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Norms for grip strength in children aged 4-16 years

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Acta Pñ diatr 91: 617± 625. 2002

Norms for grip strength in children aged 4–16 years

C Häger-Ross1 and B Rösblad1,2
Department of Community Medicine and Rehabilitatio n 1, Section for Physiotherapy , UmeaÊ University; Kolbäcken’s Child Rehabilitatio n
Centre 2, Kolbäcksvägen, UmeaÊ , Sweden

Häger-Ross C, Rösblad B. Norms for grip strength in children aged 4–16 years. Acta Pædiatr
2002; 91: 617–625. Stockholm. ISSN 0803-5253
The aim of this study was to provide norms for grip strength in children. A total of 530 Swedish
4–16-y-olds was tested with the instrument Grippit1. The instrument estimates peak grip strength
over a 10 s period, and sustained grip strength averaged across the 10 s. The increase in grip
strength with age was approximately parallel for boys and girls until 10 y of age, after which boys
were signiŽ cantly stronger than girls. Strong correlations existed between grip strength and the
anthropometric measures weight, height and, in particular, hand length. Right-handed children
were signiŽ cantly stronger in their dominant hand, while left-handers did not show any strength
difference between the hands. It is therefore suggested that when evaluating grip strength in left-
handed children both hands should be assumed to be about equally strong, while right-handed
children are expected to be up to 10% stronger with their right hand. Sustained grip strength was
consistently about 80–85% of peak grip strength, with somewhat lower values in younger children.
The present normative data for peak grip strength were slightly lower than 1980s’ data from the
USA and Australia, probably because of divergences in age grouping and in instruments used.
Conclusion: Norms for grip strength including estimates of variation were provided for children
aged 4–16 y. These data will enable therapists and physicians to compare a patient’s score with
the scores of normally developed children according to age, gender, handedness and body
measures.
Key words: Anthropometry, children, grip strength, hand, norms
C Häger-Ross, Department of Community Medicine and Rehabilitation, Section for Physiotherapy,
UmeaÊ University, SE-901 87 UmeaÊ , Sweden (Tel. ‡46 90 786 92 75, fax ‡46 90 786 92 67,
e-mail. charlotte.hager-ross@physiother.umu.se )

From early childhood it is necessary to produce enough
grip force to manage independently everyday tasks such
as eating and playing. Grip strength is important as a
measure of general health and is often estimated in
screenings of normal motor function. It is also regarded
as one of the most reliable clinical methods for
estimation of strength and is used extensively on adults
(1, 2). For children it has also become a routine as part
of the clinical assessment of hand function, since many
children with various diseases or lesions have reduced
grip strength. An estimation of grip strength is made to
identify the level of development and degree of
disability. It is also used for treatment planning and
evaluation. One problem is, however, a lack of relevant
developmental norms for the grip strength of children.
There are few studies presenting data for grip strength in
large groups of children and the most recent are from
the 1980s, providing data from children in the USA
(3, 4) and Australia (5, 6). These studies show higher
grip strength values than even earlier studies (7). In
analogy, grip strength scores in a group of American
children in 1964 were advanced by 1.5–2 y compared
with data collected as early as 1899 (8). Thus, the
general level of grip strength may change over genera-
tions and there may also be cultural differences.
Furthermore, rapid technological advances facilitate
more and more accurate and easily achieved assess-
ments. A weakness of existing studies is that the testing
procedures vary, and the instruments that have been
used are often not tested for reliability in children. There
are thus numerous reasons for repeatedly collecting data
on developmental norms for grip strength in children.
In adults, a number of different instruments and
methods to evaluate grip strength have been used (9–12)
and the importance of reliability has been emphasized
(13, 14). A relatively new instrument is the Swedish
Grippit1 (AB Detektor, Göteborg), which in addition to
a measure of maximum grip strength provides a value of
sustained grip strength re ecting endurance. The
instrument has been found to have good reliability in
healthy adults (15, 16) as well as in patients with
rheumatoid arthritis and Ž bromyalgia (15). Grippit is
now available in a version for children. The test
instrument has rapidly become widely used in clinical
settings in Sweden but so far there are no normative data
on children in various age groups. Even in healthy

