May 2, 2025 • 29 mins
This week we delve into the world of exercise physiology when we review a recent paper by Dr. Adam Powell of Cincinnati Children's Hospital on the relationship of hand grip strenth to other measures of cardiovascular and skeletal muscular health and fitness. How does hand grip strength correlate with CPET measures of exercise abilities in children? How might this inexpensive test help identify patients who might benefit from exercise therapy? Will hand grip strength one day be as ubiquitous as blood pressure in the evaluation of our CHD patients? Dr. Powell shares the answers this week.
https://doi.org/10.1016/j.jpedcp.2025.200144
https://doi.org/10.1016/j.jpedcp.2025.200144
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Episode Transcript
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Speaker 1 (00:16):
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount SINAI Thank you very much for joining me
for this three hundred and thirty ninth episode of Pdheart.
I hope everybody enjoyed last week's episode, in which we
discussed emergency action plans for patients with genetic heart disease.
(00:37):
For those of you interested in this very interesting topic,
i'd recommend you to take to listen to last week's episode.
As I say most weeks, my email's easy to remember,
it's Pdheart AT's gmail dot com. This week we move
on to the world of exercise physiology. The title of
the work we'll be reviewing is the Relationship of handgrip
strength to body composition and Cardiopulmonary fitness since Children and
(01:00):
young Adults. The first author of this work is Carter
Richardson and the senior author Adam Powell. And the work's
authors come to us from the Department of Pediatrics at
the University of Cincinnati College of Medicine and the Heart
Institute at Cincinnati Children's Hospital. In Cincinnati, Ohio. When we're
done reviewing this paper, the senior author of this work,
doctor Adam Powell, has graciously agreed to speak with us
(01:23):
about it. Therefore, let's get on to this interesting paper
and then a conversation with its senior author.
Speaker 2 (01:29):
The work begins with a number of comments about hand
grip strength, explaining that it is a non invasive and
inexpensive way to quantitatively measure musculoskeletal function. They explain that
this inexpensive device and its measurement has a high test
retest reliability, and its findings are correlated with muscular and
trunkle strength in adults. They then explain that in children
(01:52):
and adolescents, this hands grip strength has been shown to
be associated with bone density and lean mass, and they
reference prior works in which this form of strength assessment
is associated with many different health parameters in adolescence, including
things like cardiopulmonary fitness, body mass indexed, or even diet.
They also mention that handgrip strength has even been shown
(02:14):
to be a risk factor for unfavorable health outcomes, with
associations between worse values and all cause mortality and cardiovascar
disease in adults. And adolescence. The authors then review what
most of us in cardiology well know, which is that
the peak O two consumption or VO two peak can
be assessed and determined at formal exercise testing, and this
(02:36):
VO two max or peak is generally considered the gold
standard measure of exercise capacity and cardiopulmonary fitness, and they
review how studies in the young have demonstrated clearly how
VO two peak is an independent predictor of clinical outcomes,
including mortality. With this as a background, the authors explain
that hand grip strengths relationship to see pet metrics of cardiopulm,
(03:00):
leminary fitness and body composition and healthy children and young
adults is not known, and they mentioned the absence of
strong normative data in the young for hand grip strength
and how if this was determined it might be helpful,
and then applying this inexpensive but useful tool to those
young people who are actually not healthy. The authors therefore
state that there are basically three main goals of this study. First,
(03:23):
to describe handgrip strength values in the young without any
cardiac disease who are basically healthy. Two, to see if
there are relationships that can be drawn between hand grip
strength findings and other markers of fitness such as seapet
data and body composition data, and finally three to see
if there are any differences between boys and girls by
(03:44):
age and body size. This was a retrospective study in
which all children who had a clinical SEAPET at Cincinnati
Children's Hospital over a three and a half year period
from January twenty twenty to June twenty twenty three were reviewed.
