. Thus, the slopes of the force-time curve are valid and effective in detecting sincerity of effort in healthy subjects. This study represents the first step in establishing the feasibility and validity of a new sincerity of effort assessment using the slopes of the force-time curve. Future research is needed to establish the validity and effectiveness of this sincerity of effort assessment in people with hand injury.

Pilot Testing of the Restorative Care Intervention: Impact on Residents

The purpose of this pilot study was to test the feasibility and effectiveness of a two-tiered motivational intervention, the Res-Care Intervention, on nursing home residents. Twenty-one residents consented to participate in the study. The residents were 88.3 (+/- 4.9) years of age, had lived in the facility 1.6 (+/- 3.4) years, were women (93%), White (93%), and unmarried (85%). Although there were some positiv trends, there was not a statistically significant difference in any of the resident outcomes following implementation of the Res-Care Intervention. The findings have been used to revise the Res-Care Intervention to include additional education needs for the nursing assistants, revisions in the motivational intervention for the nursing assistants and nurses, clarification of documentation and motivational techniques to improve documentation, and implementation of a more comprehensive treatment fidelity plan.

Critical issues in the use of muscle testing for the determination of sincerity of effort

Over the past 20 years, there have been numerous attempts to identify methodologies that are capable of the determination of sincerity of effort during muscle testing. The ensuing paper reviewed this literature and drew several conclusions. Injured patients and healthy volunteers do produce less force and more variable force while performing submaximal contractions than maximal contractions. However, submaximal efforts during strength testing can be reproduced and the use of force variability is not adequate to distinguish sincerity of effort. Visual examination of the shape of force output curves is also not adequate for distinguishing sincerity of effort. Furthermore, much of the research using strength ratios, difference scores, and an assortment of different parameters derived during strength testing has not established reliable and clinically useful methods of differentiating effort levels. Methods examining motion variability, radial/ulnar force output ratios, difference scores of eccentric-concentric ratios, and electromyography offer some promise, but numerous critical issues need to addressed. The use of the coefficient of variation, for example, is statistically untenable given the number of trials appropriate for clinical samples. Several studies have inadequate sample size to number of variable ratios. Many studies have questionable or at least unknown generalizability to patient samples and actual functional capacity. It is critical that other explanatory variables such as fear of injury, pain, medications, work satisfaction, and other motivational factors be considered. It is our opinion that there is not sufficient empirical evidence to support the clinical application of muscle testing to determine sincerity of effort.

Effectiveness of the Five–Handle Position Grip Strength Test in Detecting Sincerity of Effort in Men and Women

OBJECTIVE

The five-handle position (five-rung) test is used to determine sincerity of effort of grip strength. However, there is a controversy in the literature concerning its validity and effectiveness. The purpose of the study was to investigate whether test results are affected by the amount of strength exerted by the gripping hand and to determine the test's effectiveness.

DESIGN

A total of 30 hand therapy patients performed the five-rung grip test both maximally and submaximally with both the injured and uninjured hands. The standard deviation across the five strength trials was used to measure the shape of the curve. Sensitivity and specificity values were calculated for each sex.

RESULTS

The repeated measures analyses of variance revealed that average strength and the standard deviation were greater for men than for women, for maximal effort than for submaximal effort, and for the injured hand in comparison with the healthy hand. The most optimal standard deviation cutoff value was 8.5 (sensitivity, 0.70; specificity, 0.83), and the proportional area under the receiver operator characteristic curve was greater for the men (89%) than for women (80%).

CONCLUSIONS

The shape of the curve generated by the five-rung test was strength dependent; thus, the test may yield biased results when assessing sincerity of effort in people with weakened hands. The five-rung test was less effective for women than for men. Thus, we recommend that the five-rung test not be used to detect sincerity of effort.

