Handgrip Strength: An Irreplaceable Indicator of Muscle Function

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Ann Rehabil Med. 2021;45(3):167-169
Publication date (electronic) : 2021 June 30
doi : https://doi.org/10.5535/arm.21106
Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, Seoul, Korea
Corresponding author: Sang Yoon Lee Department of Rehabilitation Medicine, Seoul National University College of Medicine, SMG-SNU Boramae Medical Center, 20 Boramae-ro 5-gil, Dongjak-gu, Seoul 07061, Korea. Tel: +82-2-870-2673, Fax: +82-2 831-0714, E-mail: lsy126@snu.ac.kr
Received 2021 May 24; Accepted 2021 May 24.

Handgrip strength (HGS) is a simple and reliable measurement of maximum voluntary muscle strength. It is an important tool for diagnosing sarcopenia and is widely used as a single indicator to represent overall muscle strength [1-4]. HGS can predict not only muscle mass and physical activity [5], but also the incidence of chronic diseases, nutritional status, quality of life, independence of daily life, length of hospital stay, and even mortality [6-9].

The European Working Group on Sarcopenia in Older People (EWGSOP) and the Asian Working Group for Sarcopenia (AWGS) recommended HGS as one of the axes for diagnosing sarcopenia [1,2]. HGS measurement is also the first step in the diagnosis of sarcopenia; according to the algorithm for sarcopenia detection from the EWGSOP-2, if a subject’s HGS is normal, no further screening test is necessary [2].

HGS varies according to age, sex, and race [10]. In Asians, the AWGS first proposed a low HGS to be <26 kg in men and <18 kg women or the lower 20th percentile of the HGS of the study population before outcome-based data are available [11]. An update from the AWGS in 2016 suggested that previous consensus cutoff points might require further modifications [1], and the AWGS recently suggested a low HGS of <28.0 kg for men and <17.7 kg for women with pooled datasets from various countries in Asia [12].

HGS is correlated with several medical diseases, including chronic anemia [13], dyslipidemia [14], hypertension [15], metabolic syndrome [16], and chronic kidney disease [17]. It is also associated with dietary intake [18] and dietary patterns [19]. Among micronutrients, vitamin D and HGS have been widely investigated, and low HGS is associated with vitamin D deficiency [20]. The serum 25(OH)D concentration is also significantly related to HGS [21]. These results are sufficiently predictable given the effect of vitamin D on muscle physiology. Vitamin D plays a major role in protein synthesis through vitamin D receptors in muscles, improving muscle strength and physical function [22]. Interestingly, one study reported that serum vitamin D levels were associated with HGS but not with muscle mass [23]. Thus, we conclude that HGS has a greater influence on muscle function than muscle mass.

Recent studies have shown that vitamin E is associated with muscle aging and regeneration. Vitamin E has been studied as an anti-aging agent mainly because of its anti-inflammatory and antioxidant effects [24]. However, in addition to these effects, vitamin E has been shown to induce myoblast proliferation and increase muscle mass [25]. Furthermore, vitamin E can reduce muscle damage, enhance recovery from exercise, and prevent muscle atrophy [26]. Since most of these studies were conducted as preclinical studies or basic experiments, clinical studies are indispensable.

A study on the correlation between serum vitamin E levels and HGS published in this issue of the Annals of Rehabilitation Medicine is considered the first attempt on this topic and is a very remarkable study [27]. The authors analyzed the correlation between vitamin E levels and HGS in 1,814 adults by multiple logistic regression using data from the 2018 Korea National Health and Nutrition Examination Survey (KNHANES VII). The analysis revealed that young men with higher serum vitamin E levels had higher HGS. Although the results of the study have various limitations, they are expected to be a good reference for further studies as they were obtained from a large number of human subjects.

As in a large-scale study, HGS is the simplest and most accurate indicator that can reflect an individual’s muscle strength status. Therefore, HGS has been continuously used as a biomarker of current status [28]. In addition, HGS has been identified as an indicator that can predict an individual’s future health status, even mortality; a few meta-analyses have supported the association of weak HGS with all-cause mortality in the general population [29,30] and calculated a pooled hazard ratio of 1.16 per 5 kg reduction in HGS. In addition, it is a potential predictor of cardiovascular [31] and cancer [32] mortality.

