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`Available online at www.sciencedirect.com
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`ELSEVIER
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`Diabetes Research and Clinical Practice xxx (2005) xxx-xxx
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`lDl!UillllE'1l'IE~ ~JWRICIHI
`J.\fllD)
`ICll.lIB!IltC.M. IP!llA<C'll'll<G!B
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`www.elsevier.com/locate/diabres
`
`Hand grip strength in patients with type 2 diabetes mellitus
`Ercan Cetinus a,*, Mehmet Akif Buyukbese \ Murat Uzel a,
`Hasan Ekerbicer c , Ahmet Karaoguz a
`
`a Kahramanmaras Sutcu Imam University, Faculty of Medicine, Department of Orthopedics, 46050 Kahramanmaras, Turkey
`b Kahramanmaras Sutcu Imam University, Faculty of Medicine, Department of Internal Medicine, 46050 Kahramanmaras, Turkey
`c Kahramanmaras Sutcu Imam University, Faculty of Medicine, Department of Public Health, 46050 Kahramanmaras, Turkey
`
`Received 6 December 2004; received in revised form 21 February 2005; accepted 23 March 2005
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`Abstract
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`Aim: The aim of the present study was to compare hand grip strength and pinch power, which are important parameters of hand
`14
`function, in 76 patients with type 2 diabetes mellitus (T2DM) (mean age: 50.11 ± 7.6) with 47 non-diabetic control subjects
`15
`(mean age: 46.93 ± 10.2).
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`17 Methods: Grip strength was assessed with a Jamar dynamometer and pinch power was measured with a pinch gauge. Body
`composition was measured using a Tanita body composition analyzer. Mann-Whitney, Fisher's exact and chi-square tests were
`18
`used to determine the differences within groups and a p-value <0.05 was taken as statistically significant.
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`Results: Hand grip strength test values were significantly lower in the diabetic group compared with the control group. Key
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`pinch power value for the right hand was significantly lower in the diabetic group than in the control group whereas the left hand
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`value was similar.
`Conclusion: Hand grip strength and key pinch power values were found to be lower in patients with T2DM than in age-matched
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`control subjects. Hands, as well as feet, are also affected by diabetes and physicians should be aware of this.
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`2005 Published by Elsevier Ireland Ltd.
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`1~
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`Keywords: Type 2 diabetes; Hand grip strength; Key pinch power; Jamar dynamometer; Pinch gauge
`
`1. Introduction
`
`Type 2 diabetes mellitus (T2DM), is the most
`common endocrine disorder worldwide, and it is
`
`* Corresponding author. Tel.: +90 344 2212337/364-226;
`fax: +90 344 2212371.
`ercancetinus@hotmail.com,
`E-mail
`addresses:
`s2000@yahoo.com (E. Cetinus).
`
`ecetinu-
`
`characterized by metabolic abnormalities and by
`chronic complications involving the eyes, kidneys,
`nerves, and blood vessels [l]. These complications can
`cause morbidity and premature mortality, and lead to
`serious social and cause economic problems due to
`loss of employment.
`Foot ulcers and joint problems in T2DM are the
`most significant causes of morbidity and admittance to
`orthopedic outpatient clinics. The major predisposing
`
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`0168-8227/$ - see front matter (C) 2005 Published by Elsevier Ireland Ltd.
`doi: 10.1016/j.diabres.2005.03.028
`
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`cause is diabetic polyneuropathy because the sensory
`denervation impairs the perception of trauma after
`wearing ill-fitting shoes. Alterations in proprioception
`may give rise to an abnormal pattern of weight bearing
`and sometimes to the development of Charcot's joints.
`In addition to sensory neuropathy, motor neuropathy is
`often emphasized, considering that diabetic foot
`pathology, which is characterized by intrinsic muscle
`atrophy, can result in a motor imbalance and diffuse
`claw-toe. This pathology affects both
`the foot
`function and postural stability [2].
`In diabetic patients, the strength of flexor and
`extensor muscles at the elbow, wrist, knee, and ankle
`have been evaluated clinically using manual muscle
`testing (MMT) and isokinetic dynamometry [3,4].
