Reliability and validity of grip and pinch

strength evaluations
Twenty-seven college women participated in a study to evaluate the reliability and validity of four
tests of hand strength: grip, palmar pinch, key pinch, and tip pinch. Standardized positioning
and instructions were followed. The results showed very high inter-rater reliability. Test-retest
reliability was highest in all tests when the mean of three trials was used. Lower correlations were
shown when one trial or the highest score of three trials were utilized. The Jamar dynamometer
by Asimow Engineering and the pinch gauge by B&L Engineering demonstrated the highest
accuracy of the instruments tested. (J HAND SURG 9A:222-6, 1984.)

Virgil Mathiowetz, M.S., Karen Weber, B.S., Gloria Volland, B.S., and
Nancy Kashman, B.S., Milwaukee, Wis.

Therapists and physicians frequently mea-
sure hand strength. The tests establish a baseline from
which to assess improvement, compare the effective-
ness of various surgical or treatment procedures, set
realistic treatment goals, and assess a patient's ability
to return to previous employment. 1 Any evaluation
used to measure hand strength must be reliable and
valid. This is normally enhanced by the use of standard-
ized positioning and instructions. 2
Normative data for grip and pinch strength that were
collected by Kellor et al. 3 are the most commonly used
in therapy clinics. Their study controlled for age and
sex variables but lacked standardized procedures for
testing (e.g., test position, instruction, etc.). Neither
test-retest nor inter-rater reliability data were reported.
The pinch meter used in their study is no longer com-
mercially available. Therapists have noted that the
newer pinch gauge appears to register a higher score for
the same person than the original pinch meter. 1 Be-
cause of these limitations new norms are needed for
grip and pinch strength evaluations .
Grip strength measurement
The American Society of Hand Therapists (ASHT)
recently recommended standardized positioning for
From the University of Wisconsin-Milwaukee Occupational Therapy
Program.
Received for publication April 18, 1983; accepted in revised form
June 30, 1983.
Reprint requests: Virgil Mathiowetz, M.S ., University of Wiscon-
sin-Milwaukee, Occupational Therapy Program, P. O. Box 413,
Milwaukee, WI 53201.
grip-strength measurements. 4 They recommended that
"the patient should be seated with his shoulder ad-
ducted and neutrally rotated, elbow flexed at 90° and
the forearm and wrist in neutral position. " Published
studies on the effects of positioning on grip measure-
ment pertain to wrist position only . Pryce5 found no
significant difference in grip strength with the wrist
positioned at 0° and 15° ulnar deviation and 0° and 15°
extension or any combination of these. Kraft and De-
tels 6 found no significant difference with the wrist po-
sitioned at 0°, 15°, and 30° extension (0° ulnar devia-
tion) in measuring grip strength. Both studies found
grip strength to be significantly less at 15° of palmar
flexion. 5 , 6 Although there are no studies on the effect
of elbow position on grip strength, it is reasonable to
assume it might be a variable that should be controlled.
In addition, none of the studies on hand strength2. 7-9
report specific verbal instructions given to subjects. It is
thought that verbal instruction can affect performance
on evaluation tests.2
A variety of instruments are available to measure
grip strength. A California Medical Association com-
mittee study headed by Kirkpatrick \0 compared the
three types of grip-measurement instruments available:
(1) a pneumatic instrument that depends on compres-
sion of air by means of a rubber bulb, (2) a spring
device that depends entirely on compression of a steel
spring to register the amount of compression, and (3) a
sealed hydraulic system that registers force in pounds.
The committee found that devices which measure grip
pressure by squeezing a bulb filled with fluid, liquid, or
air and the common spring dynamometers can only
measure the pressure of grip and not its force. The