Based on this evidence, HGS is now irreplaceable as an indicator of muscle function. Thus, HGS measurement should be strongly recommended as a routine test in hospital practice and community healthcare and not only in the research field.


No potential conflict of interest relevant to this article was reported.


This work was supported by a National Research Foundation of Korea grant funded by the Korean government (MSIT) (No. 2019R1C1C100632).


1. Chen LK, Lee WJ, Peng LN, Liu LK, Arai H, Akishita M, et al. Recent advances in sarcopenia research in Asia: 2016 update from the Asian Working Group for Sarcopenia. J Am Med Dir Assoc 2016;17:767.e1–7.
2. Cruz-Jentoft AJ, Bahat G, Bauer J, Boirie Y, Bruyere O, Cederholm T, et al. Sarcopenia: revised European consensus on definition and diagnosis. Age Ageing 2019;48:16–31.
3. Wisniowska-Szurlej A, Cwirlej-Sozanska A, Woloszyn N, Sozanski B, Wilmowska-Pietruszynska A. Association between handgrip strength, mobility, leg strength, flexibility, and postural balance in older adults under long-term care facilities. Biomed Res Int 2019;2019:1042834.
4. Miljkovic N, Lim JY, Miljkovic I, Frontera WR. Aging of skeletal muscle fibers. Ann Rehabil Med 2015;39:155–62.
5. Lauretani F, Russo CR, Bandinelli S, Bartali B, Cavazzini C, Di Iorio A, et al. Age-associated changes in skeletal muscles and their effect on mobility: an operational diagnosis of sarcopenia. J Appl Physiol (1985) 2003;95:1851–60.
6. Taekema DG, Gussekloo J, Maier AB, Westendorp RG, de Craen AJ. Handgrip strength as a predictor of functional, psychological and social health: a prospective population-based study among the oldest old. Age Ageing 2010;39:331–7.
7. Kerr A, Syddall HE, Cooper C, Turner GF, Briggs RS, Sayer AA. Does admission grip strength predict length of stay in hospitalised older patients? Age Ageing 2006;35:82–4.
8. Bohannon RW. Hand-grip dynamometry predicts future outcomes in aging adults. J Geriatr Phys Ther 2008;31:3–10.
9. Jang A, Bae CH, Han SJ, Bae H. Association between length of stay in the intensive care unit and sarcopenia among hemiplegic stroke patients. Ann Rehabil Med 2021;45:49–56.
10. Lee YL, Lee BH, Lee SY. Handgrip strength in the Korean population: normative data and cutoff values. Ann Geriatr Med Res 2019;23:183–9.
11. Chen LK, Liu LK, Woo J, Assantachai P, Auyeung TW, Bahyah KS, et al. Sarcopenia in Asia: consensus report of the Asian Working Group for Sarcopenia. J Am Med Dir Assoc 2014;15:95–101.
12. AuYeung TW, Leung J, Yu R, Lee JS, Kwok T, Woo J. Decline and peripheral redistribution of fat mass in old age: a four-year prospective study in 3018 older community-living adults. J Nutr Health Aging 2018;22:847–53.
13. Gi YM, Jung B, Kim KW, Cho JH, Ha IH. Low handgrip strength is closely associated with anemia among adults: a cross-sectional study using Korea National Health and Nutrition Examination Survey (KNHANES). PLoS One 2020;15:e0218058.
14. Kim BM, Yi YH, Kim YJ, Lee SY, Lee JG, Cho YH, et al. Association between relative handgrip strength and dyslipidemia in Korean adults: findings of the 2014-2015 Korea National Health and Nutrition Examination Survey. Korean J Fam Med 2020;41:404–11.
15. Ji C, Zheng L, Zhang R, Wu Q, Zhao Y. Handgrip strength is positively related to blood pressure and hypertension risk: results from the National Health and nutrition examination survey. Lipids Health Dis 2018;17:86.
