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Isometric hand grip strength measured by the Nintendo Wii Balance Board - a
reliable new method

Article in BMC Musculoskeletal Disorders · February 2016

DOI: 10.1186/s12891-016-0907-0

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Blomkvist et al. BMC Musculoskeletal Disorders (2016) 17:56
DOI 10.1186/s12891-016-0907-0

RESEARCH ARTICLE Open Access

Isometric hand grip strength measured by

the Nintendo Wii Balance Board – a reliable
new method
A. W. Blomkvist1, S. Andersen1,2, E. D. de Bruin3* and M. G. Jorgensen1

Abstract
Background: Low hand grip strength is a strong predictor for both long-term and short-term disability and
mortality. The Nintendo Wii Balance Board (WBB) is an inexpensive, portable, wide-spread instrument with the
potential for multiple purposes in assessing clinically relevant measures including muscle strength. The purpose
of the study was to explore intrarater reliability and concurrent validity of the WBB by comparing it to the Jamar
hand dynamometer.
Method: Intra-rater test-retest cohort design with randomized validity testing on the first session. Using custom
WBB software, thirty old adults (69.0 ± 4.2 years of age) were studied for reproducibility and concurrent validity
compared to the Jamar hand dynamometer. Reproducibility was tested for dominant and non-dominant hands
during the same time-of-day, one week apart. Intraclass correlation coefficient (ICC) and standard error of measurement
(SEM) and limits of agreement (LOA) were calculated to describe relative and absolute reproducibility respectively. To
describe concurrent validity, Pearson’s product–moment correlation and ICC was calculated.
Results: Reproducibility was high with ICC values of >0.948 across all measures. Both SEM and LOA were low
(0.2-0.5 kg and 2.7-4.2 kg, respectively) in both the dominant and non-dominant hand. For validity, Pearson correlations
were high (0.80-0.88) and ICC values were fair to good (0.763-0.803).
Conclusion: Reproducibility for WBB was high for relative measures and acceptable for absolute measures. In addition,
concurrent validity between the Jamar hand dynamometer and the WBB was acceptable. Thus, the WBB may be a
valid instrument to assess hand grip strength in older adults.
Keywords: Nintendo Wii Balance Board, Isometric hand grip strength, Reliability, Reproducibility, Test-retest, Validity,
Jamar hand dynamometer

Background HGS is a strong predictor of future disability [4] and

Muscle function is pivotal to overall physical fitness and mortality [2, 3, 5–7] in the old and middle-aged [4, 7, 8].
a change in muscle strength is an important risk factor In addition to being a marker for nutritional status
for functional decline, independent of disease processes [9, 10], low HGS is also associated with increased risk
[1]. Hence, the assessment of muscle function is an im- of postoperative complications, extended hospitalisation,
portant measure in many situations. It may be assessed higher re-submission rates and increased short-term
by proxies such as muscle mass or muscle strength. mortality following acute admission [9–11].
Compared to muscle mass, it is easier and more reliable In clinical settings, there are several methods for asses-
to measure muscle function in terms of strength, par- sing muscle strength. Manual muscle testing (using a
ticularly hand grip strength (HGS) [2, 3]. Accordingly, subjective scale from 0 to 5) is one of the most com-
monly used methods because of its simplicity and speed,
however, a serious drawback is its crudeness [12, 13].
* Correspondence: [email protected]
3
Department of Health Sciences and Technology, Institute of Human
Another way of evaluating HGS is by using an objective
Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland handgrip dynamometer, which can be hydraulic, pneumatic,
Full list of author information is available at the end of the article

© 2016 Blomkvist et al. Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0
International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and
reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to
the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver
(http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
Blomkvist et al. BMC Musculoskeletal Disorders (2016) 17:56 Page 2 of 7

