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Getting a Grip! Handgrip Strength Examination for Malnourished Populations

DPG Spotlight

www.cnmdpg.org

Barbara Lusk, MFCS. RD, LDN, FAND

Chair 2017-2018

Disclosures

• Instructor & Master’s Program Coordinator

⎻ Graduate Programs in Human Nutrition at OHSU

• Nutrition-Focused Physical Exam Trainer

⎻ Academy of Nutrition and Dietetics

• Speaker has no relationship to manufacturer or vendor of dynamometry equipment

Julie McGuire, MS, RDN, LD Clinical Nutrition Management Dietetic Practice Group Spotlight

Disclosures

• Regional Clinical Nutrition Manager

⎻ Providence Health and Services, Oregon

• Chair-Elect

⎻ Clinical Nutrition Management Dietetic Practice Group of the Academy of Nutrition and Dietetics

• Owner

⎻ MySurgeryPlate LLC

• Consultant

⎻ Nasco

• Author

⎻ Nutrition Dimension

• Speaker Bureau

⎻ Nestle Health Science

⎻ Nutricia North America, Inc.

• Speaker has no relationship to manufacturer or vendor of dynamometry equipment

Terese Scollard, MBA, RDN, LD, FAND Clinical Nutrition Management Dietetic Practice Group Spotlight

Learning Outcomes

• Gain insight into the history and applications of handgrip strength measurement as both a clinical and research instrument, which supplies relevant clinical information and brings value in evaluation of individuals and populations at risk of malnutrition and sarcopenia.

• Apply handgrip strength examination methodology and assessment in clinical practice as a functional measurement of a nutrition diagnosis of protein-calorie malnutrition and of sarcopenia.

• Learn the correct methodology, patient and examiner positions, practice basics as seated and documentation of results; provide access to resources that support such competency training to other RDNs at their own worksites.

Agenda

Handgrip strength, muscle function and malnutrition

Applications in practice including methodology

Demonstration and practice

Resources and questions

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How do dietitians assess muscle mass and function? And why is it important?

Muscle Function

Handgrip strength

Knee flexion/extension

Peak expiratory flow

Gait speed

Timed get-up-and-go test

Stair climb power test

Short physical performance battery

Muscle Mass

BIA

DEXA

CT

MRI

MUAC

Palpation

Visual inspection

Russell Nutr Clin Pract 2015 30 211-218 Choi Korean J Intern Med 2016 31 1054-1060 Peterson and Braunschweig Nutr Clin Pract 2016 31 40-48 Prado et al. Clin Nutr 2012 31 583-601

Clinical Outcomes

• Frequent readmissions

• Longer lengths of stay

• Increased morbidity

• Increased mortality

Physical Dysfunction

• Risk of falls

• Fractures

• Disability

• Loss of independence

Immune Dysfunction

• Risk of infection

• More complications

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Bigaard 2004 Obesity Research 12 1042-1048 Prado et al. 2012 Clin Nutr 31 583-601 Peterson and Braunschweig 2016 Nutrition in Clinical Practice 31 40-48

Prado et al. 2016 Proc Nutr Soc 75 188-198

Handgrip Strength When & Why

Handgrip Strength

Assessment

Upper limb impairment

Work capacity

after injury

Efficacy of treatments

Functional status

Overall fitness

assessment

Evaluation of other

impairments

Innes 1999 Aust Occup Ther J 46 120-140 Roberts et al. 2011 Age Ageing 40 423-429

Russell 2015 Nutr Clin Pract 30 211-218

Dynamometers

Roberts et al. 2011 Age Ageing 40 423-429

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Age

Handedness

Gender

Illness Innes Aust Occup Ther J 1999 46 120-140 Nicolay and Walker International Journal of Industrial Ergonomics 2005 35 605-618 Norman et al. Clin Nutr 2010 29 586-91 Russell Nutr Clin Pract 2015 30 211-842 Image: 2011 Pearson Education; accessed at https://classconnection.s3.amazonaws.com/754/flashcards/566754/png/50.291320964532138.png

