Open Access

Preoperative muscle weakness as defined by handgrip strength and postoperative outcomes: a systematic review

BMC AnesthesiologyBMC Series - open, inclusive and trusted201212:1

DOI: 10.1186/1471-2253-12-1

Received: 23 May 2011

Accepted: 17 January 2012

Published: 17 January 2012

Abstract

Background

Reduced muscle strength- commonly characterized by decreased handgrip strength compared to population norms- is associated with numerous untoward outcomes. Preoperative handgrip strength is a potentially attractive real-time, non-invasive, cheap and easy-to-perform "bedside" assessment tool. Using systematic review procedure, we investigated whether preoperative handgrip strength was associated with postoperative outcomes in adults undergoing surgery.

Methods

PRISMA and MOOSE consensus guidelines for reporting systematic reviews were followed. MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Clinical Trials (1980-2010) were systematically searched by two independent reviewers. The selection criteria were limited to include studies of preoperative handgrip strength in human adults undergoing non-emergency, cardiac and non-cardiac surgery. Study procedural quality was analysed using the Newcastle-Ottawa Quality Assessment score. The outcomes assessed were postoperative morbidity, mortality and hospital stay.

Results

Nineteen clinical studies (17 prospective; 4 in urgent surgery) comprising 2194 patients were identified between1980-2010. Impaired handgrip strength and postoperative morbidity were defined inconsistently between studies. Only 2 studies explicitly ensured investigators collecting postoperative outcomes data were blinded to preoperative handgrip strength test results. The heterogeneity of study design used and the diversity of surgical procedures precluded formal meta-analysis. Despite the moderate quality of these observational studies, lower handgrip strength was associated with increased morbidity (n = 10 studies), mortality (n = 2/5 studies) and length of hospital stay (n = 3/7 studies).

Conclusions

Impaired preoperative handgrip strength may be associated with poorer postoperative outcomes, but further work exploring its predictive power is warranted using prospectively acquired, objectively defined measures of postoperative morbidity.

Background

A substantial minority of patients sustain an excess of postoperative complications [1] and accelerated, post-hospital discharge mortality [2]. In surgical procedures known to have a mortality of greater than 5% in the UK, elderly patients (mean age 75 years) and emergency procedures account for over 80% of deaths but less than 15% of total procedures [3]. Physician- and patient-friendly, practical and inexpensive tools are required to guide and risk-stratify perioperative management objectively for this cohort of patients. Measurements of exercise capacity and muscle strength are associated with increased all-cause and cardiovascular mortality in the general population [47]. However, the comprehensive assessment of cardiovascular reserve - most objectively using cardiopulmonary exercise testing [8] - is challenging for immobile patients, time-consuming, and costly to extend as a general screening tool to the wider, at-risk surgical population. By contrast handgrip strength is an inexpensive, objective bedside test which has established population norms [913] and has been extensively tested in a range of chronic general medical conditions [14]. It may reflect, in part, the association of impaired muscle strength with malnutrition [15] and cardiopulmonary or metabolic diseases [47]. Hand grip strength can be assessed by instructing the patient to keep their shoulders adducted and neutrally rotated, the arm in a vertical position, the wrist in a neutral position and to squeeze the grip with maximal strength. The highest result in a seated or semi-seated position may be used [16, 17]. Whether a robust relationship between preoperative handgrip strength and postoperative outcomes exists is unclear, since variable, and frequently retrospective, definitions of postoperative morbidity have been employed as outcome measures [18]. Therefore, we performed a systematic review of the literature to ascertain if preoperative assessment of handgrip strength is associated with (i) postoperative morbidity, (ii) length of hospital stay.

Methods

The systematic review was undertaken in accordance with the PRISMA [19] (Preferred Reporting Items for Systematic reviews and Meta-Analyses) and MOOSE (Meta-analysis of Observational Studies in Epidemiology) [20] guidelines. Figure 1 summarizes the flow of information through the different phases of this systematic review. A checklist demonstrating adherence to the PRISMA guidelines is available online (Additional File 1).
https://static-content.springer.com/image/art%3A10.1186%2F1471-2253-12-1/MediaObjects/12871_2011_Article_119_Fig1_HTML.jpg
Figure 1

Flow diagram showing systematic review synthesis, in accordance with PRISMA guidelines.