mechanical or electrical. The handgrip dynamometer has ethics committee, The North Denmark Region Committee
shown high reliability and validity when appropriately cali- on Health Research Ethics, which is appointed by The
brated [14–16] and it can be useful for identifying individ- Regional Council of the North Denmark Region.
uals at high risk of poor disease outcomes [17]. The gold
standard by which other dynamometers are evaluated is the
Overall experimental and calibration procedures
Jamar hand dynamometer (JD) [16].
Participant characteristics such as height, weight, hand-
Most handgrip dynamometers are primarily found in
edness, number of drugs taken and physical activity in
the hands of health care professionals as they only meas-
hours per week were obtained prior to testing. All tests
ure HGS and prices range from 250 to 1484 USD. In
were performed at the same time-of-day, in the same
contrast, the Nintendo Wii Balance Board (WBB) is
clinical examination room at Aalborg University Hos-
widely available globally and it sells at approximately 60
pital and by the same rater. The rater was a trained
USD. Moreover, the WBB has been demonstrated to be
physiologist (MGJ). Devices were calibrated by applying
a reliable and valid instrument for the assessment of
known weights of 0.2, 0.5, 1.0, 1.5, 2, 4, 5, 8, 10, 20, 30
other physical characteristics such as balance [18] and
and 50 kg to the force transducers.
reaction-time [19]. In 2014, an American research group
demonstrated that both new and used WBB recorded
static forces accurately in a laboratory setting [20]. In- WBB
spired by these findings, researchers at Aalborg University WBB is a rigid square-shaped platform with four uni-
Hospital have developed software that enabled isometric axial vertial stain gauge transducers in the corners.
strength recordings to be performed using the WBB. This Using Bluetooth HID wireless and custom programs
software has shown high reproducibility and concurrent written in C#, data was streamed to a computer (Lenovo
validity for measuring isometric muscle strength in the Yoga Pro, Windows 8). The software recorded the iso-
lower limbs [21]. Next, we want to establish whether this metric force-time curve from the sensor values reported
software can be used for isometric HGS testing. Hence, as four channels of 16-bit digital data samples at ap-
the aim of this study was (1) to explore both relative and proximately 100 Hz and subsequently filtered using a
absolute reproducibility of the WBB to measure HGS in 4th order Butterworth filter (cut-off frequency 20 Hz).
the dominate and the non-dominate hand and (2) to ex- The resulting accuracy of the software is 100 gram on
plore concurrent validity when compared to the gold the whole measurement range (from 0 to 300 kg).
standard, the JD. Before starting the actual tests, participants received a
set of standard instructions and demonstration of the
Method procedure. Afterwards they were seated in a standard
Design chair (seating height 43 cm), which was used for all tests.
Following the guidelines for reporting reliability and Participants were then asked to hold the WBB with their
agreement studies (GRRAS) [22], we tested the intra- left and right hand around the middle of the WBB with
rater reproducibility of the WBB performing tests one the lower face of the board towards their torso. All tests
week apart. Concurrent validity was also explored by were initiated with the right hand, which held and
comparing the WBB to JD on the first session. Partici- squeezed the upper right corner. This was followed by
pants were randomized to start with either the WBB or the left hand holding and squeezing the upper left
JD in order to avoid order effects. corner, as illustrated in Fig. 1. Prior to the actual testing,
2–3 sub-maximal recordings were performed. This served
Study-population both as habituation and warm-up. After the warm-up,
Thirty older adults were recruited using the member the actual tests were performed with a total of three
lists from senior citizen clubs and organizations in
Aalborg, Denmark. Using telephone interview, partici-
pants were included if they were 65 years or more, will-
ing and able to come to the hospital twice within a week
by themselves, and able to pass a small custom dementia
screening (correctly answering the current year, month
and prime minister of Denmark). Participants were ex-
cluded if they had acute illness within the previous
3 weeks, orthopaedic surgery on upper or lower limbs
within 6 months or neurologic disease (e.g. Parkinson’s
Fig. 1 Demonstration of a left hand grip strength measurement by
disease, severe dementia). All participants gave written
pressing the upper left corner of the Nintendo Wii balance board
consent and the study was approved by the regional
Blomkvist et al. BMC Musculoskeletal Disorders (2016) 17:56 Page 3 of 7