`The volume of ankle dorsal and plantar flexors, and
`intrinsic muscle atrophy of the foot have been
`investigated radiologically usmg magnetic reso(cid:173)
`nance 1magmg (MRI) [2,5] . In contrast to the
`measurement of the strength of the lower extremity
`muscles; hand grip strength has seldom been studied
`in patients with diabetes mellitus (DM) [6] . In the
`present study, our aims were to establish, using a
`Jamar dynamo meter and a pinch gauge, whether the
`grip and pinch power of the hand in patients with
`DM were different than those of healthy non-diabetic
`control subjects.
`
`2. Patients and methods
`
`Seventy-six patients with T2DM (mean age:
`50.11 ± 7.6 years) were recruited from outpatient
`clinics of the Department of Internal Medicine, at
`Kahramanmaras Sutcu Imam University. Forty-seven
`healthy volunteers (mean age: 46.93 ± 10.2) without
`diabetes, established by an oral glucose tolerance test
`(OGTT), served as the control group.
`to American
`DM was diagnosed according
`Diabetes Association (ADA) diagnostic criteria as
`follows: a fasting plasma glucose ?_7.0 mmol/L or 2-h
`plasma glucose ?_II.I mmol/L after a 75 g oral
`glucose load [7]. Criteria for inclusion in the study
`were that the patients had T2DM (known or newly
`diagnosed after glucose challenge test or those
`receiving oral hypoglycemic pills) and that the control
`subjects had no glucose abnormality, no history of
`pain in the shoulder, arm or hand, no documented
`
`history of trauma or cervical radiculopathy in the
`previous 12 months.
`A calibrated, Jamar dynamometer (Smith and
`Nephew, Irwington, NY 10533, USA) was used to
`assess grip strength at the first three settings. A pinch
`gauge (PG-30, B&L Engineering Santa Fe, CA, USA)
`was used
`to assess
`the key pinch. Both
`the
`dynamometer and pinch gauge were reset to zero
`prior to each reading and were read to the nearest
`increment of the two scale divisions. The American
`Society of Hand Therapists' recommendations for
`testing both grip and pinch strengths were followed
`[8]. Subjects were seated comfortably on a chair
`without armrests. The shoulder was adducted and
`neutrally rotated, with the elbow at 90° flexion, and the
`forearm and wrist in a neutral position. Standard
`verbal encouragement in the same tone of voice
`("squeeze the handle/button as hard as possible") was
`used during the measurements. Three measurements
`of each grip and pinch were obtained at 15 s intervals
`and mean values were analyzed. Measurements started
`with the dominant hand. The right hand was dominant
`in 67 (88.2%) of T2DM patients, whereas in 2 (2.6%)
`the left hand was dominant, and the remaining 7
`(9.2%) were ambidextrous. In the control group the
`dominant hand was the right in 38 (80.9%) subjects,
`the left in 6 (12.8%), and 3 subjects (6.4%) were
`ambidextrous.
`Percentages of body fat (BF), the basal metabolism
`rate (BMR), and fat mass of the subjects were obtained
`using a Tanita body composition analyzer TBF-300
`(Tanita Corp., Tokyo, Japan). Tanita TBF-300 is a
`commercially available
`foot-to-foot bioelectrical
`impedance analysis (BIA) system. The manufac-
`turer-supplied equations incorporate gender, mass,
`height, activity category and a measured impedance
`value to determine the percentages of BF, BMR, and
`fat mass. In order to assess these measurements, girth-
`hip ratio (G/H), height, body weight, and body mass
`index (BMI) were all measured.
`All T2DM patients were examined for hyperten-
`s10n, smoking and diabetes duration, and were
`investigated for diabetic complications using clinical
`examination and laboratory findings (Urine protein,
`HbAlc).
`The study was reviewed and approved by the local
`research and ethics committee and all subjects gave
`written consent.
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`E. Cetinus et al.I Diabetes Research and Clinical Practice xxx (2005) xxx-xxx
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`3
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`Parametric or nonparametric tests were chosen to
`134
`test for statistical significance depending on the data
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`distribution. Mann-Whitney, chi-square, Fisher's
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`exact, T-test, Kruskal-Wallis analysis of variance,
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`138 Wilcoxon's signed rank test and Pearson's correlation
`coefficient were used to determine the differences and
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`relations between groups. A p-value of <0.05 was
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`taken as statistically significant. Statistical analysis
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`142 was performed using SPSS 9.0 for Windows (SPSS
`Inc., Chicago, IL, USA).