Two of the authors (P.S. and M.A.H.) searched the electronic databases MEDLINE, EMBASE, and the Cochrane Central Register of Controlled Clinical Trials independently using the following population search terms: 'postoperative complications' OR 'perioperative complications' OR 'surgical complications' OR 'surgical outcome'. These search results were combined with 'handgrip dynamometry' OR 'hand grip dynamometry' OR 'hand grip strength' OR 'handgrip strength' OR 'maximal voluntary contraction' in the title or abstract text using the Boolean search operator 'AND'. (Maximal voluntary contraction is the term used most commonly in the literature to describe maximal force produced by a muscle as it contracts while contracting against the hand dynamometer). The references of retrieved articles were hand searched for any relevant articles not identified in the original search. The study selection criteria were limited to include only studies reported in the English language and those involving human adults undergoing surgery (including cardiac and transplant surgery). Each abstract was screened to identify studies that had assessed handgrip strength prior to surgery. Studies were excluded if postoperative outcomes focussed on upper limb neuromuscular functional outcomes alone.

The data were extracted on to a standardized data entry form by each reviewer. Differences between the reviewers were resolved by re-examination of the original manuscript until consensus was obtained. Data extracted for comparison included year of publication, primary author, total number of subjects, mean patient age, proportion of male subjects and co-morbidity (where reported). The method of quantifying or qualifying handgrip strength was recorded.

The specific outcomes sought in each article were: (i) mortality, (ii) postoperative morbidity, categorized according to the Post Operative Morbidity Survey, (iii) length of hospital stay [21]. Primary and/or secondary outcomes were recorded according to the a priori intention of each original article. Each outcome was evaluated qualitatively according to either qualitative and/or quantitative assessment of handgrip strength. Because there were a limited number of studies with homogenous design for each outcome, a meta-analysis could not be performed.

The procedural quality of each trial was assessed using several criteria, although no studies were excluded on the basis of these assessments. The quality of studies was scored according to the Newcastle-Ottawa Quality Assessment Scale [22] (Additional File 2), on a scale from 1 (poor) to 8 (excellent), which includes patient follow-up rates as a marker of study quality. Disagreements about the eligibility of a study or differences between the two sets of information extracted were resolved through discussion between all authors. After abstraction of information, a level of evidence was assigned to the outcomes of each study. Two authors (P.S. and M.A.H.) independently reviewed and scored each study using this method.

Results

Nineteen studies were identified that compared postoperative outcomes in relation to handgrip strength (Table 1), comprising 2194 patients [913, 16, 17, 2334]. A wide range of surgical sub-specialties was explored. Four studies were conducted in patients undergoing urgent surgery for hip fractures. One study explored the effect of pre-operative nutritional supplementation on grip strength [25]. Although supplementation improved post-operative grip strength compared to the control group, it was not related to patient outcome. Only two studies ensured that investigators who evaluated postoperative morbidity also remained blinded to the pre-operative grip strength values [10, 17]. A wide range of exclusion criteria were reported between studies. One-third of studies reported the patient drop-out rate.
Table 1

Basic demographics, defined primary/secondary outcomes and handgrip site used for patient studies.

Author

Year

Study type

Surgery

(urgency/type)

Number of patients

(n)

Age

(mean ± SD or

mean [range])

Gender (% male)

Primary

Outcome

Secondary

Outcome

Handgrip:

dominant vs.

non-dominant?