16. Hong S. Association of relative handgrip strength and metabolic syndrome in Korean older adults: Korea National Health and Nutrition Examination Survey VII-1. J Obes Metab Syndr 2019;28:53–60.
17. Lee YL, Jin H, Lim JY, Lee SY. Relationship between low handgrip strength and chronic kidney disease: KNHANES 2014-2017. J Ren Nutr 2021;31:57–63.
18. Tak YJ, Lee JG, Yi YH, Kim YJ, Lee S, Cho BM, et al. Association of handgrip strength with dietary intake in the Korean population: findings based on the Seventh Korea National Health and Nutrition Examination Survey (KNHANES VII-1), 2016. Nutrients 2018;10:1180.
19. Kang Y, Kim J, Kim DY, Kim S, Park S, Lim H, et al. Association between dietary patterns and handgrip strength: analysis of the Korean National Health and Nutrition Examination Survey data between 2014 and 2017. Nutrients 2020;12:3048.
20. Mendoza-Garces L, Velazquez-Alva MC, Cabrer-Rosales MF, Arrieta-Cruz I, Gutierrez-Juarez R, IrigoyenCamacho ME. Vitamin D deficiency is associated with handgrip strength, nutritional status and T2DM in community-dwelling older Mexican women: a crosssectional study. Nutrients 2021;13:736.
21. Wang J, Wang X, Gu Y, Liu M, Chi VT, Zhang Q, et al. Vitamin D is related to handgrip strength in adult men aged 50 years and over: a population study from the TCLSIH cohort study. Clin Endocrinol (Oxf) 2019;90:753–65.
22. Remelli F, Vitali A, Zurlo A, Volpato S. Vitamin D deficiency and sarcopenia in older persons. Nutrients 2019;11:2861.
23. Gumieiro DN, Murino Rafacho BP, Buzati Pereira BL, Cavallari KA, Tanni SE, Azevedo PS, et al. Vitamin D serum levels are associated with handgrip strength but not with muscle mass or length of hospital stay after hip fracture. Nutrition 2015;31:931–4.
24. Niki E. Role of vitamin E as a lipid-soluble peroxyl radical scavenger: in vitro and in vivo evidence. Free Radic Biol Med 2014;66:3–12.
25. Chung E, Mo H, Wang S, Zu Y, Elfakhani M, Rios SR, et al. Potential roles of vitamin E in age-related changes in skeletal muscle health. Nutr Res 2018;49:23–36.
26. Lukaski HC. Vitamin and mineral status: effects on physical performance. Nutrition 2004;20:632–44.
27. Park N, Kim SA, Oh K, Kim Y, Park S, Kin JY, et al. Association Between Vitamin E and Handgrip Strength in the Korean General Population in KNHANES VII (2018). Ann Rehabil Med 2021;45:170–7.
28. Bohannon RW. Grip strength: an indispensable biomarker for older adults. Clin Interv Aging 2019;14:1681–91.
29. Rijk JM, Roos PR, Deckx L, van den Akker M, Buntinx F. Prognostic value of handgrip strength in people aged 60 years and older: a systematic review and metaanalysis. Geriatr Gerontol Int 2016;16:5–20.
30. Garcia-Hermoso A, Cavero-Redondo I, Ramirez-Velez R, Ruiz JR, Ortega FB, Lee DC, et al. Muscular strength as a predictor of all-cause mortality in an apparently healthy population: a systematic review and metaanalysis of data from approximately 2 million men and women. Arch Phys Med Rehabil 2018;99:2100–2113.e5.
31. Wu Y, Wang W, Liu T, Zhang D. Association of grip strength with risk of all-cause mortality, cardiovascular diseases, and cancer in community-dwelling populations: a meta-analysis of prospective cohort studies. J Am Med Dir Assoc 2017;18:551.e17–551.e35.
32. Garcia-Hermoso A, Ramirez-Velez R, Peterson MD, Lobelo F, Cavero-Redondo I, Correa-Bautista JE, et al. Handgrip and knee extension strength as predictors of cancer mortality: a systematic review and meta-analysis. Scand J Med Sci Sports 2018;28:1852–8.

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