measurements per hand alternating between right and the difference between session one and two (for
left hand. The participants were encouraged to squeeze WBB) was tested for normal distribution both
as long and as tightly as possible until a plateau had statistically (Shapiro-Wilk) and visually (histogram).
been reached. This took about 3–5 seconds and was vi- Further, the difference between each participant’s indi-
sualized on the monitor which both the examiner and vidual score from the mean of the measurements in
participant could see. The examiner instructed the par- both sessions was plotted in a simple scatter plot for
ticipant when to stop. The participants rested their signs of heteroscedasticity [24]. Paired t test was used
hands for 15 seconds before the next measurement. to explore systematic bias between sessions. For rela-
tive reproducibility, intra-class correlation coefficient
JD (ICC) was calculated with a 95 % confidence intervals
The JD (Lafayette Instruments Company, USA) is the [25] using absolute agreement in a two-way mixed
most widely cited dynamometer in the literature and it model, and the results of a single measurement was
is accepted as the gold standard by which other dyna- reported. The ICCs were interpreted based on the
mometers are evaluated. It reads force in both kilograms recommended ranges of poor (<0.69), fair (0.70-0.79),
and pounds, with markings at intervals of 2 kg. Accord- good (0.80-0.89), and high (0.90-1.00) for both relative
ing to our calibration procedures, the JD required a reproducibility and validity [26]. For absolute repro-
minimum of 2 kg to make the manometer move, which ducibility, the standard error of measurement (SEM)
may be inappropriate when measuring very weak pa- and limits of agreement (LOA) was calculated using
tients. Accordingly, it has been reported that the meas- the SD of the participants difference score between
pffiffiffiffiffiffiffiffiffiffiffiffiffiffi
urement error of the JD is greater at lower loadings [23]. the two session multiplied by 1−ICC and 1.96, re-
Similar to the WBB test, participants received a set of spectively [27]. The absolute values were also pre-
standard instructions for the procedure followed by a sented as percentages by dividing SEM and LOA with
demonstration. They performed 2–3 sub-maximal re- the mean value of all participants for both sessions.
cordings prior to actual testing. In addition, participants For validity, Pearson’s product–moment correlation
rested their arm on a standard table (height 71 cm) with between WBB and JD from session one were calculated
the JD initially in the right hand followed by the left for the first measurement, mean of two measurements,
hand. The hand was positioned with the thumb on one mean of three measurements and highest value of all
side of the handle, while the other fingers were on the three measurements. The correlations were interpreted
other side (see Fig. 2). The handle was set to position no as high (>0.70), moderate (0.50-0.69), low (0.26-0.49),
2. Similar to the WBB, a total of three measurements and absent (0.00-0.25) [26]. To further support the valid-
per hand were completed and the participants were en- ity analysis we included a calculation of ICC using a
couraged to squeeze as long and tight as possible until a two-way mixed consistency model and reporting results
plateau had been reached. of a single measurement.

Statistics
Data are presented as mean ± standard deviation (SD), Results
and all statistical analyses were performed using SPSS The study-population consisted of 18 women and 12
(version 22). The dominant and non-dominant hands men with a mean age of 69 ± 4.2 years. Characteristics
were analysed separately and measurements were pre- included height 168.5 ± 6.9 cm, weight 72.5 ± 13.7 kg,
sented as first measurement, mean of two measure- BMI 25.5 ± 4.2 kg/m2, number of medications 1.5 ± 1.7,
ments, mean of three measurements and highest while physical activity was 8.1 ± 3.5 hours per week. Two
value out of three measurements. For reproducibility, participants did not show up for session two. Their re-
sults were excluded for the reproducibility analysis,
while their measurements from the first session were
retained for the validity analysis.
In Fig. 3, the mean value for three measurements is
shown for the WBB on both sessions and the JD. The
between-subjects variation is greater than the within-
subject variation. Also, the JD reads on average higher
values than the WBB. Post hoc analysis using the mean
score of three measurements from the first session dem-
onstrates an average difference of 15.4 ± 5.5 kg for the
Fig. 2 Demonstration of a left hand grip strength measurement by
dominant hand and 11.9 ± 5.5 kg for the non-dominant
pressing the Jamar handdynamometer
hand with the JD giving higher values.
Blomkvist et al. BMC Musculoskeletal Disorders (2016) 17:56 Page 4 of 7

Fig. 3 Mean of three measurements for the WBB on both sessions and for the JD. Vertical axis shows the results in kilogram. Horizontal axis
represents each participant. Results from two participants, who did not show up for second session, are omitted (no 16 and 18)

Reproducibility results for dominant and non- and LOA values were comparable to or lower than [34]
dominant hands are shown in Tables 1 and 2, respect- those observed with the JD, reflecting an acceptable
ively. ICC values were 0.948-0.976, SEM between 0.2 absolute reproducibility. Moreover, we found a high
and 0.5 kg and LOA were between 2.7 and 4.2 kg across concurrent validity between the JD and WBB with
all measurements. There were no statistically significant Pearson’s product–moment correlation averaging 0.85.
differences between sessions one and two, and there As expected, the Pearson correlation was somewhat
were no visual signs of heteroscedasticity. lower than reported correlations between the JD and
Validity results are shown in Tables 3 and 4. The Pear- other handgrip dynamometers [35, 36]. Still, the cor-
son correlations between WBB and JD for all measure- relation was higher than that found between other
ments were between 0.80 and 0.88 with the differences HGS measurement techniques, such as the sphygmo-
being statistically significant, and ICC values were be- manometer [37], grip-ball [32] and vigorimeter [38],
tween 0.793 and 0.803. and comparable to stationary alternatives, such as the
BTW work simulator [39].
Discussion On the other hand, the ICC values between the JD and
To the best of our knowledge, this is the first report WBB were a bit weaker than the Pearson’s correlations,
measuring HGS using the WBB. The results demon- ranging between fair and good (0.793-0.803). The confi-
strated good reproducibility for the WBB in measuring dence intervals for the ICC validity analysis were signifi-
isometric HGS with ICC values similar to JD [23, 28–33], cantly wider than for the reproducibility analysis,
the gold standard for measuring HGS. In addition, SEM spanning from 0.525 to 0.901 and thus encompassing