Beloosesky [16]

2010

Cohort*

Urgent fractured neck of femur

105

81 ± 7

31

Functional outcome

Not stated

Dominant

Wehern [23]

2005

Cohort

Urgent Hip fracture

205

81 ± 8

0

Functional outcome

Not stated

Right arm

Mahalakshmi [10]

2004

Case control

Elective general

100

42[13-70]

62

Complications

Not stated

Non dominant

Cook [17]

2001

Case control

Elective CABG

200

Not stated

73

Complications

Not stated

Both hands

Figueiredo [24]

2000

Cohort

Elective Liver transplant

53

50 ± 12

59

Complications

Not stated

Both hands

Le Cornu [25]

2000

Case control

Elective liver transplant

82

24-68

73

Complications

Not stated

Not stated

Visser [26]

2000

Cohort

Urgent Hip fracture

90

79 ± 8

0

Mobility

Not stated

Not stated

Guo [11]

1996

Case control

Elective oral and maxillofacial cancers

127

54 ± 15

69

Complications

Not stated

Non dominant

Watters [27]

1993

Cohort

Elective general

40

< 50 y group (36 ± 9)

> 70 y group (77 ± 5)

65

Relate Muscle strength to body composition and nitrogen balance

Not stated

Non dominant

Schroeder [34]

1993

Cohort

Elective general

84

54 ± 18

44

Post-op fatigue

Not stated

Dominant

Griffith [28]

1989

Cohort

Elective general and vascular

61

66#[41-82]

75

Complications

Not stated

Dominant

Kalfarentzos [12]

1989

Case control

Elective general

95

70 [42-88]

56

Complication

Not stated

Not stated

Brenner [29]

1989

Cohort

Elective general and vascular

249

Not stated

66

Complications

Not stated

Not stated

Webb [30]

1989

Case control

Elective general

90

58 [20-88]

60

Complications

Not stated

Not stated

Shukla [31]

1987

Case control

Elective Major general

110

20-70

49

Complications

Not stated

non dominant

Hunt [13]

1985

Case control

General, Orthopedic, Urology, Gynaecology, Cardiovascular, Endocrine and Miscellaneous

205

45 ± 17

46

Complications

Not stated

Not stated

Davies [32]

1984

Cohort

Urgent Fracture neck of femur

76

Not stated

Female

Complications

Not stated

Not stated

Klidjian [33]

1982

Case control

Elective general

120

60 [24-86]

55

Complications

Not stated

Non dominant

Klidjian [9]

1980

Case control

Elective general

102

57 [16-81]

46

Complications

Factors impairing handgrip strength

Non dominant

*Retrospective study; # median value.

The majority of studies measured handgrip strength pre-operatively (Table 2). Eleven studies did not comment on how long before surgery the handgrip strength was measured [9, 10, 17, 24, 25, 28, 3033]. Guo et al did not comment on whether handgrip strength was measured pre or post-surgery [11]. Very few studies achieved a quality assessment score less than 6, consistent with moderate quality (Table 3, Additional File 1).
Table 2

Timing of handgrip measurements in patient studies.

Author

Year

Timing of measurement

Beloosesky [16]

2010

7-10 days and 1, 3, 6 months post-op

Wehern [23]

2005

During hospitalisation and 2, 6, 12 months post-op

Mahalakshmi [10]

2004

Pre-op- timing not specified

Cook [17]

2001

Pre-op- timing not specified

Figueiredo [24]

2000

Pre-op- timing not specified

Le Cornu [25]

2000

Pre-op- timing not specified

Visser [26]

2000

2-10 days and 12 months following admission

Guo [11]

1996

Not specified whether pre or post-surgery

Watters [27]

1993

Pre-op on day of surgery and post-op days 2, 4 and 6

Schroeder [34]

1993

Pre-op on day of surgery

Griffith [28]

1989

Pre-op- timing not specified

Kalfarentzos [12]

1989

2-3 days pre-op

Brenner [29]

1989

2 days pre-op

Webb [30]

1989

Pre-op- timing not specified

Shukla [31]

1987

Pre-op- timing not specified

Hunt [13]

1985

12-72 hours pre-op

Davies [32]

1984

Pre-op- timing not specified

Klidjian [33]

1982

Pre-op- timing not specified

Klidjian [9]

1980

Pre-op- timing not specified

Table 3

Newcastle -Ottawa Quality Assessment Scores (NOS score).

