Effect of hand grip strength on balance and

cardiovascular endurance among dynapenic

and non-dynapenic postmenopausal
women: A cross-sectional study.

Simran Shaikh (MPT – Community physiotherapy)

Under the Guidance of – Dr. Pothiraj Pitchai (PT)
 Research question
Can change in the muscle strength of dynapenic postmenopausal women
influence balance and endurance?
 Introduction
• The World Health Organization defines natural menopause as the permanent
cessation of menstruation resulting from the loss of ovarian follicular activity
without an obvious intervening cause and is confirmed only after 12
consecutive months of amenorrhea. Post menopause describes the period
following final menses. (1)
• Age at menopause for Indian women is 45 years.(2)
• Due to these hormonal variations postmenopausal women are prone for many
complications like increased Coronary heart disease risk factors, osteoporosis,
obesity and urinary incontinence.(5)
• Menopause is usually associated with increased adiposity and decreased
muscle mass and strength with or without weight gain. One of the possible
explanations related to these body composition changes at menopause is
related to hormonal factors and modification in lifestyle and diet habits which
often predispose postmenopausal women to present higher risks of functional
limitations falls and fractures with an ultimate impact on quality of life. (6)
• Dynapenia is defined as the age-related loss of muscle strength and power.
Dyna refers to “power, strength, or force” and penia refers to “poverty”. (3)
• In addition, there is evidence that dynapenia increases the probability of falls,
fractures and mortality.(4)
• Cardiorespiratory fitness is related to the ability to perform large muscle,
dynamic, moderate to high intensity exercise for prolonged periods.(6)
 Need of study
• Menopausal period in women has been associated with a decline in estrogen
production, which often causes marked physiologic changes in the body,
including fatigue, decreased strength, and vascular calcification.
• There is also a risk of developing osteoporosis during menopause.
• During menopause there is a changes in muscle strength and bone density.
• Literatures revealed that change in muscle strength can affect balance and
cardiovascular endurance in older post menopausal women.
• Also studies identified that dynapenic population has an effect on endurance and
recommended to explore on the balance.
• As there are very limited studies done on effect of hand grip strength on balance
and cardiovascular endurance in dynapenic postmenopausal women. Hence there
was a need to study.
Review of literature
Title Methodology Conclusion

1. Is handgrip strength • 136 postmenopausal women aged from • The results showed that
normalized to body 50 to 75 years were recruited in this handgrip strength was
weight a useful tool to study. positively correlated with
identify dynapenia and • Body composition (Dual Energy X-ray functional capacity. In addition,
functional incapacity in Absorptiometry [DEXA], Bio- non-dynapenic women
post-menopausal electrical Impedance Analysis [BIA]), displayed a better functional
women? By Dulac M et grip strength (dynamometer), and status when compared to
al. Brazilian Journal of functional capacity (senior fitness dynapenic women.
Physical Therapy. 2016 tests) were evaluated.
• Dynapenia was established according
to a handgrip strength index (handgrip
strength divided by body weight (BW)
in Kg/KgBW) obtained from a
reference population of young women.
Title Methodology
2. The effects of • A total of 46 females aged over 65 years • 21.7% women were diagnosed
selected lifestyle were included. Body composition was
components on the risk assessed using anthropometry
of developing measurements and bioelectrical impedance
dynapenia in women – analysis (BIA).
a pilot study conducted • Dynapenia was diagnosed using hand grip
by Bogucka A et al. strength measurement with the use of a
Anthropological hydraulic dynamometer and was classified
Review. 2018 based on the cut-off values according to
BMI.
• Lifestyle of the participants was
determined based on the sedentary
behavior questionnaire.
Conclusion
with dynapenia and they had
significantly higher waist and
hip circumferences and higher
BMI as well as weaker hand
grip strength.
• It concluded that sedentary
lifestyle is the main risk of
dynapenia.
• Hence physical activity is
required for women to reduce
the risk of developing
dynapenia.
Title Methodology Conclusion
3. Dynapenic abdominal • A total of 201 women aged 55 years and • The results showed overall
obesity and the incidence above underwent waist circumference incidence of falls over the
of falls in older women: a measurement, and had handgrip follow-up was 27.5%; and for
prospective study strength assessed using a hydraulic normal, dynapenic, abdominal
conducted by Gadelha Aet dynamometer. obesity, and D/ AO were
al. • Dynapenia was classified using the 14.7%, 17.2%, 27.5%, and
Aging Clinical and lower tertile of handgrip strength, while 40.4% respectively.
Experimental Research. abdominal obesity was considered as a • The study concluded that D/AO
2019 waist circumference>88 cm. is more closely related to falls
• Classified into four groups: normal, than either dynapenia or
abdominal obesity, dynapenic, and abdominal obesity alone, and is
D/AO. independently associated with
• Participants were then tracked by phone an increased incidence of falls
calls for ascertainment of falls in older women.
Title Methodology
4. Cardiorespiratory • Objective of this study was to analyze
Fitness and Body the relationship between aerobic fitness
Composition in and body composition in
Postmenopausal Women. postmenopausal women.
Helena Moreira et al. • Body composition was assessed using
Journal of Human octopolar bioimpedance and basal
Kinetics. 2014 metabolic rate (BMR) was calculated
using the Cunningham’s equation.
Cardiorespiratory fitness was assessed
by modified Bruce protocol.
Conclusion
• These results suggest
worsening of the
cardiorespiratory condition
with an increase of central
adiposity and a decrease of the
BMR, regardless of age and
menopause characteristics.
 Aims and Objectives
AIM : To study the effect of hand grip strength on balance and
cardiovascular endurance among dynapenic postmenopausal women.