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`3. Results
`
`The characteristics and body composition values of
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`the subjects were given in Tables 1 and 2. There were
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`no significant difference between the groups with
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`respect to age, sex, hypertension, proteinuria, and
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`smoking (p > 0.05). However HbAlc values
`in
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`diabetic patients were significantly higher than those
`150
`(7.14 ± 1.64%
`of
`the
`control group
`versus
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`5.16 ± 0.62%, p < 0.001) (Table 1). BMI, G/H, BF,
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`BMR, and fat mass were similar in both groups
`153
`(Table 2).
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`Working status of subjects is given in Fig. 1. All
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`subjects in both groups were classified as non-manual
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`157 workers
`(housewives, civil servants,
`tradesmen,
`retired etc.) (Fig. 1).
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`The results of the hand grip strength test with the
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`Jamar dynamometer were significantly lower in the
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`diabetic group compared with the control group
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`(p < 0.05). The key pinch strength value for the
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`right hand was significantly lower in the diabetic
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`group than in the control group (p < 0.05), whereas
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`the left hand value was lower than in the control
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`group but this was not statistically significant
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`
`(p > 0.05) (Table 3). However, when the subjects
`of both the diabetic and control group were classified
`according to age intervals, hand grip and pinch
`strength values were found to be lower in diabetic
`patients in both the 30-49 and the >50 age groups
`(p < 0.05) (Table 4).
`54.5% of the diabetic patients reported that daily
`activities and hand grasping power were not affected
`and 10.6% said that decreased hand power did not
`affect their daily activities. However, patients who
`reported that their hand power affected daily activities
`comprised 34.9% of the diabetic study group.
`The relationship between HbAlc level and values
`of hand grip and key pinch strength of diabetic and
`control groups were analyzed using Pearson's
`correlation coefficient. There was no relationship
`found among HbAlc levels, proteinuria, hypertension
`and values of hand grip and key pinch strength in
`neither
`the diabetic patients nor
`the controls
`(p > 0.05).
`The relationship between age, BMI and values of
`hand grip and key pinch strength of both the diabetic
`and control group were analyzed using Pearson's
`correlation coefficient but no significant relationship
`was (p > 0.05).
`Both the hand grip and key pinch strength values
`were found to be higher in males than in females in
`both the diabetic and the control group (p < 0.05)
`(Table 5). Furthermore, there was a relationship
`between the grip strength and key pinch power in both
`the diabetic and control groups (p < 0.001). In the
`diabetic group, the relationship between grip strength
`and key pinch power was relatively higher than those
`of the control group (Table 6).
`There were significant differences in the hand grip
`and key pinch strength values of the subjects between
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`Table 1
`Characteristics of subjects
`
`Age (years) (mean± S.D.)
`Sex F/M (n and % )
`Hypertension
`Proteinuria
`Smoking
`HbAlc (%)(mean± S.D.)
`Diabetes duration (years)
`
`Diabetic patients (n = 76)
`
`Control (n = 47)
`
`50.11 ± 7.6
`51 (67.1 %)/25 (32.9%)
`(n = 49) 65.3%
`(n = 13) 17.1 %
`(n = 1) 1.3%
`7.14 ± 1.64 (4.6 - 10.9)
`5.94 ± 6.18
`
`46.93 ± 10.2
`28 (59.6%)/19 (40.4%)
`(n = 20) 42.5%
`(n = 6) 12.8%
`(n = 3) 6.4%
`5.16 ± 0.62 (4.1 - 7.9)
`
`p-Value
`
`>0.05
`>0.05
`>0.05
`>0.05
`>0.05
`<0.001
`
`No significant difference between groups (p > 0.05) in age, sex, hypertension, proteinuria, smoking, but significant difference between groups
`(p < 0.001) in HbAlc.
`
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`E. Cetinus et al. I Diabetes Research and Clinical Practice xxx (2005) xxx-xxx
`
`Table 2
`Comparison of the body composition values (values are mean ± S.D.)
`Diabetic patients (n = 76)
`30.59 ± 6.03
`0.88 ± 0.07
`34.86 ± 9.19
`6341.77 ± 795.49
`28.39 ± 12.19
`No significant difference between groups (p > 0.05) in BMI, G/H, BF, BMR, and fat mass.