To be included in this study, a patient had to
be less than twenty tenty five years at the time
of the study, completed a maximal effort CEPET on a cyclergometer,
(04:05):
and could have no known cardiac disease, so this again
was presumably a healthy group of young people, and the
authors review how most of the patients who were referred
for things like chest pain, palpitation, syncopede dyspanyon exertion, or
a question of long QT syndrome, but actually not having
the diagnosis of that condition. At the same time, a
(04:26):
hand grip strength measurement using a common hydraulic hands dynamometer
was used, and the authors explained that the arm would
be flexed to ninety degrees in both arms and three
voluntary contractions recorded in the dominant and non dominant hands
and the peak measurements on each hand were recorded and
for analysis the peak handgrip strength recording was used. Again,
(04:48):
all the patients underwent a cyclar gomita test using a
typical ramp protocol and the effort had to be maximal
and this was confirmed by achieving a respiratory exchange ratio
greater than are equal to one point one and a
maximal heart rate equal to or more than eighty five
percent of age predicted maximal heart rate. They explained the
standard way that maximal VO two was calculated, and they
(05:10):
also performed a body composition measurement using the so called
in body device prior to the sepad and so the
results After sorting through over two thy eight hundred patients
who had stress tests in that time period at that institution,
the authors found three hundred and sixteen patients to review
with a mean age of fifteen point one years, with
(05:31):
ninety three percent less than eighteen years at the time
of the study. The average height was one hundred and
sixty five sonometers and weight sixty one kilograms. And so
what were some of the most important findings that the
authors identified. First, they found that male patients had a
greater peak dominant hands and non dominant hand grip strength
than female patients, with the greater differences, perhaps not surprisingly,
(05:55):
being seen in the teenagers. Second, the peak dominant hand
grip strength was even more correlated with total body skeletal
muscle mass. Third, and this may be the most important observation,
peak dominant hand grip strength was most strongly correlated with
both peak oxygen consumption and peak work rate. In their discussion,
(06:15):
the author stated, and I quote. In this study, we
explored the relationship between hand grip strength, body composition, and
VO two peak in children and young adults. On c PET,
hand grip strength had a positive relationship with absolute VO
two peak, VO two peak Z score and peak work rate,
but not percent of predicted VO two peak. In addition,
(06:38):
hand grip strength was strongly and positively correlated with both
total and segmental skeletal muscle mass, but not atipacity. Lastly,
hand grip strength correlated to age, height and weight, and
these differences became more pronounced by sex in the mid
teen age years. The authors review how these data are
(06:58):
important because now we can go to this paper and
see precisely what the normative values for handgrip strength are
in young people, and that is of course the first
step in then assessing the value of this form of
testing in patients who are not healthy, like cancer patients
or congenital heart patients. Because of the close correlation between
skeletal muscle mass and hand grip strength, in this work,
(07:21):
the authors make the point that this may be a
reasonable and inexpensive circuit for complicated body composition assessments and
patients where these more sophisticated testing apparatuses are not available.
They wonder aloud if this simple test can serve as
a predictor of poor outcomes in children as it can
in adults. Given the inexpensive nature of this testing, the
(07:43):
authors state that multi center studies using this tool would
be easy to design and perform given how easy it
is to perform this form of testing, both technically and
from the perspective of cost. The authors provide a few
suggestions as to why there was a good association between
hand grip strength and VS two peak, but not with
percent of predicted VO two peak, and I'd suggest those
(08:05):
interested in exercise physiology read the paper for the interesting
suggestions about what hand grip strength may be measuring. The
authors then re review the findings of sex based differences,
particularly from the middle teen years onward, and they speak
of how the boys become taller and heavier and how
this is likely a partial explanation, as well as differences
(08:25):
in pubertal body composition. They explain the interesting observation that
women and men had similar handgrip strength if they had
a similar skeletal muscle mass, and how the differences between
the males and females likely was mostly mediated by differences
in the average skeletal muscle mass. They wonder if training
a muscular strength could be a modifiable risk factor for
(08:46):
overall frailty that could help patients like congenital heart disease patients.