Table 1 Results from the reproducibility analysis for the dominant hand
Dominant hand Session 1 Session 2
Measurement(s) MEAN SD MEAN SD M-Diff (paired T-test) ICC [95 % CI] SEM (SEM%) LOA (LOA%)
First measurement 21.74 1.19 21.94 1.29 0.20 (n.s.) 0.955 [.906-.979] 0.4 (1.9) 3.8 (17.6)
Mean of the two first measurements 21.54 1.19 21.70 1.27 0.16 (n.s.) 0.970 [.937-.986] 0.3 (1.3) 3.1 (14.3)
Mean of all three measurements 21.37 1.18 21.60 1.23 0.23 (n.s.) 0.966 [.927-.985] 0.3 (1.4) 3.1 (14.6)
Highest value of all three measurements 22.33 1.19 22.81 1.34 0.48 (n.s.) 0.960 [.905-.982] 0.4 (1.6) 3.4 (15.4)
Mean, standard deviation (SD), standard error of measurement (SEM) and limits of agreement (LOA) in kilograms. M-diff is the mean difference in kilograms
between the mean of the two sessions and the comparison using the paired T-test. n.s. not significant (all p-values are less than 0.001). SEM and LOA are also
given in percentages (SEM% and LOA%). Intraclass correlation coefficient (ICC) with 95 % confidence intervals [95 % CI] are given. Results are given for one
measurement, mean of two measurements, mean of three measurements and highest value of three measurements
Blomkvist et al. BMC Musculoskeletal Disorders (2016) 17:56 Page 5 of 7

Table 2 Results from the reproducibility analysis for the non-dominant hand
Non-dominant hand Session 1 Session 2
Measurement(s) MEAN SD MEAN SD M-Diff (paired T-test) ICC [95 % CI] SEM (SEM%) LOA (LOA%)
First measurement 21.47 1.28 20.78 1.27 −0.69 (n.s.) 0.948 [.891-.975] 0.5 (2.4) 4.2 (20.1)
Mean of the two first measurements 21.08 1.22 20.68 1.25 −0.40 (n.s.) 0.973 [.943-.988] 0.2 (1.2) 2.9 (14.3)
Mean of all three measurements 21.30 1.20 20.65 1.23 −0.65 (n.s.) 0.976 [.947-.989] 0.2 (1.1) 2.7 (13.3)
Highest value of all three measurements 22.30 1.24 21.61 1.32 −0.69 (n.s.) 0.961 [.917-.982] 0.4 (1.7) 3.7 (16.8)
Mean, standard deviation (SD), standard error of measurement (SEM) and limits of agreement (LOA) in kilograms. M-diff is the mean difference in kilograms
between the mean of the two sessions and the comparison using the paired T-test. n.s. not significant (all p-values are less than 0.001). SEM and LOA are also
given in percentages (SEM% and LOA%). Intraclass correlation coefficient (ICC) with 95 % confidence intervals [95 % CI] are given. Results are given for one
measurement, mean of two measurements, mean of three measurements and highest value of three measurements

the full range from poor to high correlations. Hence, we for this difference cannot be deduced from our results,
have less confidence on the ICCs for the validity ana- but it might be expected that the strength difference
lysis, which must be interpreted with caution. The result between the two sides will result in lower correlation for
from our study also indicate lower errors of measure- the weaker side, i.e. non-dominant side (about 5 %
ment when considering the mean value of two or three weaker according to our results), since the JD allows as-
measurements rather than one measurement or the sessment to the nearest kilogram, while the WBB allows
maximum of three measurements, which is consistent assessment down to the nearest 100 gram. In combin-
with other studies [40]. ation with the increased measurement error for lower
Although the WBB showed a acceptable correlation loadings with the JD, this may explain the difference
with the JD, there was a systematic difference in the re- observed.
sults. On average this was 15.4 ± 5.5 kg for the dominant One limitation with the WBB method for measuring
hand and 11.9 ± 5.5 kg for the non-dominant hand with HGS is the lack of adjustable handles to accommodate
the JD giving higher values. Hence, there is an inter- different hand sizes. Thus, the effect of hand size on our
instrument difference between the WBB and the JD, and method is unknown. Still, this is the first investigation of
the instruments are not interchangeable. However, this HGS using the WBB. Compared to the above mentioned
lack of agreement has also been found between different techniques the WBB has advantages in that it is a low-
dynamometers [35, 41, 42] and even between different cost, portable and wide-spread tool. Furthermore, it has
models of JD [43]. These studies [35, 41, 42] are consist- the potential for multiple roles in the clinical setting.
ent with our results in that the JD tends to give higher This may include objectified measurements of reaction-
values when compared to other instruments. time [19], balance [18] and lower limb muscle strength
Comparing our results from the dominant and non- [21]. The data presented here demonstrate the applic-
dominant hand there is similar reproducibility between ability of an additional facility, the HGS. The WBB has
hands, but a somewhat better correlation with the JD for also been successfully used as an intervention tool for
the dominant side, both with Pearson’s correlation (0.87 balance in healthy eldery [44], as well as in chronic dis-
vs 0.82 on average) and ICC (.793 vs .768). The cause eases [45, 46] and for physical rehabilitation [47–49].