`
`BMI
`Girth-hip ratio (G/H)
`Percentages of body fat (BF)
`Basal metabolism rate (BMR)
`Fat mass
`
`Control (n = 47)
`31.22 ± 5.0
`0.86 ± 0,06
`34.89 ± 7.85
`6565.51 ± 1283.85
`29.08 ± 10.82
`
`p-Value
`
`>0.05
`>0.05
`>0.05
`>0.05
`>0.05
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`the dominant and non-dominant hand (p < 0.05)
`(Table 7).
`Implications on life and activities, as a conse(cid:173)
`quence of the patients' lower hand grip and pinch
`strength values were investigated. All the diabetic
`patients were studied. 54.5% of the diabetic patients
`reported that daily activities and hand grasping power
`were not affected and 10.6% stated that decreased
`hand power did not affect their daily activities.
`However, subjects with affected hand power and daily
`activities comprised 34.9% of the diabetic population.
`
`4. Discussion
`
`It is well known that mild distal muscle weakness
`can accompany predominant distal symmetrical
`
`sensory neuropathy in DM patients [9]. While there
`are numerous quantitative studies on sensory neuro-
`pathy and autonomic disturbances, there is little data
`about motor function in diabetic patients [10,11].
`Dyck et al. [3] indicated that clinically apparent
`muscle weakness was a severe disturbance in type 1
`diabetes
`(TlDM) patients with more advanced
`neuropathy. However, neither the severity nor the
`distribution of the muscle weakness due to manual
`muscle testing (MMT) was reported in their clinical
`studies. Andersen and Jakobsen stated that
`the
`sensitivity of MMT was low and dynamometry should
`be considered in clinical trials of motor function in
`neuropathic patients [12]. Some investigators reported
`that there was a significant reduction in the muscle
`strength of the ankle dorsal and plantar flex ors, and the
`knee extensors and flexors in 56 TlDM patients using
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`40
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`30
`
`20
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`10
`
`0
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`c :::;
`8
`
`housewife
`occupation
`
`civil cervant
`
`retired
`
`tradesman
`
`Fig. 1. Working status of subjects.
`
`Groups
`
`.Diabetes
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`E. Cetinus et al.I Diabetes Research and Clinical Practice xxx (2005) xxx-xxx
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`Table 3
`Hand grip strength and key pinch values (kg) of both groups
`
`Strength
`
`Diabetic patients
`
`Control
`
`R Jamar first setting
`R Jamar second setting
`R Jamar third setting
`L Jamar first setting
`L Jamar second setting
`L Jamar third setting
`R key pinch
`L key pinch
`
`27.61 ± 9.76
`31.53 ± 11.82
`28.92 ± 10.86
`25.91 ± 9.53
`29.77 ± 11.15
`27.54 ± 10.51
`8.47 ± 2.56
`8.15 ± 2.50
`
`31.89 ± 8.88a
`36.34 ± 11.01 a
`33.22 ± 10.53a
`31.10 ± 9.08a
`35.48 ± 10.35a
`32.05 ± 9.30a
`9.37 ± 1.89b
`8.92 ± 1.83c
`
`R: right; L: left.
`a p < 0.05. Hand grip strength was significantly lower in the
`diabetic group than those of control group.
`b p < 0.05. Key pinch strength value for right hand was signifi(cid:173)
`cantly lower in the diabetic group than value of control group.
`c p > 0.05. Key pinch strength value for left hand was lower in
`diabetic patients than value of control group. But there was no
`statistically significant difference.
`
`isokinetic dynamometer, but a reduction in muscle
`234
`strength of the wrist flexors and extensors was not
`235
`significant [ 4]. Lord et al. [ 13] found impaired muscle
`236
`strength of the knee extension in a group of aged
`237
`238 women with T2DM. Andersen et al. [14] pointed out
`that T2DM patients may have weakness of the
`239
`extensors and flexors at the ankle and of the knee
`240
`flexors and extensors, with a preservation of muscle
`241
`strength at the wrist and elbow. It was thought that the
`242
`distribution of muscular weakness indicated a distal
`243
`neuropathic process underlying the impaired motor
`244
`performance, and this assumption was supported by
`245
`the observation that muscular strength at the ankle and
`246
`knee was related to
`the degree of severity of
`247
`neuropathy.