Ó 2002 Taylor & Francis. ISSN 0803-525 3

618 C Häger-Ross and B Rösblad
children of the same age, there is usually a large
variability in grip strength. It is therefore essential to
obtain an estimate of the average grip strength and the
variations that exist in children of different ages. By
studying the development of muscle strength in normal
children one can, in addition to the age effect, highlight
in detail the impact of body composition and examine
whether there are substantial differences between boys
and girls. In a recent review on muscle function
assessment in children, Jones and Stratton (17) empha-
size the need for normative databases, and they
speciŽ cally point out the importance of reliability and
standardization in the context.
The reliability of the use of the Grippit instrument in
children will be addressed in a parallel study, while the
aim of the present study was to create normative
measures of grip strength in healthy Swedish 4–16-y-
olds using Grippit. SpeciŽ c issues were: (ii) to describe
in detail the increase in grip strength with age; (ii) to
examine differences between boys and girls; (iii) to
investigate how anthropometric values such as body
weight, height and hand length relate to grip strength;
and (iv) to determine whether there are differences in
grip strength between the hands.
Subjects and methods
A total of 530 Swedish children participated (267M,
263F). The children were Caucasian, with very few
exceptions. They were aged 4–16 y (range 3 y, 8 mo to
16 y, 5 mo), distributed over approximately equal
numbers of girls and boys in each age group of 1 y
intervals. Only in the youngest group of 4-y-olds were
there fewer than 15 children of each gender. Each child
was included in the year category closest to her or his
exact age. The mean age of each group was always
within about §1 mo of the precise year age and had an
SD of less than 3 mo. The only exceptions were the 12-
y-old boys who had on average 3 mo left until their 12th
birthday. To be included in the study the child was
required to be born healthy and not later than 36 wk of
gestation. No children with medical diagnoses or other
functional limitations that may have in uenced hand
strength at the time of testing were included.
All children and their parents gave their informed
consent according to the Declaration of Helsinki and the
study was approved by the ethics research committee of
UmeaÊ University. The children were recruited from and
tested at about 20 different day care centres and schools
randomly chosen in the municipality of UmeaÊ in
northern Sweden. Data collection took place during
the school year 2000–2001.
Instrument
The Grippit dynamometer (Fig. 1) was used to measure
grip strength. Previous versions of the instrument have
been described in detail elsewhere (15, 16). It consists
ACTA PÆDIATR 91 (2002)
Fig. 1. Schematic drawing of the Grippit1 instrument.
of a strain gauge with exchangeable handles that are
connected to an electronic unit. For power grip there are
two different handle sizes. The smaller handle, adapted
to a child’s hand size, is 27 mm in both depth and width,
with a circumference of 95 mm. The larger handle, for
an adult’s hand size, has a depth of 45 mm, a width of
27 mm and a circumference of 125 mm. The handles
and the strain-gauge unit are mounted on a portable
table measuring 45 £ 35 cm on which is Ž xed a
supporting plastic cast for the forearm. The apparatus
is programmed to measure grip strength over a period of
10 s, during which the values are displayed on the
electronic unit every 0.5 s. At the end of the 10 s period
three values are displayed: (i) the peak value obtained
during the 10 s, here denoted “peak grip strength”; (ii)
the mean value averaged across the 10 s, termed
“sustained grip strength”; and (iii) the Ž nal value over
the last 0.5 s period, referred to as “Ž nal grip strength”.
All of these values are given in Newtons (N) in the
range 0–999 N with a resolution of 1 N. The apparatus is
easy to transport and mount. The Ž xed position for the
handles and the supporting cast facilitate reproducible
measurements. The calibration of the instrument was
checked before, during and after the test period using
different exact weights in the range 0.5–50 kg. The
accuracy was proved to be satisfactory; any deviations
were always within 1.5% of the calculated adequate
value.
Test procedure
The child was seated upright on a chair in front of the
instrument, which was placed on a table. The subject’s
feet were supported and the arm was held in the
supporting cast of the instrument while gripping the
handle. The recommendations of the American Society
of Hand Therapists for a standardized position were
followed; shoulder adducted and in neutral rotated
position, elbow in about 90°  exion, forearm semiprone
ACTA PÆDIATR 91 (2002)