Simultaneous bilateral testing: validation of a new protocol to detect insincere effort during grip and pinch strength testing

The detection of feigned weakness in hand grip strength assessment is difficult. The authors review several proposed methods and their weaknesses. A comparison of unilateral testing and simultaneous bilateral testing with the Jamar dynamometer and the Baseline pinch gauge is demonstrated as a solution. An experiment involved 100 asymptomatic subjects who were tested twice, once under instructions to give a full effort and once under instructions to feign weakness. Seven statistical criteria of noncompliance were chosen. Defining noncompliance as failing two or more of the seven criteria, 99% of the instructed noncompliant subjects were correctly classified as noncompliant. No subjects were incorrectly classified as noncompliant during instructed compliant testing. Twelve subjects failed on a single criterion. On retesting, all but one were correctly classified. One subject in the instructed noncompliant group passed all criteria. Accuracy was 99.5%, including retesting of the 12 "gray-zone" subjects.

In-season physiological and biochemical status of reforestation workers

Tree-planting demands sustained high work-output and is associated with high injury rates but has not been characterized previously. Data were collected from 10 male planters after 19 +/- 5 (T1) and 37 +/- 5 days (T2) of planting. One severe infection and one knee strain injury were noted. Loads carried were 32% +/- 5% body mass and heart rates were between 60% to 75% of maximum for 57% +/- 26% of the planting shift. A loss of 1.7% +/- 1.5% body mass occurred, although intake exceeded 5000 kcal/day. From 8% (T1) to 27% (T2) of postprandial blood glucose samples were found to be < 3.3 mmol/L. Further evidence of the cumulative stress was seen in increased levels of resting cortisol (428 +/- 163 to 741 +/- 103 mmol/L), norepinephrine (2.09 +/- 1.34 to 3.09 +/- 1.05 mmol/L), and creatine kinase (184 +/- 82 to 397 +/- 174 U/L) at T2. The postactivity neutrophilia and lymphophilia (absolute count, CD4+ and CD8+) observed at T1 were blunted at T2. The implications of mild hypoglycemia, including possible effects on cognitive and motor function, warrant further study.

How do therapists administer the rapid exchange grip test? A survey

The rapid exchange grip (REG) test is one of many methods devised to detect insincere grip strength efforts. Studies investigating the REG test have used different testing protocols and different interpretation criteria for what constitutes a sincere effort. Since therapists get information about evaluation tools from the literature, inconsistencies among researchers may lead to a lack of standardization in the administration of the REG test among therapists. The purpose of the study was to survey therapists to determine what protocol they follow during REG test administration and how they interpret the REG test results. Fourteen therapists working in hand clinics completed the survey. The ways in which the therapists administered the REG test varied widely. Differences among therapists in administering the REG test included the position of the patient, the handling of the dynamometer, the number of repetitions, the hand switch rate, and the comparative test used to interpret the REG test. On the basis of these results, we concluded that the REG test does not meet the most basic testing and measurement criteria. This may impede the ability of therapists to report the outcomes of the REG test accurately and correctly. The implications for the profession due to the lack of standardization of the REG test are discussed.

The coefficient of variation as a measure of sincerity of effort of grip strength, Part I: the statistical principle

The coefficient of variation (CV) is a widely used measure of sincerity of effort of grip strength despite contradictory research findings and lack of empirical support in the literature. The purpose of this study was to investigate whether the CV is an appropriate measure of sincerity of effort. One hundred forty-six uninjured volunteers underwent a series of grip strength tests. The mean, standard deviation (SD), and CV of repeated strength trials were calculated, and paired comparisons were conducted between maximal and submaximal efforts. While the mean of maximal trials was significantly greater, there were no differences in SD between maximal and submaximal trials. Therefore, the increased CV associated with submaximal effort was an artifact of reduced torque rather than an indicator of a true increase in variability. Consequently, the CV is not an appropriate measure of sincerity of effort of grip strength.