The authors conclude this work with some comments about the
limitations and start by reviewing how it was believed that
no patient in this work had actual cars pathology, but
may not be generalizable to non hospital based populations of children,
and they mention how they did not exclude patients with
(09:08):
pulmonary or orthopedic issues that might have affected outcomes. They
speak of limitations of the cyclorgometer test, especially in young
patients and possible inaccuracies with this form of testing, and
speak of the absence of Tanner staging in the data set,
making it hard to know what stage of puberty the
patients were in who participated. And finally, they used a
(09:30):
form of body composition assessment with bioelectric impedance testing that,
though accurate, is not as accurate as the so called
DAXA testing which is the gold standard for body composition. Well,
this is certainly not the usual pediatric cardiology paper we
have on this podcast, but I thought it of interest
in that it suggests that a fairly inexpensive and easy
(09:51):
to administer test can yield results that are associated closely
with other more sophisticated markers of cardiovascular health. Two, I'm
interested to know a bit more about skeletal mass assessment,
how it's done, and why it's important. And also, what
if anything, we know about this form of testing in
the congenital heart disease patient group. Is this, for example,
(10:14):
a test that we could potentially use as ubiquitously as
a vital sign in clinic like blood pressure, to give
us a general overview of patient health. I'm unsure, but
I'm excited that we have doctor Powell today with us
to better inform us of the possible benefits of this
form of testing, and so in the interest of time,
let's move forward to our conversation with the works. Senior
(10:34):
author joining us now to discuss this week's work is
doctor Adam Powell. Doctor Powell is a graduate of the
Medical University of South Carolina and he performed his residency
at Wright State University Wright Patterson Air Force Base. During
his time in the Air Force, he was promoted to
the level of major in the Air Force and he
was the recipient of the Air Force Achievement Medal and
(10:56):
the Air Force Commendation Medal. And we certainly thank doctor
Powell for his service to our nation. Following this, he
did his fellowship at Cincinnati Children's Hospital in cardiology, and
he also completed a master's program in exercise physiology at
the University of Florida. It is delight in an honor
to have him join us this week to discuss the
UK's work. Welcome doctor Powell to PD HART.
Speaker 3 (11:17):
I'm here now with doctor Adam Powell of Cincinnati Children's Hospital. Adam,
thank you very much for joining us this week on
PD Heart.
Speaker 4 (11:24):
Hi. Thanks Bob. I'm excited to.
Speaker 3 (11:25):
Be here, really excited to have you. You are the
first cardiologist who is an exercise physiologist that we've had on.
Only took me three hundred and thirty nine episodes to
get one, So thank you, Adam. Sometimes when I start
out these interviews, I'll ask the author if they could
maybe summarize for the audience what they believe as the author,
(11:45):
are maybe the three or four most important observations made
in your work?
Speaker 4 (11:49):
Well, absolutely, I'm so.
Speaker 5 (11:51):
I think my first kind of take home points sounds
somewhat simple, but I think it's wildly important. Is that
peak handgrip strength. It's cheap, it's reproducible, and it's easy
to perform in children and young adults with congeneral heart disease.
Especially as an assessment of skeletal muscle strength.
Speaker 4 (12:09):
Wells.
Speaker 5 (12:10):
Hand grip strength is strongly associated with total it's segmental
skeletal muscle strength, peek work great and peak oxygen consumption.
And hand grip strength tends to increase throughout childhood, with
sex based differences beginning around adolescents likely ready to expected
pubial changes.
Speaker 3 (12:30):
I see you know, Thank you, Adam. That was great,
you know you've demonstrated in your work as you just
mentioned that peak hand grip strength correlates with more skeletal
muscle mass. And I'm going to ask you to excuse
the simplicity of this question by abozo here, but how
does bioelectric impedance give us the answer about body composition?
(12:51):
And perhaps more a foolish question, why is skeletal mass
assessment important for children and adults?
