Reliability and validity of an enhanced paper grip test; A simple clinical test for assessing lower limb strength

Reliability of enhanced paper grip test for testing foot strength in volleyball and soccer players

OBJECTIVES

To evaluate the reliability of the Enhanced Paper Grip Test (EPGT) for assessing foot strength in volleyball and soccer players.

DESIGN

A cross-sectional observational study with repeated measurements.

SETTING

Field-based study.

PARTICIPANTS

A convenience sample of 28 athletes (13 volleyball players and 15 soccer players) participated in the study.

MAIN OUTCOME MEASURES

The main outcome measures were the intraclass correlation coefficients (ICC) for intra-visit and inter-visit reliability, typical error, and coefficient of variation for the force (N) recorded in EPGT test.

RESULTS

The EPGT demonstrated good to excellent relative reliability (ICC values ranged from 0.93 to 0.97) and acceptable absolute reliability (typical error = 5-8 % of the mean). Significant inter-limb asymmetries were observed in both volleyball (16.0 ± 10.2%) and soccer players (15.3 ± 9.8%).

CONCLUSIONS

The EPGT is a reliable tool for assessing foot strength in volleyball and soccer players. Further research is required to explore the applicability of EPGT in different athletic and clinical contexts, and its potential role in athletic performance and injury prevention.

Implementing a contextually appropriate foot-ankle exercise programme in primary care for the prevention of modifiable risk factors for ulcers in people with diabetes: protocol for a hybrid type 2 study

INTRODUCTION

Diabetes is a highly prevalent disease that negatively impacts people's health and quality of life. It can result in diabetic peripheral neuropathy (DPN) and foot complications, which in turn lead to ulcers and amputations. The international guidelines on diabetic foot included specific foot-ankle exercises as preventive strategy capable of modifying the risk factors for ulcers. Our aim is to test the effectiveness and to implement a contextually appropriate preventive intervention-a foot-ankle exercises programme alongside educational strategies-in a primary care setting to improve range of motion (ROM), strength, functionality of foot-ankle, and quality of life in people with diabetes.

METHODS AND ANALYSIS

This is a hybrid type 2 implementation-effectiveness study organised in four phases, being undertaken in Limeira, São Paulo. Phase 1, preimplementation, aims to gather information about the contextual characteristics, barriers, and facilitators and to form the implementation team. In phase 2, the implementation team will structure the foot-ankle programme, adapting it to the context of primary healthcare, and develop the training for health professionals. In phase 3, effectiveness of the 12 week group-based intervention will be tested by a cluster randomised controlled trial. Primary care units (18 clusters) will be randomly allocated to a control or intervention group, with a total sample of 356 people. Primary outcomes will be DPN symptoms and ankle and first metatarsal phalangeal joint ROM. Reach, adoption, and implementation will be evaluated by Reach, Effectiveness, Adoption, Implementation, and Maintenance framework. In phase 4, maintenance and expansion of the programme in the municipality will be assessed.

ETHICS AND DISSEMINATION

This protocol and the informed consent to be signed by the participants were approved by the Ethics Committee of the School of Medicine of the University of São Paulo (CAAE:63457822.0.0000.0068, 29 November 2022). The project will generate and share data in a public repository. Results will be disseminated through peer-reviewed journals, conference proceedings, and electronic communications for health professionals.

TRIAL REGISTRATION NUMBER

NCT05639478.

The enhanced paper grip test can substantially improve community screening for the risk of falling

BACKGROUND

Lower-limb strength measures can enhance falls risk assessment but due to the lack of clinically applicable methods, such measures are not included in current screening. The enhanced paper grip test (EPGT) is a simple-to-use and cost-effective test that could fill this gap. However, its outcome measure (EPGT force) has not yet been directly linked to the risk of falling.

RESEARCH QUESTION

Is the EPGT a good candidate for falls risk screening in older people in the community?

METHODS

Seventy-one older people living independently in the community were recruited for this prospective observational study (median age 69 y, range 65y-79y). Lower-limb and whole-body strength were assessed at baseline using the EPGT and a standardised hand-grip method respectively. Incident falls were recorded monthly for a year through follow-up telephone conversations. The capacity of individual strength measures to predict falls and to enhance an established falls risk assessment tool (FRAT) commonly used by UK's national health service (NHS) was assessed using binomial logistic regression. The analysis was repeated for the subset of participants without history of falling at baseline (prediction of first-ever falls).

RESULTS

Increased EPGT force and increased symmetry in strength between limbs were significantly associated with reduced risk of falling. Compared to the NHS-FRAT, the EPGT correctly classified more people (73% vs 69%), it achieved higher sensitivity (56% vs 26%) and higher negative predictive value (76% vs 68%). Complementing the NHS-FRAT with the EPGT produced a more comprehensive model that correctly classified 91% of participants and achieved 98% specificity, 81% sensitivity, 89% negative and 96% positive predictive value. Replacing the EPGT with hand-grip strength consistently undermined prediction accuracy. The EPGT remained highly accurate when focused on the prediction of first-ever falls.