Norman 2011 Clin Nutr 30 135-142 Russell et al. 1984 Am J Clin Nutr 39 503-513

Normal mosaic of type I and type II muscle fibers

Atrophy of type II fibers

Type I fibers Type II fibers

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Oumi 2001 Ultrastruc Pathol 25 431-436

Handgrip Strength Review of the Research

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At Look at the Research • Mendes et al 2014

Length of stay • Vaz et al 1996

• Turnbull et al 2002

• Matos et al 2007

• Norman et al 2010

• Norman et al 2011

• Garcia et al 2013

• Guerra et al 2013

• Flood et al 2014

Nutrition status

• Norman et al 2010

• Jakobsen et al 2010

• Kilgour et al 2013 Quality of life

• Klidjian et al 1980

• Webb et al 1989

• Mahalakshmi et al 2004

• Alvares-da-Silva et al 2005

• Norman et al 2011

Post-op complications

• Norman et al 2011

• Peterson et al 2017 Disability

Image accessed at https://s-media-cache-ak0.pinimg.com/originals/7a/44/c6/7a44c6d66c1d8f3ca7c5f8bafdf06f4b.jpg

Handgrip Strength Characteristic of Malnutrition

White et al. J Acad Nutr Diet 2012 112 730-8

Malnutrition Weight loss

Inadequate energy intake

Loss of muscle mass

Loss of subcutaneous

fat

Fluid accumulation

Reduced handgrip strength

Characteristics of Malnutrition

White et al. J Acad Nutr Diet 2012 112 730-8

Handgrip Strength as a Characteristic of Malnutrition

Malnutrition in the Context of Acute Illness or Injury

Malnutrition in the Context of Chronic

Illness

Malnutrition in the Context of Social or

Environmental Circumstances

Non-severe (moderate)

malnutrition

Severe malnutrition

Non-severe (moderate)

malnutrition

Severe malnutrition

Non-severe (moderate)

malnutrition

Severe malnutrition

Reduced grip

strength

N/A Measurably reduced

N/A Measurably reduced

N/A Measurably reduced

White et al. J Acad Nutr Diet 2012 112 730-8

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Standard Deviations

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Normative Data European Working Group on Sarcopenia in Older People (EWGSOP)

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Cruz-Jentoft et al. Age and Aging 2010 39 412-423 European Working Group

• Men < 30 kg

• Women < 20 kg General

By BMI

Men Grip Strength Women Grip Strength

BMI ≤24 ≤ 29 kg BMI ≤ 23 ≤ 17 kg

BMI 24.1-26 ≤ 30 kg BMI 23.1-26 ≤ 17.3 kg

BMI 26.1-28 ≤ 30 kg BMI 26.1-29 ≤ 18 kg

BMI >28 ≤ 32 kg >29 ≤ 21 kg

Foundation for the National Institutes of Health Biomarkers Consortium (FNIH)

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Studenski el al. J Gerontol A Biol Sci Med Sci 2014 69 547-58

Piece of the Puzzle

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Handgrip Strength

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Handgrip Strength ASHT Methodology & Practice Applications

Potential Nutrition-Related Applications

Clinical

• Clinical characteristic of disease-related malnutrition

• Acute care

• Ambulatory care

• Outpatient

• Eating disorders

• Cancer

• Surgical

• Elderly

Research

• Elderly

• Eating disorders

• Cancer

• Athletics and sporting

• Disease

Health and wellness

• Senior wellness fairs

• Student athletes

• School-age

• Community health events

Tools and Preparation

• Supervisor approves competency

• Approved hand grip dynamometer and method

⎻ Digital (includes to the tenth decimal, easier visually)

⎻ Manual - dial face

• Facility engineering

• Calibrate annually

• Cleaning wipes

• Gloves if preferred

• Paper, calculator & writing instrument

• Facility approved forms

• Facility approved reference charts

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Performing the Exam

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http://pattersonmedical.com/ accessed 10/20/2016

Notch #2 Generally used unless really large hand where fingers wrap too far around grip

Note: make sure arrow on arc

of positioning piece points up

when moving inside handle.