    

Selection

Comparability

Outcome

Study

Year

Study type

NOS score

1

2

3

4

1

1

2

3

Beloosesky [16]

2010

Cohort

6

D

a*

a*

a*

 

b*

a*

a*

Wehren [23]

2005

Cohort

6

a*

a*

b*

a*

 

b*

a*

c < 60%

Figueiredo [24]

2000

Cohort

6

D

a*

a*

a*

 

b*

a*

a*

Visser [26]

2000

Cohort

6

D

a*

a*

a*

 

b*

a*

a*

Watters [27]

1993

Cohort

7

a*

a*

b*

a*

 

b*

a*

a*

Schroeder [34]

1993

Cohort

6

D

a*

b*

a*

 

b*

a*

a*

Griffith [28]

1989

Cohort

7

a*

a*

b*

a*

 

b*

a*

a*

Brenner [29]

1989

Cohort

6

D

a*

b*

a*

 

b*

a*

a*

Davies [32]

1984

Cohort

7

a*

a*

b*

a*

 

b*

a*

a*

Mahalakshmi [10]

2004

Case-control

7

a*

a*

b*

a*

b*

a*

a*

Cook [17]

2001

Case-control

7

a*

a*

b*

a*

b*

a*

a*

Le Cornu [25]

2000

Case-control

7

a*

a*

b*

a*

a*

c

a*

a*

Guo [11]

1996

Case-control

6

a*

a*

b*

a*

 

c

a*

a*

Kalfarentzos [12]

1989

Case-control

6

a*

a*

b*

a*

c

a*

a*

Webb [30]

1989

Case-control

4

C

b

b*

a*

c

a*

a*

Shukla [31]

1987

Case-control

6

a*

a*

b*

a*

c

a*

a*

Hunt [13]

1985

Case-control

4

C

b

b*

a*

c

a*

a*

Klidjian [33]

1982

Case-control

4

C

b

b*

a*

c

a*

a*

Klidjian [9]

1980

Case-control

4

C

b

b*

a*

c

a*

a*

Letters represent answer for corresponding numbered question in each section. A study can be awarded a maximum of one star for each numbered item within the Selection and Outcome categories. A maximum of two stars can be given for Comparability. See Additional File 1 for full details of assessment criteria.

Definition of impaired handgrip strength

Variable definitions for impaired handgrip strength have been used across studies (Table 4). Studies compared values of grip strength obtained from healthy controls, reference populations or patients who did not sustain postoperative morbidity with surgical patients. For example, 9 studies defined impaired handgrip strength as < 85% of a general, age-matched population - but these reference populations were not common between studies. Table 1 demonstrates that six studies measured handgrip strength exclusively from the non-dominant hand, compared to 3 studies that measured handgrip strength in the dominant hand. Seven studies did not report which hand was tested. 11/19 studies did not report the timespan over which handgrip strength measurements preceded surgery. Variable time points were used between studies to assess postoperative handgrip strength. Detailed protocols for the performance of handgrip strength were absent in the majority of studies.
Table 4

Definitions used for impaired handgrip Strength.

Author

A priori definition of Impaired handgrip strength?

Definition of impaired handgrip strength

Post-hoc Definition/comparison

Beloosesky [16]

NO

 

Functional Independence Measure 6 months postoperatively

Wehren [23]

NO

 

Activities of Daily Living

Mahalakshmi [10]

YES

< 85% control values

 

Cook [17]

NO

 

According to low or high risk status

Figueiredo [24]

NO

 

Critical Care length of stay

Le Cornu [25]

NO

 

< 85% and > 85%

Visser [26]

NO

 

Loss in grip strength post-operatively

Guo [11]

YES

< 85% control values

 

Watters [27]

NO

 

Loss in grip strength post-operatively

Schroeder [34]

NO

 

Post-operative fatigue

Griffith [28]

NO

 