SIGNIFICANCE

The EPGT can substantially enhance falls screening in the community. These results can also inform effective personalised strength exercise interventions.

Reliability and clinical applicability of lower limp strength using an enhanced paper grip strength

The enhanced paper grip test (EGPT) quantitatively assesses lower limb strength. EGPT assesses the hallux grip force by reacting a pulling force derived from a card, being positioned underneath the participant's hallux. This study aimed to investigate the repeatability and clinical applicability of the EPGT for assessing foot muscle strength. EPGT force was measured using a dynamometer. The reliability of the measurement of EPGT force was assessed by having two examiners performing the test on the same group of healthy adults. Clinical applicability was assessed in community-dwelling adults of both genders. EPGT force was recorded for both feet using the same standardised protocol for all participants. Regarding reliability, 20 healthy adults aged 23.04±5.5 years participated in the present study. The EGPT demonstrated good to excellent test-retest (ICC1,2 0.8 to 0.86) and interrater reliability (ICC1,2 0.82 to 0.88). A convenience sample of 15 community-dwelling adults (71.6±7.8 years, 68.5% women) was recruited for clinical applicability testing. All participants performed the test with mean score 15±5.7 N. EPGT is a reliable measurement of the hallux grip force strength and can be used for clinical and research purposes.

The impact of diabetic polyneuropathy on toe grip strength in patients with type 2 diabetes mellitus: a cross-sectional study

Purpose

Type 2 diabetes mellitus (T2DM) and concomitant diabetic polyneuropathy (DPN) induce muscle weakness. Muscle weakness in the foot is associated with foot deformities and falls. However, factors affecting toe grip strength (TGS) are not well known. Therefore, the present study investigated factors related to TGS in patients with T2DM.

Methods

This was a cross-sectional study involving 100 patients with T2DM who were hospitalized for the treatment of T2DM and 50 healthy adults. The subjects were divided into three groups: a group of healthy subjects, a group of T2DM patients without DPN, and a group of T2DM patients with DPN. Hierarchical multiple regression analysis was performed with TGS and the TGS-to-weight ratio (TGS/Wt%) as dependent variables and with age, the presence of T2DM, and DPN as independent variables, and sex and BMI as confounders.

Results

There were no significant differences in age or sex among the three groups. In the final regression analysis, age and presence of T2DM and DPN were associated in both models with TGS and TGS/Wt% as dependent variables.

Conclusion

DPN, T2DM, and age were found to be related to TGS. The findings of this study could contribute to healthcare providers developing foot care and rehabilitation programs for diabetic patients.

Trial registration

This study was registered with UMIN-CTR (UMIN000034320) on 1 November 2018.

An exploration of the mechanistic link between the enhanced paper grip test and the risk of falling

The enhanced paper grip test (EPGT) offers an easy-to-use measure of hallux plantar-flexion strength that does not need expensive specialised equipment. Literature suggests that it could be a useful screening tool to assess the risk of falling in older people. However, research on a specific mechanistic link to the risk of falling is lacking. It is hypothesised here that muscle weakening (assessed by the EPGT) is indicative of impaired ability to recover balance after a slip or a trip. To get an initial assessment of validity of the above hypothesis, the EPGT is compared against an established lab-based measure of lower-limb strength that is capable of assessing a person's ability to recover balance after a slip or a trip: maximum isometric leg press push-off force (leg press force). A gender-balanced sample of twenty people (median age=34 y) was recruited. Two different but equaly valid techniques of administering the EPGT were included regarding whether the participants' ankle was supported by the examiner or not. Results for the two EPGT techniques differed susbtantialy but they were both significantly associated with leg press force and therefore linked to better ability to maintain balance after a slip or a trip. The "ankle not held" EPGT technique was more strongly correlated to leg press force (r(18) = 0.652, p = 0.002) than the "ankle held" (r(18) = 0.623, p = 0.003) and appears to be the more favourable technique to administer the EPGT. These findings offer new insight on a potential mechanistic link between the EPGT and the risk of falling and support its optimal use in future research involving older people.