222 THE JOURNAL OF HAND SURGERY

Vol. 9A, No.2
March 1984
•.•.
Fig. 1. Grip strength measurement. This standardized arm
and hand positioning was used for all hand strength mea-
surements .
authors summarized three basic factors of grip mea-
surements: "(1) Grip is a force, (2) Grip is not a pres-
sure, (3) Measurement of grip must be in force units
such as the pound or gram." This committee further
studied the Jamar Dynamometer* and found it "per-
fected to the extent that its sealed hydraulic system is as
nearly leakproof as any mechanical appliance can be
made." The Jamar Dynamometer was recommended as
the best measure of grip strength.
A study using the Jamar Dynamometer has shown
that maximum readings occur most frequently with the
second or third handle position and on the first or sec-
ond attempt of a series of successive trials. II Conse-
quently the ASHT recommended that "the second
handle position of the dynamometer be used when
evaluating grip strength" and that the mean of three
successive trials be used as the measure of grip
strength. 4 This is in contrast to Kellor's study,3 which
did not standardize handle position and used the higher
score of two trials.
Pinch strength measurement
There are few instruments commercially available to
measure pinch strength. 12 • 13 The Osco pinch meter
used in Kellor's study is no longer commercially avail-
able. It appears that most clinics are now using the
Pinch Gauget as an alternative. Recently the Preston
Pinch Gauget was made available commercially. No
*Jamar Dynamometer, Asimow Engineering Co, Los Angeles, CA
90024.
tPinch Gauge: B&L Engineering, Santa Fe Springs. CA 90670.
tPreston Pinch Gauge: J.A . Preston Corporation , Clifton, NJ
07012.
Grip and pinch strength evaluations 223
~
Fig. 2. Palmar pinch is thumb pad to pads of index and long
fingers .
studies testing the accuracy of these instruments have
been published.
The only study that reported pinch-strength norms
for an adult population was by Kellor et al. 3 Patients
were given only one opportunity to exert maximum
force with three types of prehension: three point, lateral
(key), and palmar. In three-point prehension the pinch
meter was grasped with the tips of thumb, index finger,
and long finger. For lateral prehension the pinch gauge
was positioned between the pad of the thumb and the
radial side of the middle phalanx of the index finger.
For palmar prehension the pinch gauge was grasped
between the pads of the thumb, index finger, and long
finger. Testing was done with the forearm pronated.
This contrasts with ASHT's recommendation, which
suggests the same arm positioning as for grip-strength
testing (i.e ., forearm in neutral position). Other differ-
ences include ASHT's recommendation for using the
mean of three successive trials and the use of the thun1b
and index finger only for tip pinch.
The purpose of this study was: to establish standard-
ized positioning and instructions (based on the recom-
mendations of the ASHT), to evaluate inter-rater reli-
ability, to compare test-retest reliability for one trial,
two trial, three trial, and highest score, and to report on
the calibration accuracy of the test instruments.
Methodology
Subjects. Twenty-seven University of Wiscon-
sin-Milwaukee junior occupational therapy students
volunteered for this study. All subjects were women
and their ages ranged from 20 to 39 years, with the
mean age 25 years. Screening criteria for subjects in-
cluded no previous history of neuromuscular or ortho-

224 Mathiowetz et al.
Fig. 3. Key pinch is thumb pad to lateral aspect of middle
phalanx of the index finger.
paedic dysfunction that would significantly affect hand
strength.
Equipment. To test the calibration accuracy of the
dynamometers, known weights were suspended from
the center of the hand pieces. For the pinch gauges, cal-
ibration was evaluated by suspending known weights
from the finger grooves. For the actual study of reli-
ability, two Jamar Dynamometers were used to mea-
sure grip strength and two Pinch Gauges (B&L En-
gineering) were used to measure palmar, key, and tip
pinch.
Design. Before the study began, all instruments were
checked for calibration. All 27 subjects were tested for
grip strength and three types of pinch strength. Dur-
ing the initial testing two examiners were present and
each independently recorded ratings of grip and pinch
strength. Subjects were retested within a week by one
examiner. Instruments were again checked for calibra-
tion upon completion of testing.
Procedure. Subjects name, age, sex, hand domi-
nance, and health status were recorded. Hand domi-
nance was determined by asking "Are you right-
handed or left-handed?" The dominant hand was tested
first. Subjects were tested in a classroom setting while
seated comfortably on a standard height chair (46 cm)
without arm rests. Grip strength was tested first, fol-
lowed by palmar (three-jaw chuck) pinch, key (lateral)
pinch, and tip (two-point) pinch. For each of the tests
of hand strength, the subjects were seated with their
shoulder adducted and neutrally rotated, elbow flexed
at 90°, forearm in neutral position, 4 and the wrist be-
tween 0° and 30° dorsiflexion and between 0° and 15° of
ulnar deviation. 5 . 6 For each strength test the scores of
three successive trials were recorded.
The standard adjustable handle dynamometer was set
The Journal of
HAND SURGERY
Fig. 4. Tip pinch is thumb tip to index finger tip.
at the second handle position for all subjects. The
dynamometer was lightly held around the readout dial
by the examiner to prevent inadvertant dropping. The
pinch gauge was held by the examiner at the distal end
to prevent dropping.
Instructions
1. Grip strength. (Fig. 1) "I want you to hold the handle
like this and squeeze as hard as you can." The exam-
iner demonstrates and then gives the dynamometer to
the subject. After the subject is positioned appropri-
ately, the examiner says, "Are you ready? Squeeze as
hard as you can." As the subject begins to squeeze.
say, "Harder! ... Harder! ... Relax." After the
first trial score is recorded. the test is repeated with the
same instructions for the second and third trial and for
the other hand.
2. Palmar (three-jaw chuck) pinch. (Fig. 2) "I want you
to place your thumb on this side and your first two
fingers on this side as I'm doing and pinch as hard as
you can." The examiner demonstrates the position and
gives the pinch gauge to the subject. After the subject is
positioned appropriately, the examiner says, "Are you
ready? Pinch as hard as you can." As the subject begins
to pinch, say, "Harder! ... Harder! ... Relax."
After the first trial score is recorded, the test is repeated
with the same instructions for the second and third trials
and for the other hand.
3. Key (lateral) pinch. (Fig. 3) "I want you to place your
thumb on top and your index finger below as I'm doing
and pinch as hard as you can." The examiner demon-
strates the position and gives the pinch gauge to the
subject. After the subject is positioned appropriately,
the examiner repeats the series of questions, state-
ments, and tests recorded for palmer pinch.
4. Tip (two-point) pinch. (Fig. 4) "I want you to place
the tip of your thumb on this side and the tip of your
index finger on this side as if to make an O. Curl your
other fingers into your palm as I'm doing." The exam-
iner demonstrates the position and gives the pinch
Vol. 9A, No.2
March 1984 Grip and pinch strength evaluations 225