`248
`
`In addition to clinically determined lower extre(cid:173)
`mity muscular weakness in DM patients, it was
`reported that there was a 32% reduction in the volume
`of dorsal and plantar flex ors [ 5], and also using MRI,
`remarkable atrophy in the intrinsic muscles of the foot
`in neuropathic patients was reported [2]. Both
`biochemical and structural changes in the plantar
`foot muscles of DM patients with neuropathic ulcers
`and a reduction in high-energy metabolites with an
`increase in fat content were also demonstrated via
`magnetic resonance spectroscopy [15]. Significant
`relationships between motor nerve conduction velo(cid:173)
`city, and these physiological variables were suggested
`as atrophy in the intrinsic muscles of the foot was seen
`as secondary to motor nerve dysfunction. Remarkable
`atrophy of the foot and ankle muscles was thought to
`be secondary to diabetic neuropathy [2, 15] .
`A number of investigations related to the evaluation
`of the muscle strength in D M patients were carried out
`on the lower extremity muscles, and mild distal
`muscle weakness in the lower extremity, due to
`diabetic neuropathy, was identified. However, hand
`grip strength and pinch power values in diabetic
`patients are unclear in the literature.
`In the present study, we evaluated the grip and
`pinch power of the hand in T2DM. Grip strength and
`pinch power are
`important parameters of hand
`function. The grip strength test was commonly used
`to evaluate the integrated performances of hand
`muscles by determining maximal grip force that could
`be produced in one muscular contraction [ 16]. Hand
`strength can be used to determine a treatment [ 17], to
`assess nutrition [18], to assess risk of mortality in
`
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`Table 4
`Comparisons of hand grip and pinch strength (kg) values (mean± S.D.) of subjects according to age intervals
`
`Strength (kg)
`
`Diabetic patients
`
`R Jamar first setting
`R Jamar second setting
`R Jamar third setting
`L Jamar first setting
`L Jamar second setting
`L Jamar third setting
`R key pinch
`L key pinch
`
`30-49
`
`28.32 ± 10.78
`32.49 ± 12.65
`29 .44 ± 11.26
`26.91 ± 10.03
`30.46 ± 11.96
`27.54 ± 10.88
`8.78 ± 2.66
`8.11 ± 2.36
`
`>50
`
`27.06 ± 9.01
`30. 79 ± 11.24
`28.52 ± 10.66
`25.13 ± 9.18
`29.25 ± 10.61
`27.55 ± 10.36
`8.21 ± 2.49
`8.18 ± 2.65
`
`Control
`
`30--49
`
`32.35 ± 9.31 a
`35.87 ± 10.78a
`32.55 ± 9.90a
`31.69 ± 9.49a
`35.18 ± 10.48a
`31.78 ± 9.38a
`9.42 ± 1.95a
`8.94 ± 1.72a
`
`>50
`
`30.62 ± 7.81 b
`37.65 ± 12.03b
`35.04 ± 12.39b
`29.48 ± 8.00b
`36.32 ± 10.38b
`32.82 ± 9.46b
`9.24 ± 1.80b
`8.85 ± 2.22b
`
`R: right; L: left.
`a p < 0.05. Hand grip and pinch strength values of diabetic patients were lower than those of controls in 30-49 age interval.
`b p < 0.05. Hand grip and pinch strength values of diabetic patients were lower than those of controls in >50 age.
`
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`Table 5
`Comparisons of hand grip and pinch strength (kg) values (mean ± S.D.) of subjects according to gender
`Strength
`Diabetic patients
`Control
`
`R Jamar first setting
`R Jamar second setting
`R Jamar third setting
`L Jamar first setting
`L Jamar second setting
`L Jamar third setting
`R key pinch
`L key pinch
`
`Female
`22.24 ± 5.80
`24.78 ± 6.34
`22.67 ± 5.61
`20.78 ± 5.46
`23.18 ± 5.19
`21.36 ± 5.09
`7.10 ± 1.39
`6.78 ± 1.36
`
`Male
`38.36 ± 6.70a
`45.02 ± 8.01 a
`41.44 ± 7.39a
`36.15 ± 7.43a
`42.96 ± 7.52a
`39.92 ± 6.97a
`11.51 ± 1.84a
`11.19 ± 1.60a
`
`Female
`25.96 ± 5.06
`28.88 ± 5.09
`26.03 ± 4.38
`25.31 ± 5.23
`28.48 ± 4.81
`25.95 ± 4.42
`8.23 ± 1.29
`7.72 ± 1.08
`
`Male
`40.00 ± 6.11 a
`46.56 ± 8.36a
`43.04 ± 8.25a
`39.02 ± 7.ooa
`45.07 ± 7.87"
`40.41 ± 7_55a
`10.93 ± 1.41 a
`10.49 ± 1.35a
`
`R: right; L: left.