Speaker 6 (12:58):
No?
Speaker 5 (12:59):
I think this is good and this is important, especially
because you know, up until I don't know ten twenty
years ago, bioelectrical impedance analysis technology was pretty lacking, but
it's improved quite a bit over the past couple decades.
And what bioelectrical impedance analysis or BIA, as I might
slip up and say it during this, what it does
(13:20):
is it non evasively measures body composition using the premise
that electricity is conducted at different speeds through different tissue types.
Electricity goes differently through muscle versus out of post tissue
versus whatever versus both. While dual energy X ray absorbed
geometry or GETXA is regarded as the gold standard for
(13:41):
body composition, BIA is used more and more frequently in
clinical or research settings, not just in since I Children's,
but in other children's hospitals too around the country. BIA
also has the advantage of being smaller. It's more convenient
for the patient because they don't have to go across
the hospital the radiology department and a DEXA. And I
(14:02):
think maybe most importantly it is DEXA uses ionizing radiation
while BIA doesn't.
Speaker 3 (14:09):
I see, I see, yeah, go ahead, I'm sorry, Ada'm
go ahead.
Speaker 5 (14:13):
Oh no, no, actually, so I think that I'm trying.
I think we now have this easy to use tool
to measure body composition. Body compositions impoint our patients because
there was actually a pretty good amount of data that
shows that our patients with contineral heart disease tend to
have lower scale to muscle mass and higher at a
(14:34):
post tissue to compare to those without Kean heart disease.
Speaker 4 (14:37):
Multiple studies have shown that.
Speaker 5 (14:38):
I think, you know, we showed it back in twenty
twenty in the study that we published in JAHA, which
is noteworthy because we looked at young adults children with
a fontance circulation using BIA, which agreed previously with the
smaller studies looking at DEXA.
Speaker 4 (14:55):
In this population.
Speaker 5 (14:57):
These differences kind of help for a window for us
into the fitness of these patients with digital heart disease BMI.
Speaker 4 (15:05):
It can be misleading.
Speaker 5 (15:07):
We can have one patient with a BMI but an
unusually high skeletal muscle mass and a low body fat percentage.
You know, their level of fitness is only different usually
than someone with the opposite low skeleter muscle mass and
high body fat percentage. And knowing this this can help
me when I'm interpreting an exercise test, when I'm interpreting
(15:29):
a cardio upon an exercise test. If I get a
body composition on a patient digital heart disease and their
skeletal muscle mass is high, their body fat percentage is low,
but their peak VO two is unusually low compared to
that level of muscle compared to whatever their underlying diagnoses is,
it makes me raise an eyebrow. It makes me second guess,
(15:50):
you know, maybe some of the validity of my measurements.
Speaker 4 (15:53):
Was the machine calibrated correctly? Was there a gas leak?
Speaker 5 (15:56):
Maybe I use the wrong prediction equation, I think, I
think either way, FORSTED me to look at the data
a little bit closer and maybe interpret the test in
a different way.
Speaker 3 (16:04):
Interesting. Interesting, very interesting, And excuse the naive to hear Adam,
but I'm guessing in general, patients who have more skeletal
masks are on average healthier. Is that right, have better
exercise tolerance in general?
Speaker 4 (16:20):
Yeah, that is true. And I think.
Speaker 5 (16:25):
Since there's been minimal, minimal studies in our cogeneral art
plot patients looking at skeleton muscle mass comparing to peak
VO two, we don't know for sure if that's the case,
but just in some of the minimals kind of smallest
days we've had, included some of our work with fontanes,
you know, we have seen that those with higher peak
VO two didn't have kind of a more higher functioning,
(16:49):
higher athletic look, looking built with more skeletal muscle mass
and lower ataplocities.