Table I. Inter-rater reliability for tests of grip and pinch strength in 27 women aged 20 to 39 years

Right hand Left hand

Correlation between
Strength test Rater M S.D. S.E. M S.D. S.E. two raters*

Grip A 70.9 11.9 2.3 59.7 11.5 2.2 Right .996

B 70.8 11.6 2.2 59.6 11.6 2.2 Left .999
Palmar pinch A 18.9 2.5 0.49 17.7 3.1 0.60 Right .979
B 18.8 2.5 0.49 17.6 3.0 0.59 Left .995
Key pinch A 17.2 2.0 0.39 15.6 2.2 0.42 Right .989
B 17.2 2.1 0.41 15.7 2.1 0.41 Left .987
Tip pinch A 11.4 2.1 0.41 10.3 2.2 0.42 Right .991
B 11.4 2.1 0.41 10.3 2.2 0.41 Left .996

'Pearson product-moment correlation.

Table II. Test-retest reliability for tests of grip and pinch strength in 27 women aged 20 to 39 years

Correlation of two separate observations*

Mean of Mean of Highest score

Strength test Hand One trial
I two trials
I three trials
I of three trials

Grip Right .788 .862 .883 .822

Left .864 .910 .929 .915
Palmar pinch Right .645 .745 .812 .749
Left .825 .813 .846 .830
Key pinch Right .725 .814 .832 .748
Left .836 .843 .870 .829
Tip pinch Right .517 .748 .818 .754
Left .702 .688 .820 .689

Average correlation .738 .803 .851 .792

'Pearson product-moment correlation.

gauge to the subject. After the subject is positioned
appropriately, the examiner repeats the series of ques-
tions, statements, and tests recorded palmer pinch.
Results
Validity. Recently the Preston hand dynamometer
and the Jamar digital dynamometer have become com-
mercially available. The accuracy of these new dyna-
mometers and the standard Jamar dynamometer were
compared by suspending known weights from the cen-
ter of their hand pieces. Neither of the new dynamome-
ters achieved the calibration accuracy of the standard
Jamar dynamometer which was accurate ± 3%. This
percent of accuracy is better than the ± 5% accuracy
reported by the manufacturer, Asinow Engineering.
The pinch gauge by B&L engineering was com-
pared to the Preston pinch gauge by suspending known
weights from the finger groove of each gauge. The
pinch gauge by B&L engineering achieved the highest
accuracy at ± 1%. This finding is consistent with re-
ports from the manufacturer, B&L engineering.
Inter-rater reliability. The Pearson product-mo-
ment correlation coefficient was used to assess the corre-
lation between two raters on each test of hand strength
for both right and left hands. Results presented in Table
I demonstrate a significant correlation coefficient of
.97 or above for all tests. This shows that two trained
raters following standardized test procedures can inde-
pendently evaluate hand strength and obtain essentially
the same scores.
Test-retest reliability. The Pearson product-mo-
ment correlation coefficient was used to assess the corre-
lation of two separate observations of hand strength
tests administered a week or less apart. Results of the
correlations for one trial, mean of two trials, mean of
three trials, and highest score of three trials are pre-
sented in Table II. The mean of three trials consistently
yielded correlation coefficients of .80 or above. The
highest correlations, in all cases, were achieved when
the mean of three trials was used (Fig. 5). On the aver-
age, the lowest correlations were achieved when one
trial was used.
 The Journal of
226 Mathiowetz et al. HAND SURGERY