`a p < 0.05. Hand grip strength and key pinch values were significantly lower in females than males in both diabetic and control group.
`
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`people with an acute illness [ 19], as a prognostic factor
`[20], and as a marker for general muscle strength [21].
`According to our study results, hand grip strength
`value using a Jamar dynamometer was significantly
`lower in the diabetic group compared with the control
`group. Again, the key pinch strength value for the right
`hand was significantly lower in the DM group,
`whereas for the left hand, the value was lower than in
`the control group but there was no statistical
`significance. Ozdirenc; et al. [6] investigated physical
`fitness in T2DM patients and found that the physical
`functional capacity was lower in T2DM patients than
`in age-matched healthy control subjects. Hand grip
`strength in their T2DM patients was found to be lower.
`But they did not test the pinch power in their study.
`Our hand grip strength results were similar with the
`results of Ozdirenc;'s study.
`Several factors affect values of hand grip and pinch
`strength measurements. These factors are gender [22-
`25], age of the subjects [22-24 ], hand dominance
`
`[22,25-27], occupation [27], body weight and height
`[24,25,28,29], position of the wrist [30,31], elbow
`[24], and shoulder [ 16].
`Gender is the most important factor acting on the
`values of hand grip and pinch strength. Mathiowetz
`et al. reported that males were stronger than females in
`both the 6-19-year-old group and the adult group
`[22,23]. Balogun et al. [24] also found that males had
`greater hand grip strength than females. Crosby et al.
`emphasized that sex was the most significant factor
`that should be taken into consideration, as men in their
`study were found to have a mean grip strength of
`137 lb whereas women had a mean grip strength of
`81 lb [25]. In this study, values of hand grip and pinch
`strength were found to be higher in males than in
`females and our findings support this (p < 0.05).
`Age of the subjects is another important factor
`acting on the values of grip and pinch strength.
`According to the results of Mathiowetz and Kash-
`man's study, grip strength peaked within the 25-39
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`Table 6
`Pearson's correlation coefficients of hand grip strength and key pinch power between diabetic patients and controls
`
`Grip strength
`
`R Jamar setting 1
`R Jamar setting 2
`R Jamar setting 3
`L Jamar setting 1
`L Jamar setting 2
`L Jamar setting 3
`
`Diabetic patients
`
`R key pinch
`
`0.83a
`0.90a
`0.90a
`0.82a
`0.90a
`0.90a
`
`L key pinch
`
`0.80a
`0.85a
`0.86a
`0.81a
`0.88a
`0.89a
`
`Control
`
`R key pinch
`
`0.78a
`0.77a
`0.77a
`0.67a
`0.74a
`0.72a
`
`L key pinch
`
`0.82a
`0.83a
`0.85a
`0.79a
`0.84a
`0.85a
`
`R: right; L: left.
`a p < 0.001. There was relation between grip strength and key pinch power in both diabetic patients and controls. In diabetic group, relation
`between grip strength and key pinch power was relatively higher than those of control group.
`
`DIAB 3346 1-9
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`E. Cetinus et al.I Diabetes Research and Clinical Practice xxx (2005) xxx-xxx
`
`7
`
`Table 7
`Comparison of hand grip and pinch strength (kg) values
`(mean± S.D.) of subjects according to hand dominance
`
`Strength
`
`Non-dominant hand
`Dominant hand
`29.25 ± 9.47a
`27.58 ± 9.55
`Jamar first setting
`33.15 ± 11.60a
`31.70 ± 10.81
`Jamar second setting
`30.34 ± 10.77a
`29.11 ± 10.07
`Jamar third setting
`8.82 ± 2.36a
`8.41 ± 2.27
`Key pinch
`a p < 0.05. There were significant differences in hand grip and key
`pinch strength values of the subjects between dominant and non(cid:173)
`dominant hand.
`
`age group for both sexes and gradually declined
`thereafter, but pinch strength scores were relatively
`stable from 55 to 59 years, after which a gradual
`decline began [32]. Balogun et al. [24] reported a
`positive correlation between grip strength and age.
`The results of Mathiowetz and Wiemer's study
`indicated that increases in grip and pinch strength
`coincide with increases in chronological age [23]. In
`the present study, we observed a negative correlation
`among values of hand grip strength, pinch strength and
`age in both diabetic patients and controls (p > 0.05).