OBJECTIVES :
1. To assess dynapenia in postmenopausal women using hand grip
dynamometer.
2. To assess balance in dynapenic and non-dynapenic postmenopausal
women using Y balance test.
3. To assess cardiovascular endurance in dynapenic and non-dynapenic
postmenopausal women using YMCA 3 min step test.
4. To compare hand grip strength on balance and cardiovascular endurance
in dynapenic and non-dynapenic postmenopausal women.
 Hypothesis
• Null hypothesis : There is no significant influence of muscle strength
on balance and cardiovascular endurance in dynapenic and non-
dynapenic postmenopausal women.

• Alternate hypothesis : There is a significant influence of muscle

strength on balance and cardiovascular endurance in dynapenic and
non-dynapenic postmenopausal women.
 Methodology
• Study design: Cross-sectional study
• Study setting: Physiotherapy OPD of a tertiary care hospital
• Study population: Postmenopausal women
• Sampling technique: Convenience sampling
• Study duration: 18 months.
• Sample size: Sample size was determined using the estimates of mean and standard
deviation values from literature (Dulac M, Boutros GE, Pion C. Is handgrip strength
normalized to body weight a useful tool to identify dynapenia and functional
incapacity in post-menopausal women? Brazilian Journal of Physical Therapy.
2016) using the formula

n = 2 (Zα+ Zβ)2 [s]2

d2
• where Zα is the z variate of alpha error i.e., a constant with value 1.96, Zβ is the z
variate of beta error i.e., a constant with value 0.84.
(Reference: Allen JC. Sample Size Calculation for Two Independent Groups: A
Useful Rule of Thumb. Proceedings of Singapore Healthcare 2011:20(2);138-40)
• Approximate estimates:

1. 80% power
2. Type I error to be 5%
3. Type II error to be 20%
4. True difference of atleast 3.9 units between the groups
5. Pooled standard deviation of 5.002
• Substituting the values,

n = 2 (2.8)2 [5.002]2

(3.9)2

n = 25.791
• Approximately 26 subjects / patients per group should complete the study at the endpoint
follow up.
• Also taking into consideration the attrition to be 10%
• n= N / (1-0.10)
• n = 26/(1-0.10) = 28.656
• Approximately 29 to 30 subjects / patients per group were recruited in the present study, i.e n
= 30.
 Criteria

Inclusion criteria:
1. Postmenopausal women aged 45-60 years.
2. Atleast 1 year of post-cessation of menses.
3. Have achieved natural menopause.
4. Having hand grip strength <18kgf.
5. Not taking estrogen therapy.
6. Not undergone hysterectomy.
7. Anyone having MET levels below 500 will be considered as Physically inactive
women using IPAQ.
Exclusion criteria:

1. History of systemic infection or any cardio-respiratory, neurological, Musculo-skeletal.

2. High blood pressure: systolic pressure > 160 mm Hg OR diastolic pressure > 100 mm Hg.

3. Onset of angina or angina-like symptoms.

4. Signs of poor perfusion like light-headedness, confusion, ataxia, pallor, cyanosis, nausea,
cold clammy skin.

5. Participant requests to stop, physical or verbal manifestations of severe fatigue.

6. Any traumatic injury to the hand, shoulder or elbow.

7. Suffering from any recent injuries of lower limbs, no important limitations of the ankle,
knee and hip joint movements, presenting normal gait without limp.

8. Premature menopause due to any surgery.

 Procedure
Approval was obtained from the Institutional ethics committee.

Subjects were screened for eligibility criteria from OPD set up

Enrollment

Enrollment: Subjects were enrolled according to the inclusion criteria

(n=60). Informed consent was obtained from the participants. Baseline
measurement and demographic data was taken
Participants were then assessed for Dynapenia using hand grip dynamometer (<18
kgf). And were divided into 2 groups i.e dynapenic and non- dynapenic.