1.00 Conclusions
.",
z This study demonstrates that high inter-rater and test-
~
c .90 retest reliability can be achieved by using the standard-
~
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II:
ized positioning and instructions we described. In ad-
II:
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Co.)
dition, this study shows that the mean of three trials is a
I-
Z
.80 more accurate measure of hand strength than one trial
w
:Ii
Q
or the highest score of three trials. Both of these find-
~
I-
ings support the recommendations of the ASHT. The
g .70
present findings also demonstrate the need to develop
CI
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II:
a..
and utilize new norms for hand strength, since previous
Z
.60
norms are based on hand strength measurements that
~ lack reliability and validity data.
II:
C
w _OneTrial The standard Jamar dynamometer continues to be the
a..
.50
+----+ Mean of Two Trials one recommended for measuring grip strength. The
A- - - - A Mean of Three Trials
. - --e Hiuhesl Score of Three Trials pinch gauge by B&L engineering was found to be the
T I I I
most accurate for measuring pinch strength.
Righi Left Righi Left Righi Left Righi Left The authors wish to thank Franklin Stein, Ph.D., and
GRIP PALMAR KEY TIP James McPherson, M.S., for research and statistical consul-
PINCH PINCH PINCH
tation, and the University of Wisconsin-Milwaukee occupa-
tional therapy students whose participation made this research
HAND STRENGTH TESTS
possible.
Fig. 5. Test-retest reliability for tests of grip and pinch
strength for 27 women 20 to 39 years of age.
REFERENCES
Discussion 1. Trombly CA: Occupational therapy for physical dys-
function, ed. 2. Baltimore, 1983, Williams & Wilkins
The results of this study support the recommendation 2. Davis FB: Standards for educational and psychological
of the ASHT.4 Of the instruments tested, the Jamar tests. Washington, D.C., 1974, American Psychological
dynamometer continues to demonstrate the highest cal- Association, Inc
ibration accuracy for the measurement of grip strength. 3. Kellor M, Frost J, Silberberg N, Iversen I, Cummings R:
The highest test-retest reliability was achieved when Hand strength and dexterity; norms for clinical use. Am J
the mean of three trials was used. Therapists and phy- Occup Ther 25:77-83, 1971
4. Fess EE, Moran CA: Clinical assessment recommen-
sicians are encouraged to use this method rather than
dations. 1981, American Society of Hand Therapists
one trial or highest score of three trials when testing
5. Pryce JC: The wrist position between neutral and ul-
hand strength clinically or for research purposes. nar deviation that facilitates the maximum power grip
We used the recommendations of the ASHT in re- strength. J Biomech 13:505-11, 1980
gards to positioning with the exception of the "neu- 6. Kraft GH, Detels PE: Position of function of the wrist.
tral" wrist position. It has been noted clinically that Arch Phys Med Rehabil 53:272-5, 1972
when subjects were positioned according to ASHT rec- 7. Schmidt RT, Toews JV: Grip strength as measured by
ommendations, their wrists tended to be in 10° to 30° the Jamar dynamometer. Arch Phys Med Rehabil 51:
extension. In addition, because previous studies have 321-7, 1970
shown no significant differences in grip strength when 8. Lunde BK,J3rewer WD, Garcia PA: Grip strength of
the wrist is in 0°, 15°, and 30° extension, 5, 6 any wrist college women. Arch Phys Med Rehabil53:491-3, 1972
position between 0° and 30° was accepted. 9. Thorngren KG, Werner CO: Normal grip strength. Acta
Orthop Scand 50:255-9, 1979
It was assumed that standardized positioning and in-
10. Kirkpatrick JE: Evaluation of grip loss; factor of perma-
struction would improve reliability. Future studies are
nent disability in California. Calif Med 85:314-20, 1956
needed to determine whether alternative positioning 11. Fess EE: Hand position on the Jamar dynamometer and
(e.g., elbow extension vs elbow flexion) and nonstan- normal grip strength. (Unpublished study.)
dardized verbal instructions would significantly affect 12. Preston: Equipment for rehabilitation and special educa-
hand strength scores. In addition new norms are needed tion. Clifton, N.J. 1982/83 Catalog, J A Preston Corpo-
for grip- and pinch-strength evaluations utilizing the ration
standardized procedures and instructions of this study. 13. Cleo: Living aids. Cleveland, 1982, Cleo Living Aids