Systematic Review of Hand Grip Strength and Pilot Study to Measure Hand Grip Strength in Participants Receiving Hematopoietic Stem Cell Transplant

Abstract

Abstract Systematic Review of Hand Grip Strength and Testing for Strength in Participants Receiving Hematopoietic Stem Cell Transplant Cindy A. Sayre Chair of the Supervisory Committee: Professor, Basia Belza Biobehavioral Nursing and Health Systems Background: Despite aggressive fall prevention programs, rates of falls in hospitals have increased from 2.7 falls per thousand patient days in 2001 (Halfon, Eggli, Van Melle, & Vagnair, 2001) to 3-5 falls per thousand patient days in 2014 (Oliver, Healey, & Haines, 2010). Patients hospitalized for oncological diagnoses are at increased risk of sustaining a fall compared with other hospitalized patients on medical surgical types of units (6.3 vs. 3.1 per thousand patient days) and are more likely to be injured if they do fall (Fischer et al., 2005). One contributing factor to this risk may be weakness. For example, patients hospitalized for Hematopoietic Stem Cell Transplant (HSCT) have been found to have weakness at the time of admission (Mello, Tanaka & Dulley 2003). Although lower extremity muscle weakness is a well-known risk factor for falls (Currie, 2006), assessment of muscle strength is not standard of care in hospitals. Hand grip strength (HGS) by dynamometry has been used to evaluate functional strength in a variety of populations. These populations include patients with a wide variety of diagnoses such as those undergoing kidney transplantation (Garonzik-Wang, et al., 2012), as well as patients with oncological diagnoses (Cantarero-Villanueva, et al., 2012; de Souza, et al., 2012; Klepin, et al., 2013). In addition, studies of HGS have taken place in both outpatient and inpatient settings (Cantarero-Villanueva, et al., 2012; Norman, et al., 2010). This dissertation is composed of two papers. The first paper is a systematic review of the use of Hand Grip Strength (HGS) in selected clinical studies. The purpose of this review was to delineate methods and identified challenges in studies of HGS by dynamometry in participants who had oncologic diagnoses or were hospitalized for any diagnosis. The second paper reports results of a pilot study that was conducted in a sample of patients undergoing myeloablative HSCT in an inpatient setting. The purposes of the pilot study were to: 1) describe changes in muscle strength as measured by daily HGS measurements; 2) describe relationships between selected laboratory values (Hematocrit [HCT], Hemoglobin [HGB], Absolute Neutrophil Count [ANC]) and HGS during the course of hospitalization; 3) determine the feasibility and acceptability of daily HGS measurements; and 4) compare relative timing of detection of change in muscle strength by HGS measurement and nursing assessment of the participant’s need for assistance with mobility. Methods: The first paper describes a systematic review of the literature that was conducted focused on identifying studies related to HGS measurement in hospitalized patients and those with oncologic diagnoses in any care setting (Khan, Kunz, Klejin & Antes, 2003). Medline, CINAHL and Web of Science databases were searched yielding 23 pertinent articles. The articles were then reviewed for quality to ensure that the study designs were appropriate to produce results that were free of bias and could be interpreted accurately. Results were summarized in a table and were used to design a study protocol for a HGS pilot study. The second paper details the results of the pilot observational study. For this study we used a prospective, repeated measures design and enrolled 45 participants hospitalized for HSCT. HGS was measured on admission and daily until discharge from the hospital or study withdrawal. Medications (opioid, benzodiazepine), physical therapy and laboratory measures of HGB, HCT and ANC were recorded as was nurse assessment of need for assistance with mobility. A single-item survey question developed for study purposes was used to assess feasibility and acceptability of HGS testing from the participant perspective. Results: Twenty-three articles were reviewed for the first paper. Analysis of these articles found that techniques for measuring HGS appeared to be similar but not identical across care settings. This included specific design elements of the studies including positioning, selection of hand for testing, attempts per trial and data included for analysis. Challenges of HGS testing in hospital settings included determining when participants were awake and alert, high percentages of ineligible participants due to complications of care, and interruptions in testing for provision of routine care. For the observational study (2nd paper), we enrolled 45 participants undergoing HSCT. Thirty-three (73%) participants completed the study with 20 (61%) followed pre and post-transplant (peri-transplant) and 13 (39%) followed after admission for complications. Nineteen (57%) participants experienced 20% or greater decline in HGS during hospitalization. Nine (45%) of the peri-transplant group experienced decline during the conditioning phase. In the peri-transplant group there was a small positive, statistically significant relationship between both HCT and HGB (p<.001) and HGS. In the complication group HGS was negatively correlated with ANC (p=.02), HGB (p=.007) and HCT (p=.001). Patients receiving allogeneic HSCT were more likely to exhibit strength loss of ≥ 20% than those receiving autologous HSCT (p=.02). Gender was highly correlated with HGS with males measuring 13.9-20 Kg higher HGS readings than females (p<.001). Nurses documented participant’s need for assistance with mobility for 8/19 (42%) of participants with ≥ 20% strength loss as assessed by dynamometry, although this nursing assessment preceded 20% strength decline in 4 participants and was noted days after the loss in 4 patients. Participants found the testing to be relatively easy, with a mean score of 1.4 (SD .73) on a 5 point scale in the peri-transplant group, and a mean score of 1.8 (SD 1.3) in the complication group (higher scores indicate greater difficulty). Testing of HGS took 7 minutes (SD 1.95) to complete. Conclusion: It is feasible to test HGS in participants who are hospitalized or have oncologic diagnoses in outpatient or inpatient care settings. Based on the literature review, a standardized protocol for HGS measurement in participants undergoing HSCT was developed and used for the pilot study. A majority of participants experienced clinically significant strength decline during HSCT with a subgroup declining during the conditioning phase. Participants who received allogeneic HSCT were more likely to experience clinically important strength loss than those who received an autologous transplant. Nurses failed to note the participant’s need for assistance with mobilization a majority of the time. Participants found the testing to be relatively easy to participate in, however data collection was impacted by issues common to hospitalized participants such as nausea, fatigue and feelings of being overwhelmed. This was the first study to our knowledge, to examine HGS daily in participants receiving HSCT. There appears to be a gap between the timing of clinically important decline of strength and nurse recognition of participants’ need for assistance with mobility. The daily use of HGS by dynamometry could be an important tool to assist direct care providers in the evaluation of strength in hospitalized patients.