Table 3 Results from the concurrent validity analysis for the Table 4 Results from the concurrent validity analysis for the
dominant hand non-dominant hand
Dominant hand Non-dominant hand
Measurement(s) Pearson’s product–moment ICC Measurement(s) Pearson’s product–moment ICC
correlation [95 % CI] correlation [95 % CI]
First measurement 0.88 (p < 0.001) .793 First measurement 0.80 (p < 0.001) .763
[.610-.896] [.559-.880]
Mean of the two first 0.88 (p < 0.001) .803 Mean of the two first 0.80 (p < 0.001) .748
measurements [.626-.901] measurements [.535-.872]
Mean of all three 0.86 (p < 0.001) .786 Mean of all three 0.82 (p < 0.001) .768
measurements [.597-.892] measurements [.562-.882]
Highest value of all three 0.87 (p < 0.001) .791 Highest value of all three 0.86 (p < 0.001) .794
measurements [.606-.895] measurements [.611-.896]
Intraclass correlation coefficient (ICC) with 95 % confidence intervals [95 % CI] Intraclass correlation coefficient (ICC) with 95 % confidence intervals [95 % CI]
and Pearson’s product–moment correlation with p-values are given for one and Pearson’s product–moment correlation with p-values are given for one
measurement, mean of two measurements, mean of three measurements and measurement, mean of two measurements, mean of three measurements and
highest value of three measurements. All measurements are from session 1 highest value of three measurements. All measurements are from session 1
Blomkvist et al. BMC Musculoskeletal Disorders (2016) 17:56 Page 6 of 7