Speaker 3 (16:56):
I see, Yeah, I guess that makes good sense. So
how should the strong correlation you showed between hand grip
strength and measures of exercise ability at SEPET help us
in assessing kids exercise abilities? I mean, can this close
correlation mean that a sort of quick and dirty hand
grip strength test could potentially screen our patients for those
(17:18):
who maybe need a SEAPET and maybe even ferret out
those in whom it may not be needed.
Speaker 5 (17:24):
I think that's a good question, and it's definitely something
that I'm interested to how to evaluate fitness with more
easy to use, more widely assessible measures. I don't think
our data, though, supports elimination of sepet who hand grip
strength as opposed to using hand grip strength as another
(17:47):
measure of assessing fitness. I think the main reason why
is hand grip strength measures peak muscular strength, which is
different than a peak VO two which measures aerobic fitness.
They use energy systems, they have different mechanisms, and we
improve them through different means. Our studies show there's really
(18:09):
strong correlation between two and peak VO two in measured
in middle leaters per minute, but when we dug deeper,
there's a much weaker association in peak VO two with
index by Z score or percent of predicted peak. And
I think teasing that out through the multi variable analysis,
the strongest predictors of hand group strength for age, s
(18:31):
DEX and scalt muscle mass, and so I think hand
group strength may not be a great surrogate for peak
VO two, but it could be a potentially good surrogate
for total scale to muscle mass. EIE is expensive, it's
it's quick, it has a lot of advantages of a DEXA,
but it still is prohibitive to some places.
Speaker 4 (18:53):
And so if we can find someone.
Speaker 5 (18:55):
That some way to approximate that to at least give
us a good estimate that we could get the benefit
of it with a much easier, much cheaper measure, I.
Speaker 3 (19:04):
See very interesting. Well, for those in the audience, Doctor
Powell was really nice to speak with us late on
Monday evening, so after a full workday. So I'm gonna
wrap it up and just ask you, you know, what
do we know about handcrup strength in the congenital heart
disease patient? And do you have any thoughts on how
this could be used in the evaluation or the serial
(19:25):
follow up of our congenital heart disease patient. As I
was thinking this reading this paper, I was wondering, you know,
should this very inexpensive test be as ubiquitous in our
cardiac evaluation of patients as something like a vital sign
like blood pressure? And how do you foresee this potentially
aiding in our care of the congenital heart disease child
(19:46):
or maybe even the ADHD patient.
Speaker 5 (19:48):
Yes, I mean this is the real question, and this
is the question really gets me excited. I think this
paper is really just the first step in hopefully getting
to that point. In Cincinnati, we use BI eight hand
grip strength on every single patient that we do a
cordial pullmer exercise test with. We also measure hand grip
(20:09):
strength in every patient who's going to be listed of
a heart transplant. We use it to any patient where
we have concern for clinical frailty. We also use it
as an outcome measure in children and adults who's enrolled
in our podiac rehab program. I don't think we're quite
yet ready to have enough evidence to say that it
(20:30):
should be another vital sign. I do think we could
get closer after a few extrastoms. I think first and
foremost with this, there have been minimal studies looking at
hand grip strength and a general heart disease. I think
the minimal ones that have been done have focused largely
on looking at hand grip strength in ipsilado and contralateral
(20:51):
upper extremities in those that have had a BT shunt,
with hand group strength being lower on the side.
Speaker 4 (20:58):
Where the b T shant occurs.
Speaker 5 (21:01):
It really hasn't been much research on hand group strength
and congenital heart patients without a BT shot, which is
the vast majority of them. Handgrip is is really strong
prognostic indicator of negative outcomes and older adults, and it's
(21:21):
romanticine critics a fact criticise they do routinely do hand
group strength as kind of a screener or potential negative outcomes.
Maybe it rolling in and rehab looking for other things,
but we don't have that evidence yet, so I think
we need to approve that.
Speaker 4 (21:38):
In the CHD population.
Speaker 5 (21:40):
I think the other interesting thing about band group too
is you know, there's this this paradigm called frailty which
is really really big in adult medicine and it's kind
of starting to make its way into cogenital cordiology as well.