Hand Position

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Grip set too far away for

small hand; fingers not

wrapped enough around grip

Grip set too close for large

hand; fingers wrapped too

far around grip

Hand Position Adjustments

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Most typical Setting #2: Keep set at #2 to avoid overusing screw setting

Setting #1: Rare for small hands

Setting #3: Rare for large hands

Adjustable screw setting

Hand Position Adjustments

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Control Panel

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1. Select ‘on’

2. Press ‘Select Test’ until screen shows L R (only need to set once with new machine - retains setting until changed or battery exchanged)

3. Press ‘# of Trials’ and set to ‘4’

4. Must press ‘test’ between each exchange of the hand to get new reading on that hand.

5. ‘Reset’ resets to LR-4 or whatever your select test defaults to (for next client)

Once you start testing, the upper left corner of screen will show where you are at in the test sequence - but this does not matter, since you are recording each result and calculating the mean by hand (not auto calculated)

• Determine pounds or kilograms

• Default setting is pounds (LB)

• Make sure use correct

reference chart for lbs or kg!

Pounds or Kilograms

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*Sample - created using Jamar® norms; alert level created by instructor, not part of original chart in norms that came with equipment

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Clinician Worksheet

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Sample Clinician Worksheet

Pt Age 76 Sex M Actual: Right Actual: Left Normal (lbs) “Alert” level (lbs)

Measure #1 (lbs) 29.2 26.3

Measure #2 (lbs) 26.5 25.4

Measure #3 (lbs) 22.2 24.7

R hand Mean (lbs) 65.7 23.7

L hand Mean (lbs) 55.0 21.0

Patient within Norm Y or N

Patient below “Alert”? Y or N

ASHT Ref: #12, p 4

Correct Arm Position

• Sitting straight up, arm at 90 degrees seated, and held at side

• Grip set to #2 position so hand fits towards top of grip with fingers wrapped

• Elbows not resting, although some references have allowed

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• Seated (chair or side of bed), feet on floor

• Arms not resting on chair arms

• Hips as far back in chair as possible, hips and knees positioned at approx. 90 degrees

• Arm adducted at side, elbow flexed to 90 degrees.

• Forearm in neutral position

• Shoulder adducted (small block held between upper arm and lateral chest)

• Remind to stay in position, breathe out during exam, and correct client as needed.

Positioning of Client

• Sit Straight up in bed as much as possible

• Same arm, shoulder position

Positioning in Bedridden Patient Common Arm Position Errors

• Throwing shoulder into the squeeze and holding breath

⎻ Instruct client to BREATH OUT to keep shoulder down.

• Arm migration during exam process

⎻ Toward mid-line

⎻ Pushing forward

⎻ Pushing outwards

• Examiner: Correct client

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Wrong patient arm position Correct patient arm position

Arm Position

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Client Examiner

Perform the exam; Record each reading on worksheet

1. Sum the 3 scores on RIGHT hand and divide by 3 to obtain the average (mean) for the right hand. Record the mean in the appropriate box on worksheet

2. Sum the 3 scores on LEFT hand and divide by 3 to obtain the average (mean) for the left hand. Record the mean in the appropriate box on worksheet

3. Locate the alert level on the reference ranges (Alert level is 2 SD below the mean for the corresponding age and gender)

4. Compare your patient’s score to that score on the chart. Is patient within the norm for age and sex? Record YES or NO

5. Is your patient less than the norm, i.e. below the alert level? Record YES or NO. Alert Level is an indication for a nutritional component of functional weakness

If patient can only be tested on one side or the other, obtain the mean for the side tested

The weaker the grip, the more below the reference mean

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Sample Clinician Worksheet

Pt Age 76 Sex M Actual: Right Actual: Left Normal (LBS) “Alert” level (LBS)