The coefficient of variation as a measure of sincerity of effort of grip strength, Part II: sensitivity and specificity

The coefficient of variation (CV) is commonly used to detect sincerity of effort. The purpose of this study was to examine whether the CV possessed adequate sensitivity and specificity to effectively detect sincerity of effort of grip strength. One hundred forty-six uninjured volunteers underwent a series of grip strength tests. Sensitivity and specificity values were calculated for various CV cut-off values (between 2.5% and 22%) of the static grip test. The receiver operating characteristic (ROC) curves based on these values demonstrated the trade-offs between specificity and sensitivity. For example, the "traditional" 15% cut-off value yielded poor sensitivity (0.55), whereas the 11% cut-off value yielded poor specificity (0.74). Selecting any cut-off value along the continuum did not provide adequate sensitivity or specificity for labeling an effort sincere or insincere. Although the CV differentiated between maximal and submaximal effort, it was not sensitive or specific enough to do so effectively. Thus, the CV should not be used to assess sincerity of effort of grip strength.

Rapid repeat testing of grip strength for detection of faked hand weakness

This study assessed the use of rapid, repeated measurement of grip strength to detect feigned hand weakness. Normal participants, performing with maximum effort or feigning hand weakness, and patients recovering from carpal tunnel surgery were asked to grip a Jamar dynamometer alternately with each hand on ten occasions. The results showed that grip strength fatigued by an average of 23% during the test in the normal participants, 18% in participants faking weakness, and increased by 2% in the carpal tunnel decompression patients. An increase in grip strength after the first effort was found in 39% of normal participants, 52% of participants faking hand weakness and in 69% of the carpal tunnel decompression patients. These results suggest that rapid, repeated measurement of grip strength is not a reliable discriminator of true and faked hand weakness.

The use of the rapid exchange grip test in detecting sincerity of effort, Part I: administration of the test

A review of studies that utilize the rapid exchange grip (REG) test revealed that there is no standardized test protocol for administering the test. The purpose of this study was to investigate three factors that affect the result of the REG test: the hand switch rate, the number of grips performed during the test, and the comparative tests used in the interpretation of the REG test. The 146 uninjured subjects performed a series of randomized grip strength tests including the REG test, the maximal static grip test (MSGT), and the five-rung (5R) test while making maximal and submaximal efforts. Results revealed no significant differences in peak REG scores between hand switch rates of 45 and 60 rpm. Significant differences were found for peak REG scores obtained from three vs. five trials. Peak scores from the 5R test vs. the MSGT differed significantly for maximal efforts but not for submaximal efforts. These results led to the following recommendations for a standardized protocol for administering the REG test: 1) the REG maneuver may be administered at a rate of either 45 or 60 rpm; 2) at least five hand-grip exchanges must be performed; and 3) only one comparative test, either the MSGT or the 5R test, should be used consistently for comparison with the REG maneuver. The findings of the present study, however, did not verify which static grip test should be used for comparison with REG scores.

The use of the rapid exchange grip test in detecting sincerity of effort, Part II: validity of the test

The rapid exchange grip (REG) test was developed to identify patients exerting insincere effort. The premise of the REG test is that a maximal, sincere effort yields a "negative REG," in which peak static grip (SG) scores are greater than peak REG scores, and that a submaximal, insincere effort yields a "positive REG," in which REG scores are greater than SG scores. There is disagreement in the literature concerning what constitutes a positive REG test, suggesting that the REG may not be a valid measure of sincerity of effort. The purpose of the present study was to investigate the validity of the REG test by examining its premise as well as its sensitivity and specificity values. The 146 uninjured subjects performed a series of randomized grip strength tests, exerting both maximal and submaximal efforts. The tests included the REG at hand switch rates of 45 rpm (REG-45) and 60 rpm (REG-60), the maximal static grip test (MSGT), and the five-rung test (5R). Our findings supported the concept of a "negative REG" for both REG maneuvers and both comparative SG tests. The concept of a "positive REG," however, was supported only when peak REG scores were compared with peak 5R scores. The authors found relatively low sensitivity and specificity values, suggesting that the REG test may not be sensitive or specific enough to effectively detect sincerity of effort. The authors discuss the likelihood that mistakes will be made when the REG test is used to diagnose sincerity of effort and the possible consequences of making such mistakes.