and wrist in a neutral resting position (2, 4). If
necessary, a folded cloth was inserted under the forearm
of the child to avoid extensive radial  exion of the wrist
in the smaller children. An antislip cloth was placed
under the platform of the instrument to prevent it from
sliding. The platform was also stabilized by the
examiner. The child grasped the handle and was
allowed to become familiar with the instrument by
obtaining a good grip, squeezing lightly and watching
the corresponding increase in grip strength on the digital
display. When ready, the child was asked to squeeze as
hard as possible for 10 s on a verbal “go” signal. Three
trials for each hand were conducted, alternating hands,
and always starting with the dominant hand. There was
always a break of at least 2 min between the tests on the
same hand. The results of each of the three tests per
hand were noted in a test protocol. Some verbal
encouragement was given, such as “do your best”,
“press harder” or “well done”.
Body weight was registered on a digital scale with an
accuracy of §0.1 kg. Height was measured with an
accuracy of 0.5 cm. The outline of the child’s hand was
drawn on paper and was used to measure hand length
(cm) from processus styloideus radii to the tip of the
distal phalanx on the third Ž nger (accuracy 0.5 cm). The
hand length determined choice of handle; if the hand
length was <16 cm the smaller handle was used, while
children with a hand length of 16 cm or more used the
bigger handle. The child was also helped by the
examiner to Ž ll in a Swedish translation of the
Edinburgh hand test (18), a 10-item questionnaire used
to quantify hand dominance on a ‡100 (maximally
right-handed) to ¡100 (maximally left-handed) lat-
erality quotient scale. Children aged 13 y or older
completed the form on their own. The youngest children
were asked to carry out most of the tasks asked about in
the questionnaire to determine which hand they
preferred. The child was considered as right-handed if
a positive value was obtained on the test and left-handed
if a negative value was obtained.
Data analysis
The following measures were used: “Peak grip
strength” refers to the highest peak grip strength value
(three per hand; six in total) observed for a child,
irrespective of which hand produced it. Peak grip
strength will also be reported for the dominant hand
separately. “Averaged peak grip strength” was calcu-
lated as the mean of the maximum value during the
three test trials per hand. “Sustained grip strength” was
the average grip strength measured over the 10 s trial
and taken from the trial with the highest peak grip
strength value. SPSS (Statistical Package for Social
Sciences 1, Version 10, 0) was used for statistical
analyses. A repeated measure analysis of variance
(ANOVA) was used, specifying age, gender and
handedness as between-subject factors, and trial number
Grip strength in children 619
Fig. 2. Box plot illustratin g peak grip strength (irrespectiv e of hand)
in each age group for boys (shaded boxes) and girls (white boxes).
Each box represents the 25th–75th percentile , and the horizonta l line
across the box is the median (50th percentile) . Whisker lines
extendin g above and below each box indicate the total range, with
the exceptio n of small circles beyond the whiskers that represen t
outliers >1.5 box lengths away from the bottom or top of the box (the
male outlier in the 16 y age category practised heavy weight lifting).
and hand as within-subject factors for peak grip
strength. The Tukey post-hoc test in separate ANOVAs
was used to examine differences in peak grip strength
between speciŽ c age groups for boys and girls.
Logarithmic transformation of the data was performed
to fulŽ l the criteria for using ANOVA. The t-test and
paired t-test were used to determine between-group and
within-subject differences regarding hand differences,
respectively. Pearson’s coefŽ cient of correlation, linear
and multiple linear regression were used to evaluate the
contribution of age and anthropometric measures to
variability in grip strength. The level of probability
chosen as statistically signiŽ cant was p < 0.05.
Results
Development of grip strength in relation to age and
gender
Figure 2 and Tables 1 and 2 describe the gradual
increase in grip strength with age for girls and boys.
Although boys were generally stronger, as indicated by
a main effect by gender (F1,481 = 41.0, p < 0.0001;
ANOVA), there was no signiŽ cant difference in grip
strength between the genders until around 10 y of age,
after which the boys were signiŽ cantly stronger than the
girls. After this age the boys displayed a steeper
increase in their grip strength year by year compared
with the girls, as supported by an interaction effect by
age and gender (F12,962 = 9.7, p < 0.0001). At the age of
620 C Häger-Ross and B Rösblad ACTA PÆDIATR 91 (2002)

