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BRIEF REPORT

Handgrip Strength in Cardiac

Rehabilitation
NORMATIVE VALUES, INTERACTION WITH PHYSICAL
FUNCTION, AND RESPONSE TO TRAINING

Alex Mroszczyk-McDonald, BS, Patrick D. Savage, MS, and Philip A. Ades, MD

■ PURPOSE: To determine normative values for handgrip (HG) strength at K E Y W O R D S

entry into cardiac rehabilitation (CR) and to examine the relationship
of HG strength with self-reported physical function and the response cardiac rehabilitation
of HG strength to exercise training.
handgrip
■ METHODS: HG strength was measured in 1,960 patients with coronary
heart disease. Other measures obtained included oxygen consumption/ physical function
unit time (peak VO2), body composition, physical function and
depression questionnaires, and assessment of comorbid conditions. strength
Subsequently, HG strength and other measures were obtained in 666
participants who completed 36 sessions of CR exercise training.
■ RESULTS: HG strength was significantly greater in men than in women
(40.6  10.1 kg vs 22.6  6.5 kg, P  .0001), but diminished with
age in both men and women from the third to the eight decade.
Factors most strongly correlated with HG strength were gender
(r2  0.40, P  .0001), height (r2  0.37, P  .0001), peak VO2
(r2  0.32, P  .0001), and age (r2  –0.23, P  .0001). Baseline HG
strength was correlated with physical function capacity in patients
older than 65 years but not in younger patients. Following CR, HG
strength increased overall by 4.6% in comparison with baseline
values (34.9  11.4 to 36.5  11.6 kg, P  .0001). For the entire From the Division of Cardiology,
cohort, the increase in HG strength was associated with an increase Department of Medicine, University of
in physical function score (P  .05). Vermont College of Medicine, Fletcher-
Allen Health Care, Burlington, Vermont.
■ CONCLUSIONS: In patients with coronary heart disease, HG strength Address correspondence to: Philip A.
decreases with age and is lower in women, patients with diabetes, Ades, MD, Cardiac Rehabilitation, 62
and patients with lower peak VO2. It remains to be determined Tilley Dr, Fletcher-Allen Health Care, S.
whether a training protocol that specifically focuses on increasing HG Burlington, VT 05482 (e-mail:Philip.
strength would have a greater impact on overall functional status. Ades@vtmednet.org).

Handgrip (HG) strength as an indicator of overall
strength provides insight into physical function status
as well as prognostic information.1–4 Normal values
for HG strength have been established in healthy
individuals by age groups and gender and demon-
strate a curvilinear relationship with strength peaking
in early adulthood, remaining fairly stable until the
fifth or sixth decade, and declining thereafter.5,6
Investigations have used HG strength to estimate
functional disability, particularly in elders.1,2,4,7
Although the presence of coronary heart disease
(CHD) can have a profound impact on physical func-
tion, especially in older patients,8 little data are avail-
able examining the value of HG strength as a predic-
tor of physical function.
Determinants of physical disability in patients with
CHD include measures of peak oxygen uptake (VO2),
strength, and mental depression.9 Previous studies
have demonstrated resistance training-related increas-
es in strength yield improvements in physical func-
tion status in elderly women with CHD.10 Yet, the
value of HG strength in predicting physical function