Loss in grip strength post-operatively

Kalfarentzos [12]

YES

< 85% control values

 

Brenner [29]

NO

  

Webb [30]

YES

< 85% population norm

 

Shukla [31]

NO

 

< 85% and > 85%

Hunt [13]

YES

< 85% healthy controls

 

Davies [32]

NO

 

< 15 kg

Klidjian [33]

YES

< 85% controls

[1980 study]

 

Klidjian [9]

NO

 

< and > 85%

Postoperative morbidity

Table 5 summarizes the 15 studies that detailed the relationship between handgrip strength and various aspects of postoperative morbidity. Ten out of these 15 studies described a significant relationship between lower handgrip strength and postoperative morbidity [9, 10, 12, 13, 25, 28, 3033]. No studies defined postoperative morbidity using validated morbidity tools. A range of morbidities were recorded prospectively: very few studies defined in detail how these morbidities were determined. Five studies used length of hospital stay as a surrogate for postoperative complications, but did not describe the associated morbidities.
Table 5

Type of Postoperative morbidity included in follow-up of patients.

 

Pulmonary

Infectious

Renal

Gastrointestinal

Cardiovasular

Neurological

Wound

Haematological

Pain

LOS

Mahalakshmi [10]

Y

Y

Y

Y

Y

Y

Y

  

Sep

Cook [17]

Y

Y

Y

 

Y

    

Sep

Figueiredo[24]

 

Y

     

Y

 

Sep

Le Cornu[25]

Y

Y

       

Sep

Guo[11]

 

Y

    

Y

  

Sep

Watters[27]

         

Sep

Schroeder[34]

          

Griffith[28]

Y

Y

  

Y

    

Y‡

Brenner[29]

Y

Y

    

Y

   

Webb[30]

         

Y*

Shukla[31]

Y

   

Y

 

Y

   

Hunt[13]

Y

Y

Y

Y

  

Y

  

Sep

Davies[32]

         

Y†

Klidjian[33]

Y

Y

       

Y*

Klidjian[9]

         

Y*

Y- Included in definition of complications. LOS(length of stay)-definition of morbidity includes length of stay greater than pre-defined level. Sep- LOS is analysed separately i.e. not included in definition of morbidity. Y* defined as complication if > 14 day LOS postop. Y† Complication resulting in ≥16 day LOS post op. Y‡ Defined as serious complication if > 14 day LOS.

Length of Hospital Stay

Tables 5 and 6 show the 12 studies which utilised length of stay as an outcome measure for postoperative morbidity. Five of these studies incorporated length of hospital stay into their definition of "complications" [9, 28, 30, 32, 33] and 7 studies separately explored the relationship between handgrip strength and length of hospital stay [10, 11, 13, 17, 24, 25, 27]. Three of these 7 studies reported an association between lower handgrip strength and prolonged length of stay [10, 13, 25]. Mean or median values were compared rather than log-rank analysis.
Table 6

Studies describing relationship between Grip Strength (GS) and Hospital Length of Stay (LOS).

AUTHOR

GS of LOS "Controls" (kg or %)

Control LOS

(mean days ± SD)

GS of LOS "comparators" (kg or %)

Comparator LOS (mean days ± SD)

Log-rank test?

LOS and Handgrip strength associated?

Mahalakshmi [10]

< 85%

12.8 ± 6.6

> 85%

9.3 ± 3.4

NO

YES

Cook [17]

Male < 32 kg

Female < 20.5 kg

8.1 ± 10

Male > 32 kg

Female > 20.5 kg

6.8 ± 7.5

NO

NO

Figueiredo [24]

ICU stay only*

Not presented

Not presented

Not presented

NO

NO

Le Cornu [25]

Not presented

Not presented

Not presented

Not presented

YES†

Positive correlation

Guo [11]

< 85%

42 ± 20

> 85%

32 ± 10

NO

 

Watters [27]

Not presented

Not presented

Not presented

Not presented

NO

NO

Hunt [13]

< 85%

11.4 ± 12

> 85%

6.8 ± 3.8

NO

YES

Griffith [28]