Table 1. Grip strength (N) for boys (n = 267).

Peak grip strength Average peak grip

Age Peak grip strength dominant hand strength dominant hand Height Weight Hand length
(y) n (N) (N) (N) (cm) (kg) (cm)
4 11 57.9 § 15.6 56.5 § 16.2 50.8 § 14.3 103.4 § 6.9 17.2 § 3.8 12.0 § 0.9
(32–83) (32–83) (25–75) (93.0–114.0) (12.0–24.0) (10.5–13.5)
5 20 69.0 § 17.1 66.2 § 17.9 57.0 § 16.4 109.0 § 4.9 18.1 § 3.0 12.7 § 0.9
(43–105) (43–102) (26–89) (101.0–118.0) (14.0–27.6) (11.0–14.5)
6 15 83.1 § 18.3 81.1 § 18.7 72.2 § 14.2 116.5 § 4.5 22.4 § 3.7 12.9 § 0.9
(52–123) (52–118) (48–96) (109.0–125.0) (18.0–30.6) (12.0–15.0)
7 21 103.1 § 20.4 97.4 § 21.9 88.0 § 21.3 123.5 § 6.0 25.1 § 3.7 13.9 § 0.6
(57–142) (42–135) (34–121) (115.0–134.0) (18.0–33.0) (13.0–15.0)
8 18 125.5 § 21.8 124.3 § 22.5 112.5 § 20.6 132.7 § 5.7 30.4 § 4.3 14.3 § 0.8
(94–163) (94–163) (68–148) (125.0–142.0) (23.2–38.0) (13.0–16.0)
9 27 136.9 § 26.0 134.0 § 27.3 124.5 § 26.6 138.0 § 7.9 29.2 § 4.5 14.8 § 0.8
(92–208) (92–208) (76–198) (126.0–154.0) (18.4–43.5) (13.5–16.0)
10 25 167.1 § 27.3 165.7 § 28.3 153.0 § 26.0 142.8 § 6.7 38.3 § 8.5 15.2 § 0.9
(111–228) (105–228) (99–221) (127.0–158.0) (24.4–59.0) (13.5–17.0)
11 20 187.6 § 39.5 183.2 § 36.0 165.3 § 33.1 145.0 § 6.1 37.7 § 6.8 15.6 § 0.9
(140–283) (135–266) (119–236) (134.0–158.0) (27.0–50.5) (14.0–17.5)
12 20 219.9 § 38.1 214.4 § 38.0 199.4 § 37.2 153.4 § 7.4 44.8 § 10.3 16.6 § 1.0
(125–282) (118–282) (114–267) (140.0–170.0) (32.0–73.0) (15.0–18.5)
13 20 274.9 § 65.7 269.6 § 66.0 255.6 § 66.3 158.2 § 9.0 46.9 § 9.4 17.0 § 1.2
(170–389) (142–387) (133–381) (140.0–176.0) (32.4–70.0) (14.5–19.5)
14 27 343.4 § 74.7 341.4 § 75.3 318.7 § 70.2 170.4 § 8.2 61.3 § 12.3 18.4 § 1.2
(228–498) (228–498) (221–468) (156.0–186.0) (40.2–94.5) (16.5–21.5)
15 21 414.7 § 84.1 413.8 § 84.4 388.9 § 81.2 173.5 § 5.4 64.1 § 12.0 19.1 § 1.1
(258–595) (257–595) (243–532) (166.0–185.0) (50.5–96.0) (17.5–21.0)
16 22 490.6 § 74.9 488.6 § 73.1 454.4 § 68.6 179.9 § 5.5 68.2 § 9.0 19.6 § 1.0
(371–720) (371–720) (340–654) (170.0–192.0) (57.8–91.0) (17.0–21.0)

Data are means § SD (minimum–maximum).

n: number of children.
Peak grip strength refers to data from the best trial independen t of hand dominance. Average peak grip strength refers to the mean of three tests.
Anthropometric measures for height, weight and hand length are also given.

13 y there was a signiŽ cantly higher grip strength
compared with that of the 1 y younger age group of
12-y-olds for boys ( p = 0.002; post-hoc Tukey), while
for girls it occurred between the age groups 10 and 11 y
of age ( p = 0.0001; post-hoc Tukey) and then again
between 12 and 13 y, after which both genders
displayed signiŽ cant differences between each year
category (Fig. 2). The 10-y-old girls generally showed
slightly lower grip strength than the 9-y-old girls, and
their average weight was also lower than the younger
girls (Table 2). By the age of 16 y, the boys displayed a
peak grip strength on average about 55% higher than
that of the girls (Tables 1, 2).
To estimate within-subject variability, the coefŽ cient
of variation of peak grip strength was calculated for all
of the children (measured over all six trials). As shown
in Fig. 3, the within-subject variability was highest
among the youngest children and diminished with age
(F12,481 = 8.6, p < 0.001).
In most of the cases, 62.3%, the children generated
the peak grip strength value in the Ž rst of the three test
trials per hand. There was a main effect by trial
(F2,480 = 52.0, p < 0.0001). In 20% of the cases the
peak grip strength was reached in the second trial, while
the peak grip strength was obtained in the third and last
trial in 17.7%. An obvious decrease in peak force over
the test trials was seen only in the teenage groups
between 13 and 16 y of age (interaction trial and age
F24,962 = 3.6, p < 0.001). The age groups <12 y did not
show such a decrease in force level over the trials.
In addition to the in uence of age and gender on grip
strength, the relationships between peak grip strength
and the anthropometric data height, weight and hand
length were analysed. Pearson’s correlation coefŽ cient
between peak grip strength and the variables height,
weight and hand length was 0.90, 0.90 and 0.91,
respectively (p < 0.0001 in all cases) for the boys.
Corresponding coefŽ cients for the girls were 0.87, 0.87
and 0.85 (p < 0.001 in all cases).
A multiple regression equation was developed to
predict peak grip strength from age, height, weight and
hand length. Within the male group the R 2 was 0.87
(p < 0.0001), indicating that the combination of age,
weight, height and hand length accounted for 87% of
the variability in peak grip strength. For the girls the R 2
was 0.83 (p < 0.0001). The R 2 was divided into the
components attributable to each variable through the
use of standardized beta (b)-weights. This analysis
showed that for both genders, the parameters age, hand
length and weight accounted for most of the variability
in peak grip strength. The contribution of age, weight
and hand length were signiŽ cant for both girls and boys
ACTA PÆDIATR 91 (2002) Grip strength in children 621