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JCRP2705_298-302 9/13/07 12:17 AM Page 299
has not been evaluated. Furthermore, normative val-
ues of HG strength are not available in patients with
CHD. The goals of this study are to determine nor-
mative values of HG strength for patients entering
cardiac rehabilitation (CR) and to determine whether
HG strength correlates with self-reported physical
function and peak VO2. In addition, HG strength was
remeasured after 3 months of CR and changes in HG
strength were correlated with changes in self-report-
ed physical function.
METHODS
HG strength was evaluated at entry into CR in 1,960
consecutive individuals between 1996 and 2006.
Participants were ambulatory and community
dwelling for a median of 33 days since their most
recent coronary events, which included coronary
artery bypass graft (CABG) surgery (n  763, 39%),
myocardial infarction (n  555, 28%), percutaneous
coronary intervention (n  365, 19%), heart failure
(n  67, 3%), stable angina treated medically (n  64,
3%), and others (n  146, 8%).
Before and after CR, HG strength was measured
using the dominant hand with the shoulder adducted
and neutrally rotated, elbow in 90 of flexion, and the
forearm and wrist neutrally positioned using a Jamar
HG strength dynamometer (Jamar, Bolingbrook,
Illinois). The average of 3 successive measures was
used as the HG strength value. Additional study mea-
sures included:
1. Symptom-limited treadmill testing using a modi-
fied-Balke protocol to fatigue or 2-mm or more
ST-segment depression on the electrocardiogram,
with collection of expired gases for determining
peak VO2.
2. Body weight (kg) and height (cm) measurements
using a digital Detecto scale and a stadiometer.
3. The Medical Outcomes Study Short-Form
Questionnaire (MOS-SF36), 11 a self-reported
Physical Function Questionnaire, which includes
10 questions to score perceived ability to per-
form physical activities ranging from heavy activ-
ities such as running and climbing several flights
of stairs to moderate and lower intensity activi-
ties such as dressing, bathing, and kneeling.
Patients describe whether they are limited a lot,
a little, or not at all. Scores range from 0 to100,
with a lower score indicating a lower functional
capacity.
4. The Geriatric Depression Questionnaire,12 with
scores ranging from 0 to 15, where a higher
number signifies more depressive symptoms.
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5. A calculated comorbidity score13 assessing the
presence of peripheral vascular disease, cere-
brovascular disease, chronic obstructive lung dis-
ease, or arthritis. If a comorbid condition was pre-
sent, it is quantified by severity as follows: 1  pre-
sent but not exercise limiting; 2  present and
affects exercise performance; and 3  exercise lim-
iting. A total score ranging from 0 to 12 was deter-
mined for each patient.
The CR training protocol14 included 36 hour-long
sessions of exercise over 3 months. Each session includ-
ed 25 minutes of treadmill walking, and 8 minutes each
of arm, cycling, and rowing ergometer. Exercise was
performed at an intensity of 70% to 85% of peak heart
rate measured at baseline exercise testing.
Resistance training was also performed 3 times
weekly and included 1 set of 10 repetitions of 6 exer-
cises (leg extension, leg curl, bench press, shoulder
press, lateral pull down, and bicep curl).13 Patients
undergoing CABG surgery did not begin resistance
training until 3 months after surgery. Patients who had
CABG surgery entered CR, a median of
44 days from the date of surgery, and thus performed
6 weeks of resistance training. Nonsurgical patients ini-
tiated resistance training within 2 weeks of commenc-
ing CR, completing 10 weeks of resistance training.
Statistical Analysis
Values are presented as means ( standard devia-
tion). Statistical analyses were performed using Stat
View 4.01 (Stat View 5.0.1, SAS Institute, Cary, North
Carolina, 1998). A level of significance of P  .05 was
used for hypothesis testing. Unpaired and paired
t tests provided data for between groups and within
group comparisons, respectively. Analysis of variance
for repeated measures was used with the Bonferroni/
Dunn procedure for post hoc analysis. Simple and
stepwise multiple regression analyses were used to
determine the factors that best explain the variance in
HG strength.
RESULTS
Patients had a mean age of 62  11 years, and 25%
were women (Table 1). HG strength was higher in
men than in women (40.6  10.1 vs 22.6  6.5 kg,
P  .0001), as was physical function score and peak
VO2 (Table 1).
For both genders, HG strength diminished from
the third to the eighth decade (Fig 1). Factors corre-
lated with HG strength were gender (r2  0.40),
height (r2  0.37), peak VO2 (r2  0.32), age
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T a b l e 1 • BASELINE DATA
Total Men Women P (men vs
Range (N  1,960) (n  1,479) (n  481) women)
Age, y 27–92 62  11 62  11 65  12 .0001
Weight, kg 42.7–175.3 86.4  18.4 90.3  17.1 74.4  16.9 .0001
Height, cm 139.7–195.6 172.2  9.4 176.0  6.9 161.0  6.6 .0001
Body mass index, kg/m2 15.2–58.9 29.0  5.5 29.1  5.2 28.7  6.2 .1
Waist, cm 63.5–157.5 101.6  14.2 104.1  13.2 94.0  14.2 .0001
Handgrip, kg 7.3–76.0 36.2  12.1 40.6  10.1 22.6  6.5 .0001
Peak exercise VO2, mLO2.kg–1.min–1 3.8–48.5 18.5  6.3 19.7  6.4 14.8  4.2 .0001
Physical function score (MOS SF–36) 0–100 61.0  25.6 63.9  25.0 52.0  25.3 .0001
Geriatric Depression Scale Score 0–15 3.3  3.0 3.2  3.0 3.5  2.9 .04
Comorbidity score 0–6 0.3  1.0 0.3  0.9 0.4  1.0 .2