Development and Earliest Validation of a Portable Device for Quantification of Hallux Extension Strength (QuHalEx)

Hallux strength is associated with sports performance and balance across the lifespan, and independently predicts falls in older adults. In rehabilitation, Medical Research Council (MRC) Manual Muscle Testing (MMT) is the clinical standard for hallux strength assessment, but subtle weakness and longitudinal changes in strength may go undetected. To address the need for research-grade yet clinically feasible options, we designed a new load cell device and testing protocol to Quantify Hallux Extension strength (QuHalEx). We aim to describe the device, protocol and initial validation. In benchtop testing, we used eight precision weights to apply known loads from 9.81 to 78.5 N. In healthy adults, we performed three maximal isometric tests for hallux extension and flexion on the right and left sides. We calculated the Intraclass Correlation Coefficient (ICC) with 95% confidence interval and descriptively compared our isometric force-time output to published parameters. QuHalEx benchtop absolute error ranged from 0.02 to 0.41 (mean 0.14) N. Benchtop and human intrasession output was repeatable (ICC 0.90-1.00, p < 0.001). Hallux strength in our sample (n = 38, age 33.5 ± 9.6 years, 53% female, 55% white) ranged from 23.1 to 82.0 N peak extension force and 32.0 to 142.4 N peak flexion, and differences of ~10 N (15%) between toes of the same MRC grade (5) suggest that QuHalEx is able to detect subtle weakness and interlimb asymmetries that are missed by MMT. Our results support ongoing QuHalEx validation and device refinement with a longer-term goal of widespread clinical and research application.

Plantar intrinsic foot muscle activation during functional exercises compared to isolated foot exercises in younger adults

BACKGROUND

Training the plantar intrinsic foot muscles (PIFMs) has the potential to benefit patients with lower extremity musculoskeletal conditions as well as the aged population. Isolated foot exercises, often standard in clinical practice, are difficult to perform, whereas functional exercises are much easier to accomplish. However, it is unclear whether functional exercises are comparable to isolated foot exercises in activating the PIFMs.

OBJECTIVE

This study aims to compare the activation of PIFMs between functional exercises versus isolated foot exercises.

METHODS

Using surface electromyography (EMG), muscle activation of three PIFMs was measured in four functional exercises (i.e. normal/unstable toe stance, toe walking, and hopping) versus a muscle-specific isolated foot exercise in 29 younger adults, resulting in 12 comparisons.

RESULTS

Functional exercises showed larger mean EMG amplitudes than the isolated foot exercises in 25% of the 12 comparisons, while there was no difference in the remaining 75%.

CONCLUSION

Functional exercises provoked comparable or even more activation of the PIFMs than isolated foot exercises. Given that functional exercises are easier to perform, this finding indicates the need to further investigate the effectiveness of functional exercises in physical therapy to improve muscle function and functional task performance in populations that suffer from PIFM weakness or dysfunction.

Association between toe pressure strength in the standing position and postural control capability in healthy adults

BACKGROUND

A method has been developed to assess toe pressure strength in the standing position, taking into account concerns about toe grip strength.

RESEARCH QUESTION

Which is more associated to postural control capability, the conventional toe grip strength or the newly devised toe pressure strength in the standing position, which is close to the actual movement?

METHODS

This study is a cross-sectional study. This study included 67 healthy adults (mean age, 19 ± 1 years; 64% male). The postural control capability was measured using the center-of-pressure shift distance in the anterior-posterior axis. Toe pressure strength in the standing position was assessed using a toe pressure measuring device to evaluate the force of pressure on the floor surface by all toes. During measurement, care is taken to ensure that the toes do not flex. However, toe grip strength in the sitting position was measured using muscle strength for toe flexion in a conventional manner. Statistical analysis was conducted by performing a correlation analysis between each of the measured items. Additionally, multiple regression analysis was used to examine the functions associated with postural control capability.

RESULT

Pearson's correlation analysis revealed that the postural control capability was correlated with toe pressure strength in the standing position (r = 0.36, p = 0.003). Multiple regression analysis demonstrated that only toe pressure strength in the standing position was significantly associated with the postural control capability, even after adjusting for covariates (standard regression coefficient: 0.42, p = 0.005).

SIGNIFICANCE

The results of this study indicated that toe pressure strength in the standing position was more strongly associated with the postural control capability in healthy adults than toe grip strength in the sitting position. It has been suggested that a rehabilitation program for toe pressure strength in the standing position would help improve postural control capability.

Intra- and inter-examiner reliability and minimal detectable change for different methods of measuring toe grip strength in healthy adults

[Purpose] This study aimed to compare the inter- and intra-examiner reliabilities of toe grip strength measurements obtained just above the first interphalangeal joint with those of toe grip strength measurements obtained in the most comfortable position for the participant. The study also aimed to calculate the minimal detectable change for the more reliable method. [Participants and Methods] The participants for each test included 20 healthy adult males and females. Intra-class correlation coefficient (1,1) and (2,1) values were calculated for both tests. Bland–Altman analysis was used to determine the systematic error and calculate the minimal detectable change. [Results] The intra- and inter-examiner reliabilities of measurements obtained by setting the position of the toe-grasping bar to the first interphalangeal joint were better than those obtained in the most comfortable position for the participant. Measurement of the minimal detectable change showed a random error of 4.97 kg. [Conclusion] We considered that toe grip strength measurements just above the first interphalangeal joint were better. The minimal detectable change was 4.97 in healthy adults.