Table 2. Grip strength (N) for girls (n = 263).

Peak grip strength Average peak grip

Age Peak grip strength dominant hand strength dominant hand Height Weight Hand length
(y) n (N) (N) (N) (cm) (kg) (cm)
4 10 64.5 § 8.9 61.6 § 10.5 54.7 § 12.0 102.7 § 1.5 16.2 § 1.9 11.8 § 1.0
(50–79) (45–79) (35–74) (100–105) (12.5–19.5) (10.5–13.5)
5 23 64.0 § 13.0 62.8 § 14.0 55.1 § 4.4 110.3 § 4.0 18.8 § 2.7 12.2 § 0.8
(40–84) (38–84) (30–80) (100.0–117.0) (15.0–25.2) (11.0–13.5)
6 22 82.0 § 22.7 78.7 § 22.2 70.6 § 21.5 114.8 § 5.8 19.9 § 4.9 13.0 § 0.7
(28–129) (18–111) (17–105) (104.0–124.0) (13.0–33.6) (11.5–14.5)
7 24 91.8 § 14.1 89.1 § 14.4 80.8 § 14.0 123.2 § 6.6 24.6 § 4.4 13.1 § 1.0
(68–120) (68–120) (51–104) (114.0–145.0) (18.0–38.5) (11.0–14.5)
8 17 106.2 § 21.6 101.9 § 21.9 96.1 § 21.8 131.1 § 6.6 29.4 § 4.2 14.1 § 0.8
(63–144) (57–137) (53–128) (122.0–141.0) (22.5–38.0) (12.5–15.0)
9 20 127.4 § 16.1 122.4 § 16.9 114.0 § 14.9 136.6 § 6.8 34.1 § 8.3 14.6 § 0.9
(99–161) (88–161) (87–148) (126.0–150.0) (22.0–51.0) (13.0–16.0)
10 20 121.0 § 28.9 118.4 § 30.1 110.1 § 30.4 138.8 § 6.6 32.6 § 5.8 14.9 § 1.0
(66–173) (66–173) (49–163) (123.0–149.0) (25.0–45.0) (13.5–17.0)
11 21 165.7 § 39.8 163.9 § 39.1 149.1 § 35.2 148.0 § 9.8 39.4 § 8.5 16.0 § 1.0
(98–224) (98–224) (91–209) (126.0–168.0) (27.0–58.6) (13.0–17.5)
12 23 177.3 § 46.3 173.9 § 47.0 158.4 § 42.3 153.6 § 7.5 45.7 § 6.8 16.3 § 1.1
(117–298) (117–298) (100–269) (142.0–170.0) (33.5–57.0) (14.5–18.5)
13 22 233.0 § 62.9 231.7 § 64.1 212.2 § 56.4 158.4 § 7.6 47.8 § 7.8 17.1 § 1.2
(125–384) (125–384) (110–360) (137.0–170.0) (31.6–67.0) (14.5–19.5)
14 24 282.5 § 54.0 276.5 § 54.1 256.1 § 52.5 162.4 § 7.5 51.3 § 9.3 17.5 § 1.0
(167–378) (167–378) (161–358) (142.0–174.0) (30.0–68.5) (15.0–19.0)
15 21 288.9 § 34.3 285.8 § 35.9 264.7 § 33.6 168.8 § 6.3 59.0 § 9.2 17.6 § 0.9
(220–356) (220–356) (199–322) (158.0–180.0) (45.4–86.6) (16.5–19.5)
16 16 322 § 53.7 318.5 § 56.2 293.2 § 50.8 167.2 § 5.0 60.4 § 6.8 17.6 § 0.8
(247–440) (222–440) (216–409) (157.0–176.0) (50.4–76.5) (16.5–20.0)

Data are means § SD (minimum–maximum).

n: number of children.
Peak grip strength refers to data from the best trial independent of hand dominance. Average peak grip strength refers to the mean of three tests.
Anthropometric measures for height, weight and hand length are also given.