(r2  –0.23), and weight (r2  0.19) (all, P  .0001).
There was a weak correlation between HG strength
and physical function score in patients older than 65
(r2  –0.09, P  .0001), but not in younger patients.
Men and women with CABG surgery had lower HG
strength than patients with other diagnoses (Fig 2).
After correcting for gender, there were no significant
differences in HG strength between patients with
other cardiac diagnoses. Of the entire cohort, 20% had
non–insulin-dependant diabetes mellitus (NIDDM) as
defined by taking hypoglycemic medication (n  406).
Patients with NIDDM had HG strength that was 8.5%
lower than the nondiabetic patients (33.7  11.3 kg vs
36.8  12.3 kg). Independent predictors, cumulatively
accounting for 65.3% (P  .0001) of the variance in
HG strength, included gender (R 2  0.384), age
(R 2  –0.173), peak VO2 (R 2  0.049), weight (R 2 
0.03), height (R 2  0.014), NIDDM (R 2  –0.002), and
comorbidity score (R 2  –0.001).
HG strength, remeasured in 666 patients after 3
months of CR, increased overall by 4.6% in comparison
with baseline values (34.9  11.4 to 36.5  11.6 kg,
P  .0001) (Table 2). Increase in HG strength in men
(5.0%) (n  505) was greater than that observed in
women (4.5%), a change of 1.9  4.4 versus 1.0  2.9
kg. Improvement in HG strength was weakly associat-
ed with an increase in physical function score in the
total population (r2  0.007, P  .05). However, this
relationship was stronger among individuals younger
than 65 (r2  0.021, P  .03). Peak VO2 increased over-
all by 17% in comparison with baseline (18.1  5.8 to
21.2  6.7 mLO2.kg–1.min–1, P  .0001).
DISCUSSION
In patients with CHD, gender, age, peak VO2, weight,
height, a diagnosis of NIDDM, and comorbid condi-
tions are all baseline independent correlates of HG

Figure 2. Handgrip strength by diagnosis for men (lined boxes)

Figure 1. Unadjusted values for handgrip strength for men (dashed
line) and women (solid line) by decade.
and women (black boxes). CABG indicates coronary artery bypass
surgery; MI, myocardial infarction; PCI, percutaneous coronary
intervention; Med Rx, medical therapy; CHF, chronic heart failure;
a
P  .0001, CABG versus other diagnosis.

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T a b l e 2 • SELECTED VARIABLES BEFORE AND AFTER CARDIAC REHABILITATION COMPLETION

Total (N  666) Men (n  505) Women (n  161)
Pre Post Pre Post Pre Post
Age, y 65  10 64  10 68  10 a