Finally, the multiple use of one instrument with rapid Author details
1
and automatic transferral of measurements to the com- Department of Geriatric and Internal Medicine, Aalborg University Hospital,
Aalborg, Denmark. 2Department of Clinical Medicine, Aalborg University,
puter system prevents loss of results and error in report- Aalborg, Denmark. 3Department of Health Sciences and Technology, Institute
ing, and it supports optimal use of staff time. of Human Movement Sciences and Sport, ETH Zurich, Zurich, Switzerland.
This study has both strengths and weaknesses. Firstly,
Received: 3 November 2015 Accepted: 27 January 2016
we did not investigate inter-rater reliability. The impact
on WBB results is likely to be limited as the results are
read automatically and hand positioning is likely to be References
similar between raters. Secondly, the participants posi- 1. Morey MC, Pieper CF, Cornoni-Huntley J. Physical fitness and functional
tioning deviates from the standardised procedure recom- limitations in community-dwelling older adults. Med Sci Sports Exerc. 1998;
30(5):715–23. http://www.ncbi.nlm.nih.gov/pubmed/9588614. Accessed 24
mended by American Society of Hand Therapists [16], Jun 2015.
but only by having a slightly more extended elbow pos- 2. Newman AB, Kupelian V, Visser M, Simonsick EM, Goodpaster BH,
ition. The magnitude of this limitation is likely to be Kritchevsky SB, et al. Strength, but not muscle mass, is associated with
mortality in the health, aging and body composition study cohort. J
minimal. Thirdly, we only investigated independent Gerontol A Biol Sci Med Sci. 2006;61(1):72–7. http://www.ncbi.nlm.nih.gov/
older adults with a high level of functioning, as evaluated pubmed/16456196. Accessed 18 Jun 2015.
by their physical activity. Caution should be taken for 3. Metter EJ, Talbot LA, Schrager M, Conwit R. Skeletal muscle strength as a
predictor of all-cause mortality in healthy men. J Gerontol A Biol Sci Med
generalizing the results to other age groups and popula- Sci. 2002;57(10):B359–65. http://www.ncbi.nlm.nih.gov/pubmed/12242311.
tions. Still, this study had a sufficient number of partici- Accessed 4 Jun 2015.
pants for the purpose under study, and the methods 4. Rantanen T, Guralnik JM, Foley D, Masaki K, Leveille S, Curb JD, et al. Midlife
hand grip strength as a predictor of old age disability. JAMA. 1999;281(6):
have been reported in sufficient detail with the relevant 558–60. http://www.ncbi.nlm.nih.gov/pubmed/10022113. 25 Accessed
statistics according to the GRRAS. Jun 2015.
5. Fujita Y, Nakamura Y, Hiraoka J, Kobayashi K, Sakata K, Nagai M, et al.
Physical-strength tests and mortality among visitors to health-promotion
Conclusion centers in Japan. J Clin Epidemiol. 1995;48(11):1349–59. http://www.ncbi.
nlm.nih.gov/pubmed/7490598. Accessed 18 Jun 2015.
Reproducibility for WBB was high for relative measures 6. Rantanen T, Volpato S, Ferrucci L, Heikkinen E, Fried LP, Guralnik JM.
and acceptable for absolute measures in both dominant Handgrip strength and cause-specific and total mortality in older disabled
and non-dominant hands in a cohort of older adults. In women: exploring the mechanism. J Am Geriatr Soc. 2003;51(5):636–41.
http://www.ncbi.nlm.nih.gov/pubmed/12752838. Accessed 18 Jun 2015.
addition, an acceptable concurrent validity was found 7. Rantanen T, Harris T, Leveille SG, Visser M, Foley D, Masaki K, et al. Muscle
between the JD and the WBB. Thus, the WBB appears strength and body mass index as long-term predictors of mortality in
to be a valid and reliable instrument when assessing initially healthy men. J Gerontol A Biol Sci Med Sci. 2000;55(3):M168–73.
http://www.ncbi.nlm.nih.gov/pubmed/10795731. Accessed 18 Jun 2015.
HGS in older adults and may be a useful tool in clinical 8. Sasaki H, Kasagi F, Yamada M, Fujita S. Grip strength predicts cause-specific
settings. Further research should aim to establish the mortality in middle-aged and elderly persons. Am J Med. 2007;120(4):337–42.
inter-rater reproducibility and to explore the method in doi:10.1016/j.amjmed.2006.04.018.
9. Norman K, Stobäus N, Gonzalez MC, Schulzke J-D, Pirlich M. Hand grip
other populations. strength: outcome predictor and marker of nutritional status. Clin Nutr.
2011;30(2):135–42. doi:10.1016/j.clnu.2010.09.010.
10. Flood A, Chung A, Parker H, Kearns V, O’Sullivan TA. The use of hand grip
Availability of Data and Materials strength as a predictor of nutrition status in hospital patients. Clin Nutr.
2014;33(1):106–14. doi:10.1016/j.clnu.2013.03.003.
Raw material can be provided upon request, please con- 11. Phillips P. Grip strength, mental performance and nutritional status as
tact AWB or MGJ. indicators of mortality risk among female geriatric patients. Age Ageing.
1986;15(1):53–6. http://www.ncbi.nlm.nih.gov/pubmed/3953331. Accessed
18 Jun 2015.
Abbreviations
12. Bohannon RW. Manual muscle testing: does it meet the standards of an
HGS: Hand grip strength; WBB: Nintendo Wii Balance Board; JD: Jamar
adequate screening test? Clin Rehabil. 2005;19(6):662–7. http://www.ncbi.
handdynamometer; SEM: Standard error of measurement; LOA: Limits of
nlm.nih.gov/pubmed/16180603. Accessed 25 Jun 2015.
agreement; ICC: Intraclass correlation coefficient; GRRAS: Guidelines for
13. Hayes K, Walton JR, Szomor ZL, Murrell GAC. Reliability of 3 methods for
reporting reliability and agreement studies.
assessing shoulder strength. J Shoulder Elbow Surg. 11(1):33–39. doi:10.
1067/mse.2002.119852.
Competing interests 14. Innes E. Handgrip strength testing: A review of the literature. Aust Occup
AWB, SA and EDB declare that they have no competing interests. MGJ Ther J. 1999;46(3):120–40. doi:10.1046/j.1440-1630.1999.00182.x.
developed and holds a patent on the software used in the study. 15. Abizanda P, Navarro JL, García-Tomás MI, López-Jiménez E, Martínez-Sánchez E,
Paterna G. Validity and usefulness of hand-held dynamometry for measuring
muscle strength in community-dwelling older persons. Arch Gerontol Geriatr.
Author contributions 54(1):21–27. doi:10.1016/j.archger.2011.02.006.
AWB, principal investigator of this study, analysed the data and drafted the 16. Roberts HC, Denison HJ, Martin HJ, Patel HP, Syddall H, Cooper C, et al. A
first version of the manuscript. MGJ designed the study and collected the review of the measurement of grip strength in clinical and epidemiological
data. AWB, SA, EDB and MGJ substantially contributed to the design and the studies: towards a standardised approach. Age Ageing. 2011;40(4):423–9.
interpretation of data for the work, revising the first manuscript critically for doi:10.1093/ageing/afr051.
important intellectual content, gave final approval of the version to be 17. Bohannon RW. Hand-grip dynamometry predicts future outcomes in aging
published and agree being accountable for all aspects of the work related to adults. J Geriatr Phys Ther. 2008;31(1):3–10. http://www.ncbi.nlm.nih.gov/
the accuracy and integrity of the work. pubmed/18489802. Accessed 11 Jun 2015.
 Blomkvist et al. BMC Musculoskeletal Disorders (2016) 17:56 Page 7 of 7