(p < 0.001 in all cases), while height did not add dominant hand (F1,481 = 1.83, p = 0.2). There was an
anything to the model for the boys (p > 0.13) and little interaction, however, between hand and hand domi-
but still signiŽ cantly for the girls (p < 0.02). The results nance (F1,481 = 45.4, p < 0.0001), as about 80% of the
for correlation coefŽ cients and multiple regression right-handed subjects were stronger in their dominant
analyses were similar when using averaged peak grip
strength (measured over the three test trials) as a
dependent variable instead of peak grip strength.
The Grippit instrument also provides a measure of
grip strength averaged over 10 s, here referred to as
sustained grip strength. The development of the
sustained grip strength with age consistently followed
the same pattern as that for peak grip strength (Tables 3,
4). The ratio between the sustained grip strength and the
peak grip strength was about 60–85%, with the lower
values relating to the younger age groups. From 9 y and
older, the ratio was above 80%, with the single
exception of the girls in the 10-y-old group (75%).

Hand dominance and grip strength

Of the 530 children, 476 were right-handed (90%) and
54 left-handed (10%), equally distributed between
girls and boys. There was a main effect by hand
(F1,481 = 15.3, p < 0.0001), indicating that the peak grip Fig. 3. CoefŽ cient of variation of peak grip strength for each year
strength for the right hand was signiŽ cantly higher than category expresse d in percent as the mean § SD (estimated over all
for the left hand, while there was no main effect of the six trials in one child). Solid lines: boys; dashed lines: girls.
622 C Häger-Ross and B Rösblad ACTA PÆDIATR 91 (2002)

Table 3. Sustained grip strength averaged over 10 s for boys aged 4–

16 y.

Ratio Sustained grip

Sustained grip Minimum– strength/ Peak grip
Age strength 10 s maximum strength
(y) (N) (N) (%)
4 35.5 § 13.6 (14–67) 61 § 13
5 45.7 § 15.2 (25–76) 65 § 10
6 60.0 § 17.7 (32–66) 71 § 9
7 73.2 § 24.5 (30–125) 70 § 12
8 97.7 § 21.9 (56–135) 77 § 7
9 113.3 § 25.0 (73–189) 82 § 5
10 137.8 § 24.3 (88–186) 83 § 7
11 156.2 § 38.0 (98–246) 83 § 7
12 186.3 § 35.5 (107–264) 85 § 5
13 236.2 § 55.7 (141–323) 86 § 6
14 304.5 § 72.2 (195–462) 88 § 4
15 359.5 § 87.1 (208–551) 86 § 5
16 423.4 § 83.0 (226–655) 86 § 1

Data are means § SD (minimum–maximum).

Values taken from trial with the highest peak grip strength value.
Proportion of sustained grip strength in relation to peak grip strength is
indicated by Ratio.
right hand while more than 60% of the left-handed
children produced a higher peak grip value with their
non-dominant right hand (Fig. 4). For left-handed
children, the difference between peak grip strength for
the dominant and non-dominant hand was not signiŽ -
cant ( p = 0.7; paired t-test). A few of the children
showed the same peak grip strength value for both
hands (Fig. 4).
Both boys and girls were on average about 10%
stronger in the right hand than in the left; the ratio
between peak grip strength for the right and the left
hand pooled across hand dominance was 1.10 § 0.15.
Fig. 4. Proportions of children who produced their peak grip strength
with the dominant and non-dominan t hand, respectively . Shaded
bars: children stronger in the dominant hand; white bars: childre n
stronger in the non-dominan t hand; black bars: children with the
same peak grip strength value for both hands.
This ratio was higher for 46% of the younger children
<10 y, indicating a more pronounced difference be-
tween the hands, while in the older children the ratio
was fairly consistent, around 1.1 in all groups. The
right-handed children were not signiŽ cantly stronger in
their right hand, compared with how the left-handed
children were in their right hand ( p = 0.1, t-test).