Weight, kg 83.7  16.6 82.6 15.6b 87.2  15.3 86.2  14.0b 72.4  15.6 71.5  15.3c
Waist, cm 100.1  13.0 98.3  12.4b 102.4  11.9 100.6  1.4b 92.7  13.0 91.4  13.2b
Body mass index, kg/m2 28.3  4.9 28.0  4.6b 28.4  4.6 28.0  4.3b 28.1  5.6 27.8  5.6c
Handgrip, kg 34.9  11.4 36.5  11.6b 39.0  9.7 40.9  9.5b 22.1  6.0 23.1  5.6bd
Peak VO2, mLO2.kg–1.min–1 18.1  5.8 21.2  6.7b 19.2  5.8 22.7  6.6b 14.6  16.4 16.4  4.5be
Physical function score (MOS SF–36) 60.4  25.7 82.1  19.4b 63.3  25.2 84.5  18.0b 51.4  25.4 74.7  21.9b
Geriatric Depression Scale Score 3.0  2.6 1.7  2.0b 3.0  2.7 1.6  2.0b 3.1  2.5 2.0  2.1b
a
P  .0001, men versus women.
b
P  .0001, within group comparison.
c
P  .0005, within group comparison.
d
P  .02, pre versus post, between groups.
e
P  .0001, pre versus post, between groups.

strength, accounting for more than 65% of the vari-
ability in HG strength. HG strength correlated with
physical function score in the entire population.
However, HG strength better predicted physical func-
tion in patients older than 65 (r2  –0.09,
P  .0001), most likely due to 2 factors. First, while
younger patients had lower HG strength measures
than the age-matched general population, their
strength was sufficient not to limit their activities of
daily living or self-reported physical function score.
Second, the physical function score may have been of
limited accuracy in younger patients in that a score of
100 does not reflect the greater range of physical
capacity of younger patients (ceiling effect).
HG values in the study group from the third
through the sixth decade were on average 4% to 5%
less than normative, healthy, gender, and age-
matched populations.6 This decrement versus healthy
individuals may be related to the short-term impact of
the cardiac event. Most of the patients in this study
were recently first diagnosed with CHD. Thus,
strength may have been within normal limits just
1–2 months previous to our measurement and HG
strength decreased with the deconditioning sur-
rounding the cardiac event. In essence, participation
in CR resulted in an increase in strength, returning
patients to the normal for age and gender. For a
minority of mostly older patients, a long history of
CHD may have contributed to a decrease of activity,
progressive muscular weakness, and disability associ-
ated with a significant decrease in strength.
It has been demonstrated that peak VO2 is a pre-
dictor of physical function15 and CR patients are 40%
below the expected value for a healthy population.9
However, HG strength is lower to a lesser degree
(5%) than peak VO2. This may be due, in part, to the
fact that decreased fitness is an established risk factor,
and thus selects for the development of CHD, where-
as HG strength is not a risk factor for the develop-
ment of CHD.
Predictors of HG strength within this study are sim-
ilar to correlates of HG strength within the healthy
population, the strongest being age, gender, and
height.5 Another powerful predictor of HG strength in
the general population is hand circumference.5 This
information was not obtained in this study, although
height and hand size may be related.
CABG had a significant impact on HG strength,
which is probably related to the fact that surgical
patients require longer convalescence than patients who
do not undergo surgery. Furthermore, patients who
underwent CABG surgery did not incorporate resistance
training into their CR programs until 3 months after the
date of surgery. Other cardiac presentations did not
have an impact on HG strength. However, this study
demonstrated that patients with NIDDM had lower peak
VO2, which confirmed a similar report.14
There are several limitations to this study including
lack of a control group, preventing differentiation of
spontaneous improvements in HG strength versus
changes attributable to participating in CR. Resistance
training was not individually tracked for the intensity
and duration, and objective measures, that is, 1-repe-
tition maximum, were not obtained. In addition,
patients were not training specifically to increase HG
strength, but rather the primary focus was to increase
aerobic endurance. It would be of interest to investi-
gate whether a specifically designed program to
increase HG strength would have a greater impact on
physical function score. Finally, the MOS SF-36 has
few questions that related directly to HG strength. A
more comprehensive questionnaire might have
demonstrated a closer relationship between HG
strength and self-reported physical function.

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In summary, HG strength, which is easily mea-
sured, provides valuable information as an integrated
predictor of physical function in older patients with
cardiac disease where strength is often a limiting fac-
tor in the performance of daily activities such as
walking, stair climbing, and lifting.
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