Mean:

Male 25.4 ± 9.1 kg

Female 14.4 ± 4.3 kg

7/61 had "Complications" (definition included LOS > 14 days)

Mean:

Male 30.2 ± 8.4 kg

Female 14.9 ± 5.7 kg

48/61 had LOS < 14 days

NO

Not reported

Webb [30]

< 85%

20/51 had "complications" (definition included LOS > 14 days)

> 85%

7/39 had LOS < 14 days

NO

Not reported

Davies [32]

< 15 kg

27/37 had "Complications" (definition included LOS > 16 days)

> 15 kg

3/14 had LOS < 16 days

NO

Not reported

Klidjian [33]

< 85%

43/72 had "complications" (definition included LOS > 14 days)

> 85%

5/48 had LOS < 14 days

NO

Not reported

Klidjian [9]

< 85%

20/44 had "complications" (definition included LOS > 14 days)

> 85%

3/58 had LOS < 14 days

NO

Not reported

*Increased ITU stay was associated with lower handgrip strength (right (27 ± 6 and 36 ± 12 kg p < 0.01) and left (27 ± 7 and 35 ± 12 kg p = 0.01)

†There was a correlation between grip strength and day of discharge post-transplant (r = -0.41, P = 0.01). There was no association between grip strength and length of time spent on ventilatory support post-transplant (r = -0.250) or length of time spent on the intensive care unit post-transplant (r = -0.112)

* Survival plot from time of listing to transplant or death (not for grip strength).

Mortality

Table 7 summarizes the 5 studies that explored the relationship between handgrip strength and postoperative mortality. Variable time points for postoperative associated death were defined across studies, ranging from 30 days to 6 month mortality following surgery. One study did not define the time period of follow-up for patients to determine mortality. Two studies reported an association between lower handgrip strength and increased mortality [12, 17].
Table 7

Studies describing relationship between handgrip strength and postoperative mortality.

AUTHOR

YEAR

Duration of mortality follow-up

Mortality

"Control" handgrip strength

Control Mortality

Mortality

"comparator"

Handgrip strength

Comparator

Mortality

Log-rank?

Cook [17]

2001

3 months

Male < 32 kg

Female < 21 kg

11.3%

Male > 32 kg

Female > 21 kg

2.9%

NO

Figueiredo [24]A

2000

1 year

GS data not presented

   

n/a

Le Cornu [25]B

2000

30 days, 6 months

GS < 85%

Not reported

GS > 85%

Not reported

YES*

Griffith [28]

1989

7 days

Male 27 ± 6 kg

Female 13 ± 4 kg

8.7%

13.3%

Figures not presented

 

NO

Kalfarentzos [12]

1989

Not stated

GS < 85%

17.2%

GS > 85%

0%

NO

GS = handgrip strength

A. None of the nutritional parameters assessed including handgrip strength were associated with increased risk of mortality

B. Survival plot from time of listing to transplant or death (not for grip strength)

*GS < 85% was significantly related to post transplant occurrence of major complications (definition includes death), minor sepsis and no sepsis (p = 0.05)

Discussion

Contrary to large population studies, our systematic review of the relationship between preoperative handgrip strength and postoperative outcome did not find compelling data to support the hypothesis that the results of studies in the general population translate to perioperative medicine. The majority of studies were considered to be of reasonable quality. Despite these quality scores, many studies contained important potential confounding factors which varied markedly between studies. A range of different instruments have been employed to measure grip strength, with other corroborative assessments of strength being frequently absent. Due to the substantial variation in the way in which each specified outcome had been defined between studies, plus the lack of analyses testing any one particular association, it was not possible to perform meta-analyses of results or formally test the heterogeneity (consistency) between studies. This marked heterogeneity between studies limits any definitive conclusions for the perioperative environment and renders this preoperative assessment largely unexplored. Nevertheless, several of these studies - albeit with the limitations as discussed above - suggest the role for preoperative handgrip strength assessment should be explored further.