Speaker 4 (21:57):
And one of the five oponents of.
Speaker 5 (22:00):
Frailty is strength and usually assessed by hand grup strength.
And this is a this is a risk factor that
has been thrown both at Cincinnati and other hospital of
like Mercy, Kansas City, that the more frail you are,
the higher your frailty scores are, you know, the worse
your clinical outcomes are. But we've also shown that we
(22:23):
can modify this risk factor through exercise, therapy, through whatever
change in clinical measures we.
Speaker 4 (22:30):
Need to do.
Speaker 5 (22:32):
So not only can we identify something that could potentially
foreshadow badness and negative outcomes of our patients, but we
can do.
Speaker 4 (22:42):
Something about it.
Speaker 5 (22:44):
And so I think that's kind of where I'm hoping
that this aper kind of starts that conversation, and I
know other people around the country are also looking at
similar things, because I do think, you know, the more accessible,
the cheaper that we can be endless less trained we
need to be to assess these things, hopefully on your patients,
(23:06):
we can help.
Speaker 3 (23:07):
Yeah, yeah, well, I certainly love the idea of assessing
something that we can modify, specifically that of recommending or
prescribing exercise for our patients, which, of course, as an
exercise physiolgist, I know, I don't need to tell you
that increasingly we're learning that the power of exercise, which
(23:30):
is probably greater than almost any medication that we can
give our patients, and so something that gives us a
clue as to who would benefit from it strikes me
as something that could be very important, particularly if it's
an inexpensive and easy test to do. As you demonstrate
in this paper. So Adam, I can't thank you enough
for joining us this week. You gave us a lot
(23:51):
to think about. Thank you for being our first exercise
physiology cardiology to cardiologist to join the podcast. It is
a great pleasure and an honor to have you joined.
Thank you so much.
Speaker 5 (24:01):
Thanks a lot, and yesterday has any questions or the
other thoughts, please reach out to me for tonight sounds great.
Speaker 4 (24:08):
Thank you again.
Speaker 1 (24:09):
Well, I think we all learned a bit more about
exercise and how we measure it and why it's important
from doctor Powell today. I found his final points about
the importance of skeletal mass and strength and how this
is a potential modifiable risk factor to be of great interest,
and it's something that I think we are rapidly coming
to grips with to use a pun and I'm excited
to see the work on this simple test of strength
(24:31):
over time in our patient groups, because based on this
paper and conversation tonight, it seems that strength may well
be an important thing to measure in the congenital heart
disease patient and one where we may have a chance
of improving overall outcomes if we come to solutions to
improve the strength of our single ventrical and other congenital
heart patients. Clearly, there's a lot to study in this topic,
(24:53):
but I'm very appreciative to doctor Powell for wetting our
appetite for more information on this exciting new endeavor within
the world of congenital heart disease. To conclude this three
hundred and thirty ninth episode of ped Hart Pediatric Cardiology,
today we hear an extra special pairing of two giants
of opera in the nineteen seventies, the spectacular Italian soprano
(25:15):
Renazzo Scotto and the magnificent tenor Jose Carreras, taken from
a live performance of Verdi's La Traviata, And we hear
the duet Undi Felice, which is part of Act one
of the opera, where Violetta mitel Fredo for the very
first time. Just listen to the beauty of Scotto's voice
matching with the lovely timber and planget sound of young
(25:38):
Carreras at the start of his career. This is the
sort of early Carrera's performance that makes the listener easily
understand why he is so highly thought of in operatic history.
Thank you for joining me for this episode, and thanks
once again.
Speaker 7 (25:52):
To doctor Powell.
Speaker 1 (25:53):
I hope we'll have a good week ahead.
Speaker 6 (25:59):
HEDI by staying back when them.
Speaker 4 (26:25):
Seeing you.
Speaker 7 (26:42):
People the safing.
Speaker 8 (26:50):
Either listen to me. He's thirty as a.
Speaker 7 (27:10):
Shot. Body are all shut.