18. Clark RA, Bryant AL, Pua Y, McCrory P, Bennell K, Hunt M. Validity and 40. Mathiowetz V, Weber K, Volland G, Kashman N. Reliability and validity of
reliability of the Nintendo Wii Balance Board for assessment of standing grip and pinch strength evaluations. J Hand Surg Am. 1984;9(2):222–6.
balance. Gait Posture. 2010;31(3):307–10. doi:10.1016/j.gaitpost.2009.11.012. http://www.ncbi.nlm.nih.gov/pubmed/6715829.
19. Jorgensen MG, Paramanathan S, Ryg J, Masud T, Andersen S. Novel use of Accessed 3 Sept 2015.
the Nintendo Wii board as a measure of reaction time: a study of 41. Massy-Westropp N, Rankin W, Ahern M, Krishnan J, Hearn TC. Measuring
reproducibility in older and younger adults. BMC Geriatr. 2015;15:80. grip strength in normal adults: reference ranges and a comparison of
doi:10.1186/s12877-015-0080-6. electronic and hydraulic instruments. J Hand Surg Am. 2004;29(3):514–9.
20. Bartlett HL, Ting LH, Bingham JT. Accuracy of force and center of pressure doi:10.1016/j.jhsa.2004.01.012.
measures of the Wii Balance Board. Gait Posture. 2014;39(1):224–8. 42. Amaral JF, Mancini M, Novo Júnior JM. Comparison of three hand
doi:10.1016/j.gaitpost.2013.07.010. dynamometers in relation to the accuracy and precision of the
21. Gronbech Jorgensen M, Andersen S, Ryg J, Masud T. Novel Use of the measurements. Rev Bras Fisioter. 2012;16(3):216–24. http://www.ncbi.nlm.
Nintendo Wii Board for Measuring Isometric Lower Limb Strength: A nih.gov/pubmed/22801514. Accessed 19 Sept 2015.
Reproducible and Valid Method in Older Adults. PLoS One. 2015;10(10): 43. Flood-Joy M, Mathiowetz V. Grip-Strength Measurement: A Comparison of
e0138660. doi:10.1371/journal.pone.0138660. Three Jamar Dynamometers. OTJR Occup Particip Heal. 1987;7(4):235–43.
22. Kottner J, Audige L, Brorson S, Donner A, Gajewski BJ, Hróbjartsson A, et al. doi:10.1177/153944928700700405.
Guidelines for Reporting Reliability and Agreement Studies (GRRAS) were 44. Bieryla KA, Dold NM. Feasibility of Wii Fit training to improve clinical
proposed. Int J Nurs Stud. 2011; measures of balance in older adults. Clin Interv Aging. 2013;8:775–81.
48(6):661–71. doi:10.1016/j.ijnurstu.2011.01.016. doi:10.2147/CIA.S46164.
23. Hogrel J-Y. Grip strength measured by high precision dynamometry in 45. Prosperini L, Fortuna D, Giannì C, Leonardi L, Marchetti MR, Pozzilli C.
healthy subjects from 5 to 80 years. BMC Musculoskelet Disord. 2015;16(1): Home-based balance training using the Wii balance board: a randomized,
139. doi:10.1186/s12891-015-0612-4. crossover pilot study in multiple sclerosis. Neurorehabil Neural Repair. 27(6):
24. Bland JM, Altman DG. Statistical methods for assessing agreement between 516–525. doi:10.1177/1545968313478484.
two methods of clinical measurement. Lancet. 1986;1(8476):307–10. 46. Gonçalves GB, Leite MAA, Orsini M, Pereira JS. Effects of using the nintendo
http://www.ncbi.nlm.nih.gov/pubmed/2868172. Accessed 9 Jul 2014. wii fit plus platform in the sensorimotor training of gait disorders in
25. Hopkins WG. Measures of reliability in sports medicine and science. Sports Parkinson’s disease. Neurol Int. 2014;6(1):5048. doi:10.4081/ni.2014.5048.
Med. 2000;30(1):1–15. http://www.ncbi.nlm.nih.gov/pubmed/10907753. 47. Negus JJ, Cawthorne DP, Chen JS, Scholes CJ, Parker DA, March LM. Patient
Accessed 1 Sept 2015. outcomes using Wii-enhanced rehabilitation after total knee replacement -
26. Domholdt E. Physical Therapy Research Principles and Application. the TKR-POWER study. Contemp Clin Trials. 2015;40:47–53.
Philadelphia: WB Saunders; 1993. doi:10.1016/j.cct.2014.11.007.