Measure #1 (lbs) 29.2 26.3

Measure #2 (lbs) 26.5 25.4

Measure #3 (lbs) 22.2 24.7

R hand Mean (lbs) 65.7 23.7

L hand Mean (lbs) 55.0 21.0

Patient within Norm Y or N

Patient below “Alert”? Y or N

26.0

25.5

Analyze Results in Setting of:

Nutrition assessment

Patient positioning

Correct methodology

Examiner positioning

Calibrated dynamometer Results Patient Mean Norm for age/sex

Right hand: sss, sss, sss pounds

Left hand: xxx, xxx, xxx Pounds

Right and left hand mean are beyond minus 2 Standard Deviations from the mean, and measurably reduced from normal for age and sex. Patient Position: Seated straight up in chair with elbows bent at 90-degrees. Patient agreed to examination Patient tolerated examination Also present for test: Spouse Jane. Comments: none XXXXX, RDN LD

Potential “results” chart note: Patient: ________ Date/time ______ Hand grip strength Examination Results

Example of Documentation: Results Reporting: “Measurably Reduced”

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In conjunction with patient 20 lb. weight loss (7% since May),

reduced intake of calories and protein to 60% of usual for last 3

months (average estimate 1200 calories/50 grams protein per

day), more than minus 2 SD below the mean for age and sex.

Data supports nutrition diagnosis of chronic severe protein-

calorie malnutrition…

Example Documentation

Patient hand grip strength test results: patient mean score is

measurably reduced and more than minus 2 SD below mean

for age and sex, indicating reduction in a measure of

functional status likely related to poor nutritional status…

Patient hand grip strength test results: Patient mean

score is within norm for age and sex…

Demonstration

Let’s Practice Groups of about 3

Your pencil/pen is your simulated dynamometer

Let’s Practice

• Rotate: Patient, Examiner, Spotter

• Examiner instruct patient

• Spotter monitor patient and examiner for positions, timing

• Exhale during grip exertion (to isolate the arm muscles)

• Practice exam and rapid exchange

⎻ Squeeze 3-5 seconds

⎻ Record (pretend) results for each hand

⎻ Do next hand, about 15 seconds between each hand

ASHT Script

• This test will tell me your maximum grip strength.

• Before each trial, I will ask you, ‘Are you ready?’ and then tell you ‘Go.’

• When I say ‘Go,’ grip as hard as you can until I say ‘Stop.’

• Stop immediately if you experience any unusual pain or discomfort at any point during the testing.

• Do you have any questions?

• Are you ready? ‘Go!’

• Then as the client begins to squeeze, the examiner should say: “Harder….harder….harder…. Relax.”

⎻ Assure correct positioning during exam.

⎻ After about 3 to 5 seconds of gripping (dial will drop off or digital will freeze)

Final Remarks

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Grip Strength Toolkit

• Member benefit

⎻ CNM DPG

⎻ DNS DPG

⎻ HA DPG

⎻ NDEP DPG

⎻ ON DPG

⎻ MNP DPG

• Toolkit includes

⎻ Readings

⎻ Webinar

⎻ Detailed Instructions

⎻ Normal tables, worksheet, competency forms and samples filled-out

⎻ Pattern for a simulated dynamometer and simulated readings

⎻ Sample results reporting and clinical analysis reporting

Clinical Pearls

• Grip strength is a useful clinical and objective measure to include as part of the clinical evaluation of muscle function in consideration of a nutrition diagnosis of protein-energy malnutrition

• Results are clinically meaningful when repeated measures using correct and repeated methodology are performed over time

• Clinical results should be interpreted in the context of a complete nutritional assessment by a registered dietitian nutritionist

• More experience and research is needed to gain more depth in applications specific to protein-calorie malnutrition and to various patient conditions

Practice Applications

Review your clinical programs for applicability of handgrip strength assessment

Figure out the nuts and blots of implementation • Purchasing a dynamometer • Staff training and competence • Reliable and reproducible documentation

Access resources including the Grip Strength Toolkit and research and review the literature, especially what pertains to your client population

Design a quality improvement project, collect data, publish what you find

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Your Questions? Thank you!