Table 4. Sustained grip strength averaged over 10 s for girls aged 4–

Discussion
16 y. In this study normative data are presented for grip
strength in children aged 4–16 y using the Grippit
Ratio Sustained grip
Sustained grip Minimum– strength/ Peak grip
instrument. The reliability of Grippit when testing
Age strength 10 s maximum strength children was evaluated in a separate report parallel to
(y) (N) (N) (%) this study and was proved to be satisfactory (Häger-
4 40.50 § 10.1 (21–50) 63 § 14 Ross, unpublished observations). The main results show
5 43.65 § 13.2 (21–74) 67 § 10 that grip strength, as expected, increases with age, that
6 58.41 § 20.0 (14–91) 70 § 11 boys are generally stronger than girls and that anthro-
7 69.38 § 13.4 (50–93) 76 § 9
8 80.47 § 21.7 (45–129) 75 § 10
pometric measures correlate positively with grip
9 103.05 § 15.9 (74–134) 81 § 7 strength. The Ž ndings are consistent with those of
10 93.1 § 29.0 (21–148) 75 § 12 previous studies in other countries presenting grip
11 133.29 § 42.0 (56–199) 80 § 14 strength norms for children (4–6). These reports did
12 145.52 § 34.8 (96–240) 83 § 7 not, however, explore in detail the differences in grip
13 197.86 § 53.9 (102–326) 85 § 5
14 238.54 § 51.3 (145–353) 84 § 7 strength between the genders in relation to age. In the
15 250.38 § 40.1 (168–328) 86 § 6 present study the 4–7-y-old girls and boys were equally
16 283.00 § 55.9 (193–408) 88 § 5 strong, after which boys tended to produce higher grip
Data are means § SD (minimum–maximum).
strength than girls. It seems, nevertheless, that it is not
Values taken from trial with the highest peak grip strength value. until towards the early teenage years that boys become
Proportion of sustained grip strength in relation to peak grip strength is signiŽ cantly stronger and display a steeper increase in
indicated by Ratio. grip strength compared with girls.
ACTA PÆDIATR 91 (2002)
Fig. 5. Comparison of studies of grip strength in children aged 5–17 y
for (A) boys and (B) girls. Earlier reports of grip strength given in
pounds have been recalculate d as Newtons (N) for comparison . Note
that different instruments and procedure s were used (see text).
As shown in Fig. 5, the development of strength with
age in this study was similar to that in previous studies
from Australia (5, 6) and the USA (4), although
different instruments and procedures were used.
Mathiowetz et al. (4) and Fullwood (6) both used a
Jamar dynamometer, whereas Newman et al. (5) used a
custom-made strain-gauge dynamometer. The Swedish
data are nevertheless at the lower end of the range of
grip strength values for each age group below 14 y. A
plausible explanation for this discrepancy, in addition to
the use of different grip strength devices, is that
different procedures for age grouping were applied.
Whereas this study included children in the year age
category closest to their total age, Mathiowetz et al. (4)
used only chronological year age grouping and divided
the groups in 2 y intervals. As pointed out by
Mathiowetz et al., it is likely that they had children
with a higher mean age in each age category than in the
Grip strength in children 623
study by Fullwood (6), and this is also expected to be
true in comparison with the present study. This is
supported by the fact that in the age groups above 14 y,
all studies show similar averages (Fig. 5).
It could also be speculated whether different grip
strength levels in different decades re ect dissimila-
rities between generations. Monpetit et al. (8), for
instance, reported increases in children’s grip strength
over the past century, followed by an increase in weight.
This trend towards an increase in grip strength may be
changing, as there are alarming reports of overweight in
childhood combined with a decrease in Ž tness (19).
Anthropometric factors
It has long been known that body measures such as
weight, body height, hand width, hand length and Ž nger
length correlate with grip strength in humans (20). To
the authors’ knowledge, however, few studies in
children have thoroughly investigated the contribution
of hand length to grip strength. A study of grip strength
in children aged 3–6 y found a positive correlation
between hand width and grip strength (21), matching
earlier Ž ndings that palm width is the most in uential
independent variable for pinch strength (22). Another
study demonstrated a strong correlation between Ž nger
length and pinch strength (23). The present analysis
using multiple regression further conŽ rms that hand
length is an important factor for grip strength, in
addition to age and weight. Height had less impact in
this study, although it contributed signiŽ cantly for girls.
The results showed a progressive increase in grip
strength with age for both genders. A signiŽ cant
increase in grip strength occurred around 12–13 y of
age for boys, and earlier for girls (see Fig. 2). This
probably coincides with puberty being reached within
these age groups, involving particular physical growth.
Biological maturity is known to have a strong impact on
strength measures, especially for boys (24).
Differences in strength between the hands
Ambiguous results in the past have left unanswered
whether people in general are stronger in their dominant
hand. Adults are often reported to be about 10%
stronger in their dominant hand (1, 12, 25). This
assumption has, however, been questioned and later
suggested to be valid only for right-handed subjects
(26). If one examines the literature on the relationship
between hand dominance and grip strength in children,
the importance of the dominant hand is likewise not
clear. A review from 1993 concluded that the right hand
is stronger for right-handed children while Ž ndings for