`Hand dominance and occupation are other impor(cid:173)
`tant factors acting on the values of grip and pinch
`strength. Josty et al. found
`that
`there was no
`statistically significant difference between the domi(cid:173)
`nant and non-dominant grip of heavy manual workers,
`but strength in the dominant hand was greater in non(cid:173)
`manual workers. The same study showed that a
`difference existed between the dominant and non(cid:173)
`dominant pinch strengths of non-manual and light
`manual workers [27]. Petersen et al.'s results showed a
`10.74% grip strength difference between dominant
`and non-dominant hands, but the results of Mathio(cid:173)
`wetz et al.'s study showed only minimal differences in
`average hand strength of right- and left-handed
`persons [22,26]. Crosby et al. reported that right(cid:173)
`handed people were on average 10% stronger in the
`right hand compared to the left, whereas they observed
`no difference m left-handed individuals. Similar
`findings were demonstrated in key and pulp pinch
`[25]. Harkonen et al. reported that there were no
`significant differences in grip strength between the
`dominant and non-dominant hand [33]. Peolsson et al.
`found only a slight, non-significant difference in hand
`strength between the dominant and non-dominant
`hand [29]. In our study, all subjects were non-manual
`workers, and grip and pinch strength values in the
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`dominant hand were higher than in the non-dominant
`hand in both the diabetic and the control group
`(p < 0.05).
`The effects of both body weight and height on the
`values of hand grip strength and pinch power were
`reported by several authors [24,25,28,29]. Crosby
`et al. [25], Balogun et al. [24], and Chau et al. [28]
`found correlations between height-weight and grip
`strength. Poelsson et al. [29] did not find any
`correlation between hand grip strength and body
`weight, however they found significant correlation
`between hand grip strength and height. In the present
`study, BMI instead of body weight and height was
`used as an anthropometric measure and a correlation
`was not observed between values of hand grip and
`pinch strength and BMI (p > 0.05).
`Some authors have stated that the position of the
`wrist, elbow and shoulder joints can affect hand grip
`strength [16,24,30,31]. In the present study, we carried
`out the American Society of Hand Therapists'
`standardized position, as recommended by several
`authors [8,32,33].
`Knee, ankle, and foot muscle weakness related to
`diabetic neuropathy had been reported by many
`investigators [2, 14, 15]. However, causes of lower
`quantitative values of hand grip strength and pinch
`power in patients with T2DM are unclear. Lundbaek
`et al. [34] stressed that stiffness of the subcutaneous
`tissue in the hand of diabetic patients might have an
`influence on the strength measurements. However, it
`cannot be the only factor. Distal muscle weakness
`connected with predominant distal symmetrical
`sensory neuropathy in diabetic patients is a reality.
`Lower values of hand grip strength and pinch power in
`T2DM patients could be explained by distal upper
`extremity flexor muscle weakness, which may be
`caused by the severity of neuropathy. Though, we did
`not analyse diabetic neuropathy in our patients.
`In hand surgery, knowing the hand grip strength
`and pinch power values of diabetic patients 1s
`important. Normative hand grip and pinch strength
`values were developed in normal healthy populations
`by many authors [21-23,25,33]. In our study, we
`found that the strength values of diabetics were lower
`than in a normal population. In our opinion, these are
`normative values for diabetic patients. Therefore, we
`suggest that lower strength values in diabetics must be
`taken into consideration, when assessing function
`
`DIAB 3346 1-9
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`RTICLE IN PRESS
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`E. Cetinus et al. I Diabetes Research and Clinical Practice xxx (2005) xxx-xxx
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`after hand surgery and the strength values of diabetics
`must not be compared directly with those of normal
`healthy persons.
`In conclusion, we found that hand grip strength
`and pinch power values were lower in T2DM
`patients. To our knowledge, this is the first study
`applying quantitative assessment of hand grip and
`pinch power in T2DM patients. Our study had two
`limitations. Firstly, nerve conduction studies were
`not performed using an electromyography since the
`study participants refused
`this procedure, and
`secondly, all patients were not evaluated according
`to the neuropathy symptom score. Therefore, further
`detailed studies are needed to explain the relation(cid:173)
`ship between neuropathy and hand grip strength and
`pinch power.
`
`References
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