27. Atkinson G, Nevill AM. Statistical methods for assessing measurement error 48. Baltaci G, Harput G, Haksever B, Ulusoy B, Ozer H. Comparison between
(reliability) in variables relevant to sports medicine. Sports Med. 1998;26(4): Nintendo Wii Fit and conventional rehabilitation on functional performance
217–38. http://www.ncbi.nlm.nih.gov/pubmed/9820922. Accessed 11 Sept outcomes after hamstring anterior cruciate ligament reconstruction:
2015. prospective, randomized, controlled, double-blind clinical trial. Knee Surgery,
28. Bohannon RW, Schaubert KL. Test-retest reliability of grip-strength measures Sport Traumatol Arthrosc. 2012;21(4):880–7. doi:10.1007/s00167-012-2034-2.
obtained over a 12-week interval from community-dwelling elders. J Hand 49. Bower KJ, Clark RA, McGinley JL, Martin CL, Miller KJ. Clinical feasibility of the
Ther. 2005;18(4):426–7. doi:10.1197/j.jht.2005.07.003. quiz 428. Nintendo WiiTM for balance training post-stroke: a phase II randomized
29. Gerodimos V. Reliability of handgrip strength test in basketball players. J controlled trial in an inpatient setting. Clin Rehabil. 2014;28(9):912–23. doi:
Hum Kinet. 2012;31:25–36. doi:10.2478/v10078-012-0003-y. 10.1177/0269215514527597.
30. Savva C, Giakas G, Efstathiou M, Karagiannis C. Test-retest reliability of
handgrip strength measurement using a hydraulic hand dynamometer in
patients with cervical radiculopathy. J Manipulative Physiol Ther. 2014;37(3):
206–10. doi:10.1016/j.jmpt.2014.02.001.
31. Peolsson A, Hedlund R, Oberg B. Intra- and inter-tester reliability and
reference values for hand strength. J Rehabil Med. 2001;33(1):36–41. http://
www.ncbi.nlm.nih.gov/pubmed/11480468. Accessed 3 Sept 2015.
32. Vermeulen J, Neyens JCL, Spreeuwenberg MD, van Rossum E, Hewson DJ,
de Witte LP. Measuring grip strength in older adults: comparing the grip-
ball with the Jamar dynamometer. J Geriatr Phys Ther. 38(3):148–153. doi:10.
1519/JPT.0000000000000034.
33. Fox B, Henwood T, Neville C, Keogh J. Relative and absolute reliability of
functional performance measures for adults with dementia living in
residential aged care. Int Psychogeriatr. 2014;26(10):1659–67.
doi:10.1017/S1041610214001124.
34. Coldham F, Lewis J, Lee H. The reliability of one vs. three grip trials in
symptomatic and asymptomatic subjects. J Hand Ther. 2006;19(3):318–26.
doi:10.1197/j.jht.2006.04.002. quiz 327.
35. Shechtman O, Gestewitz L, Kimble C. Reliability and validity of the DynEx
dynamometer. J Hand Ther. 2005;18(3):339–47. doi:10.1197/j.jht.2005.04.002. Submit your next manuscript to BioMed Central
36. Mathiowetz V. Comparison of Rolyan and Jamar dynamometers for and we will help you at every step:
measuring grip strength. Occup Ther Int. 2002;9(3):201–9. http://www.ncbi.
nlm.nih.gov/pubmed/12374997. Accessed 3 Sept 2015. • We accept pre-submission inquiries
37. Hamilton GF, McDonald C, Chenier TC. Measurement of grip strength: • Our selector tool helps you to find the most relevant journal
validity and reliability of the sphygmomanometer and jamar grip
• We provide round the clock customer support
dynamometer. J Orthop Sports Phys Ther. 1992;16(5):215–9.
doi:10.2519/jospt.1992.16.5.215. • Convenient online submission
38. Fike ML, Rousseau E. Measurement of Adult Hand Strength: A Comparison • Thorough peer review
of Two Instruments. OTJR Occup Particip Heal. 1982;2(1):43–9.
• Inclusion in PubMed and all major indexing services
doi:10.1177/153944928200200105.
39. Beaton DE, O’Driscoll SW, Richards RR. Grip strength testing using the BTE • Maximum visibility for your research
work simulator and the jamar dynamometer: A comparative study. J Hand
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