Large epidemiological studies have shown that perioperative morbidity is associated with dramatic differences in post-discharge life expectancy across different operations and health systems [2]. The cost and expertise required by certain preoperative tests, such as cardiopulmonary exercise testing, plus other limiting factors (e.g. dysmobility, acuity of surgery) necessitates an alternative approach to be developed for the objective assessment of perioperative risk in the substantial minority of patients who may sustain morbidity that impacts on their longer-term survival. The development of an inexpensive, mass screening preoperative assessment tool with high sensitivity and specificity to detect postoperative morbidity is clearly attractive. Handgrip strength is an easy, non-invasive, cheap, real-time and established independent "bedside" predictor of long-term all-cause mortality in more than 44,000 patients studied in the general population [14].

There are also compelling basic biological reasons for establishing the role of handgrip strength in preoperative assessment. Cardiopulmonary reserve is a long-established predictor of cardiovascular and all-cause mortality, in both asymptomatic individuals and patients with cardiovascular disease [35]. Cardiac insufficiency has emerged as the commonest preoperative morbidity associated with increased morbidity and mortality [36, 37]. An important component of cardiac failure is dysfunctional skeletal muscle metabolism [38] and impaired strength - as reflected by handgrip strength [39]. Skeletal muscle exerts important effects on the patterns of substrate use during periods of increased cardiopulmonary performance [40, 41]. Major alterations in skeletal muscle histology and biochemistry occur in patients with long-term heart failure [42, 43]. These skeletal muscle adaptations may underlie the early onset of anaerobic metabolism, increased lactate production and fatigue in heart failure. Handgrip strength improves following specific interventions that increase cardiopulmonary reserve [44, 45]. Muscle (handgrip) strength is also impaired in metabolic disease [46], which may in part explain its association with both poorer perioperative outcomes and all-cause mortality.

One limitation of this systematic review is that no original study data were retrieved, although given the heterogeneity of both study design and the surgical populations in question this would have been unlikely to alter the main conclusions. Because only published reports were examined (obtained from searches performed only on MEDLINE, EMBASE and Cochrane databases), a formal assessment of publication bias was not undertaken. It remains possible that not all relevant studies may have been identified since unpublished studies were not sought. There is very little perioperative demographic data provided in these studies, including cardiovascular risk and the identification of higher risk patients. Standards of postoperative care were not reported or apparently standardized. Since no interventions were conducted based on preoperative handgrip strength assessment, the studies only provide associative conclusions.

This systematic review has generated two significant clinical implications. Firstly, given the compelling general population data that predicts longevity, there is clearly a need for the further prospective assessment of whether preoperative handgrip strength can help stratify risk of adverse postoperative outcomes. Second, these studies demonstrate that handgrip strength is a feasible, pragmatic, real-time bedside tool that may enhance preoperative risk stratification.

Conclusions

Impaired preoperative handgrip strength may be associated with increased postoperative morbidity, mortality and prolonged hospital stay following surgery. Given the robust predictive power of this inexpensive, objective bedside test beyond the perioperative population, further studies of its' role in predicting postoperative outcomes appear to be warranted provided prospective, objectively defined measures of morbidity are employed.

Declarations

Acknowledgments and funding

Centre for Anaesthesia, Critical Care and Pain Management, University College London, UK [PS, MAH]; Academy of Medical Sciences/Health Foundation Clinician Scientist award [GLA]. This work was undertaken at UCLH/UCL who received a proportion of funding from the Department of Health's NIHR Biomedical Research Centres funding scheme.

Authors’ Affiliations

(1)
Department of Anesthesia, Stanford University Medical Center
(2)
Anaesthesia and Critical Care, St Georges Hospital NHS Trust
(3)
Centre for Anaesthesia, Critical Care and Pain Management, University College London
(4)
Department of Medicine, University College London

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  47. Pre-publication history

    1. The pre-publication history for this paper can be accessed here:http://​www.​biomedcentral.​com/​1471-2253/​12/​1/​prepub

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