Dynapenic Non-dynapenic
Anyone having a score of Anyone having a score of
<18 kgf was considered >18 kgf was considered
as dynapenic. as non-dynapenic.

Each group Participants were then assessed for, balance and cardiovascular
endurance using LQ Y balance test and YMCA 3 min step test.

Statistical analysis was done for both the groups once the data was collected
Outcome measures

Outcome measures Use ICC

1. Y- balance test To assess dynamic 0.98

balance
2. YMCA 3 minute To assess 0.77
step test cardiovascular
fitness

3. Hand held To diagnose 0.81

dynamometer dynapenia (<18kgf)
Fig 1: YBT- anterior Fig 2: YBT- postero- Fig 3: YBT- postero-
reach medial reach lateral reach
Fig 4: Hand grip strength Fig 5: YBT- YMCA 3
minute step test
 DATA ANALYSIS AND RESULTS:

• Shapiro-Wilk test was used to analyze the normality of data. It was

found that the data did not follow a normal curve, hence non-
parametric tests have been used.

• Mann-Whitey U test was used for inter-group comparisons. P value

<0.005 was considered significant.
 Table 1. Normality test intergroup for Dynapenic and Non- dynapenic group Study variables
INTERGR Shapiro-Wilk tests
OUP Dynapenic group Non- dynapenic group
ANALYSI statistic df significance statistic df significance Statistical test
S

Hand grip 0.807 30 0.000 0.637 30 0.000 Non-parametric test

strength Mann Whitney U test

Y- balance 0.968 30 0.475 0.920 30 0.026 Non-parametric test

test Right Mann Whitney U test
leg
Y- balance 0.968 30 0.491 0.929 30 0.045 Non-parametric test
test Left Mann Whitney U test
leg
YMCA 3 0.893 30 0.006 0.831 30 0.000 Non-parametric test
min step
Table 2. Descriptive statistics for demographic data
Variables Dynapenic group Non- dynapenic group
n= 30 n= 30
Mean Standard Mean Standard
deviation Deviation
Age 54.53 3.21 52.46 3.53
Weight 61.5 6.27 60.96 6.09
Height 150.8 6.28 152.98 6.35
BMI 27.79 3.58 25.09 2.59
Limb length (Rt) 82.16 5.26 83.5 4.57
Limb length (Lt) 82.18 5.24 83.5 4.57
IPAQ-SF 273.33 85.81 365.80 87.69
Hand grip strength 14.13 1.57 19.07 1.01
 Table 3. Intergroup analysis