left-handers are inconsistent (27). Several studies
(3, 4, 6) did not report any effect of hand dominance
on grip strength, while Newman et al. (5) found a
difference in grip strength between the dominant and
non-dominant hand. In the present study the right-
handed children were stronger in their right hand, while
624 C Häger-Ross and B Rösblad
no statistical difference between the hands was ob-
served for the left-handed children. This is also in
analogy with the Ž ndings by Fullwood (6). On the
contrary, most left-handed children produced their
maximum grip strength value with their right, non-
dominant hand. One obvious reason for the inconclusive
Ž ndings in the literature may be the often very small
sample size of the left-handed group. Moreover, that
left-handed subjects do not show any difference in
strength between their hands may re ect the expecta-
tions of society that people should be right-handed. That
is, tools are designed predominantly for right-handed
people, which may lead to a stronger right hand in left-
handed children. Nonetheless, the neurodevelopmental
background to lateralization per se, including handed-
ness, is still far from explored. It may be suggested that
when evaluating grip strength in left-handed children,
one should assume that both hands are about equally
strong, while right-handed children are expected to be
up to 10% stronger with their right hand.
Measurement procedure
To optimize comparisons between studies earlier
recommendations were followed in terms of standard
procedures, instructions and number of test trials (4).
One subject of debate is how many test trials should be
administered when estimating grip strength in children.
Most studies recommend three test trials (4, 14, 21, 28)
or more, although some authors have used only one (6)
or two trials (3, 5). In the present study the children
produced their peak grip strength value in the third and
last trial in about 18% of the cases. This was especially
true of the younger children, below 13 y of age, who
also showed the highest intra-individual variation. One
of the principal properties of normal development is
variation (29); both within-child and between-child
variability is high when estimating almost all kinds of
developmental variables. A test procedure should
therefore include at least three measures of the peak
grip strength, especially in young children. This is in
analogy with earlier suggestions for adults (14), where
some authors even suggest a multitrial approach using
the last three trials (16). Three test trials can be
performed seemingly without fatigue effects or im-
provement with practice (9). The importance of
“warming up” the muscles and being familiar with both
the instrument and the task have been emphasized in the
context of advocating even more test trials (30). In the
present study, the older children, over 13 y of age,
showed a slight decrease in grip strength over the three
trials, but the differences in means were so small that
they were not expected to be of any importance. In any
case, by calculating both the peak grip strength and the
averaged grip strength these two separate indices of
strength were covered.
The possibility of measuring grip strength endurance
with the Grippit instrument adds another dimension to
ACTA PÆDIATR 91 (2002)
the evaluation of grip strength. The consistent ratio of
about 80% between the sustained grip strength
measured over 10 s and the peak grip strength from
the age of 9 y is comparable to the stable ratio that has
been shown for healthy women and men (15). This
constant relationship could be useful when evaluating
grip strength in a clinical context.
The Ž nal grip strength, that is the grip strength value
provided by the Grippit instrument during the last 0.5 s,
may be less valuable when testing children. The
apparatus does not by default provide a consecutive
curve of the force measurement over time, which in
adults would typically show a more or less continuous
slow force decline after the peak value. In children,
however, the force level could rise and fall substantially
over the 10 s period, as could be seen by glancing at the
display while testing. In fact, 343 children (¹65%)
showed, on at least one of their total of six tests, a higher
Ž nal grip strength for the last 0.5 s than the sustained
grip strength (averaged over the entire test trial). For
this reason these data were not reported.
In summary, normative data for grip strength includ-
ing estimates of variation were provided for children
aged 4–16 y using the Grippit instrument. The results
were consistent with previous studies from other parts
of the world using different measuring devices. Boys
were found to be stronger than girls after the age of 10 y.
In addition to age, hand length and body weight
accounted for most of the variability in grip strength.
Right-handed children were about 10% stronger with
their dominant right hand, while left-handed children
did not show any difference in grip strength between the
hands. The data reported will enable therapists and
physicians to compare a patient’s score with the scores
of normally developed children according to age,
gender and body measures.
Acknowledgements.—We would like to thank all of the children, their
parents and the staff in schools, childcare centres and the Educational
Department of UmeaÊ community whose participation and co-operation
made this project possible. The assistance of the physiotherapist s Anna
Berglund, Iréne Kats, Elisabeth Nilsson and Ulrika Segolson in the
project is gratefully acknowledged . Financial support was received from
Oscarsfonden, UmeaÊ University.
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Received Sept. 10, 2001; revision received Feb. 18, 2002; accepted
Feb. 20, 2002