Variables Dynapenic Non- • A Mann-Whitney U test

group dynapenic was conducted to compare
group both the groups for YBT-Rt
Z p- Effect
Median Median and YBT-Lt.
value value size
(IQR) (IQR) • It revealed that there was a
significant difference
between the dynapenic and
non-dynapenic groups.
Y- 73.55 (88.5 88.3 (94.03 5.29 0.000 0.68 • The magnitude of the
balance to 72.8) to 82.36)
difference between the
test right
medians (r= 0.68, r= 0.69)
leg
having a large effect size
Y- 72.97 87.7 (94.15 5.37 0.000 0.69
based on the guidelines
balance (77.10 to to 81.34)
proposed by Cohen for
test left 68.95)
interpreting the value.
leg
Variable Dynapenic Non- • A Mann-Whitney U test was
s group dynapenic conducted to compare both
group groups for YMCA.
Z p- Effect
• It revealed that there was a
value value size
significant difference between
Median Median the dynapenic and non-
(IQR) (IQR) dynapenic group.
• The magnitude of the
difference between the
3 min 4 (5 to 3) 5 (6 to 4) 3.2 0.001 0.41 medians (r= 0.41) having a
YMCA medium effect size based on
step test the guidelines proposed by
Cohen for interpreting the
value
Discussion
1. Statistically significant difference in Y- balance test in dynapenic and non-
dynapenic group.
• Author Haripriya et al conducted a study in 2021 to establish a relationship
between ankle ROM, ankle strength, and balance using YBT in postmenopausal
women. In their study, they showed that they found a positive correlation between
ankle strength and balance, which suggests that decreased muscle strength can
cause impaired balance. (6)
• In 2013 a study done by Shaffer et al found that YBT has been shown to have a
strong relationship with the strength of the knee flexors. (42,14,28)
• Richard Bohannon in a study conducted in year 2012 found that hand grip
strength is a good indicator of the strength of the whole body. However, in our
study, we directly assessed for balance based on their handgrip strength. Reduced
lower extremity muscle strength may be the cause of the dynapenic group's
reduced excursion on YBT.
• A study by Fidel Hita et al. examined the relationships between body mass index
(BMI) and the distribution of body fat in postmenopausal women aged 50 to 65
years. They concluded that obesity (BMI > 25 kg/m2) and increased waist-to-hip
ratio (>0.76) were associated with worse postural balance
• We found a similar finding in our study that the participants in the dynapenic group
were obese (BMI > 26 kg/m2) and had a lower score on the Y-balance test. And thus,
it supports our findings that the affection of balance in the dynapenic group could be
due to high BMI.
• The IPAQ score in the dynapenic group indicated that a lack of physical exercise
may have contributed to the altered balance in our study.
• Physical inactivity for a long period of time leads to an increase in body weight and
causes substantial loss of muscle mass, which leads to a reduction in muscle strength.
Reduction in the number and size of type II muscle fibers following menopause,
along with this there is an irregularity in the motor unit firing that plays a role in
diminishing the capacity of muscle strength and power.
2. Statistically significant difference in cardiovascular endurance in dynapenic and
non-dynapenic group.
• A study done in 2017 on postmenopausal women by Niyati et.al concluded that there
was a positive correlation between IPAQ and cardio-respiratory fitness. (1)
• It has been found in earlier studies that a decrease in physical activity levels raises
BMI, visceral fat percentage, and body fat percentage. (32)
• Thus lower the physical activity lower was the Cardiovascular endurance. In the
present study, we found a similar result that the participants in the dynapenic group
had low levels of physical activity on IPAQ compared to the non-dynapenic and had
a BMI >26 kg/m2, which is a potential cause for low cardiovascular endurance.
• Se´ bastien Barbat-Artigas did a similar study in 2016. They noted a significant
relationship between handgrip strength and VO2 max i.e., a person with reduced
handgrip strength had reduced VO2 max.
• In addition, they observed significantly lower levels of VO2 max in dynapenic
women compared with nondynapenic participants. (11)
Limitations:
• We did not assess for the range of
motion, flexibility, and strength of the
lower extremities which could be a
factor in affecting balance.
• Body fat percent could have been
calculated.
• Dominance of the lower limb could
have been considered.
Suggestions:
• Future studies should consider
exploring an interventional program to
improve balance and cardiovascular
endurance in dynapenic women.
• Prevalence of dynapenia in
postmenopausal women can be done
in the Indian population.
Conclusion
• The findings of this study conclude that hand grip strength, balance, and
cardiovascular endurance was reduced in the dynapenic group as compared to the
non-dynapenic group.

Clinical implications
• With this study, we recommend early screening for dynapenia and plan an
intervention program for postmenopausal women that involves strengthening
exercises that will improve balance and cardiovascular endurance.
References:

1. Khona N, Maiya A, Acharya K, Samuel S. Correlation of Physical Activity Level

with Bone Mineral Density, Cardio-Respiratory Fitness And Body Composition in
Post-Menopausal Women. International Journal of Physiotherapy. 2017;4(1):6-11.
2. Ahuja M. Age of menopause and determinants of menopause age: A PAN India
survey by IMS. Journal of mid-life health.2016;7(3):126.
3. Pérez-López F. Dynapenia and Sarcopenia During Female Midlife. Menopause.
2017;317-331.
4. Clark B, Manini T. What is dynapenia? Nutrition. 2012;28(5):495-503.
5. Bogucka A, Kopiczko A, Głębocka A. The effects of selected lifestyle components
on the risk of developing dynapenia in women – a pilot study. Anthropological
Review. 2018;81(3):289-297.
6. Dulac M, Boutros GE, Pion C, Barbat-Artigas S, Gouspillou G, Aubertin-
Leheudre M. Is handgrip strength normalized to body weight a useful tool to
identify dynapenia and functional incapacity in post-menopausal women?
Brazilian Journal of Physical Therapy. 2016;20(6):510-516.
7. Gadelha A, Neri S, Vainshelboim B, Ferreira A, Lima R. Dynapenic abdominal
obesity and the incidence of falls in older women: a prospective study. Aging
Clinical and Experimental Research. 2019;32(7):1263-1270.
8. Moreira H, Passos B, Rocha J, Reis V, Carneiro A, Gabriel R. Cardiorespiratory
fitness and body composition in postmenopausal women. Journal of human
kinetics. 2014 1;43(1):139-48.
9. Hita-Contreras F, Martínez-Amat A, Lomas-Vega R, Álvarez P, Mendoza N,
Romero-Franco N, et al. Relationship of body mass index and body fat distribution
with postural balance and risk of falls in Spanish postmenopausal women. The
Journal of The North American Menopause Society. 2013;20(2):202–8.