Speaker 6 (27:14):
Body are very CIC.
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He saty.
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We thirty s of the.
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Pylos, the.
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IC.
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Oh it tr
Welcome to Pdheart Pediatric Cardiology Today. My name is doctor
Robert Pass and I'm the host of this podcast. I
am Professor of Pediatrics at the Icon School of Medicine
at Mount SINAI Thank you very much for joining me
for this three hundred and thirty ninth episode of Pdheart.
I hope everybody enjoyed last week's episode, in which we
discussed emergency action plans for patients with genetic heart disease.
(00:37):
For those of you interested in this very interesting topic,
i'd recommend you to take to listen to last week's episode.
As I say most weeks, my email's easy to remember,
it's Pdheart AT's gmail dot com. This week we move
on to the world of exercise physiology. The title of
the work we'll be reviewing is the Relationship of handgrip
strength to body composition and Cardiopulmonary fitness since Children and
(01:00):
young Adults. The first author of this work is Carter
Richardson and the senior author Adam Powell. And the work's
authors come to us from the Department of Pediatrics at
the University of Cincinnati College of Medicine and the Heart
Institute at Cincinnati Children's Hospital. In Cincinnati, Ohio. When we're
done reviewing this paper, the senior author of this work,
doctor Adam Powell, has graciously agreed to speak with us
(01:23):
about it. Therefore, let's get on to this interesting paper
and then a conversation with its senior author.
Speaker 2 (01:29):
The work begins with a number of comments about hand
grip strength, explaining that it is a non invasive and
inexpensive way to quantitatively measure musculoskeletal function. They explain that
this inexpensive device and its measurement has a high test
retest reliability, and its findings are correlated with muscular and
trunkle strength in adults. They then explain that in children
(01:52):
and adolescents, this hands grip strength has been shown to
be associated with bone density and lean mass, and they
reference prior works in which this form of strength assessment
is associated with many different health parameters in adolescence, including
things like cardiopulmonary fitness, body mass indexed, or even diet.
They also mention that handgrip strength has even been shown
(02:14):
to be a risk factor for unfavorable health outcomes, with
associations between worse values and all cause mortality and cardiovascar
disease in adults. And adolescence. The authors then review what
most of us in cardiology well know, which is that
the peak O two consumption or VO two peak can
be assessed and determined at formal exercise testing, and this
(02:36):
VO two max or peak is generally considered the gold
standard measure of exercise capacity and cardiopulmonary fitness, and they
review how studies in the young have demonstrated clearly how
VO two peak is an independent predictor of clinical outcomes,
including mortality. With this as a background, the authors explain
that hand grip strengths relationship to see pet metrics of cardiopulm,
(03:00):
leminary fitness and body composition and healthy children and young
adults is not known, and they mentioned the absence of
strong normative data in the young for hand grip strength
and how if this was determined it might be helpful,
and then applying this inexpensive but useful tool to those
young people who are actually not healthy. The authors therefore
state that there are basically three main goals of this study. First,
(03:23):
to describe handgrip strength values in the young without any
cardiac disease who are basically healthy. Two, to see if
there are relationships that can be drawn between hand grip
strength findings and other markers of fitness such as seapet
data and body composition data, and finally three to see
if there are any differences between boys and girls by
(03:44):
age and body size. This was a retrospective study in
which all children who had a clinical SEAPET at Cincinnati
Children's Hospital over a three and a half year period
from January twenty twenty to June twenty twenty three were reviewed.
To be included in this study, a patient had to
be less than twenty tenty five years at the time
of the study, completed a maximal effort CEPET on a cyclergometer,
(04:05):
and could have no known cardiac disease, so this again
was presumably a healthy group of young people, and the
authors review how most of the patients who were referred
for things like chest pain, palpitation, syncopede dyspanyon exertion, or
a question of long QT syndrome, but actually not having
the diagnosis of that condition. At the same time, a
(04:26):
hand grip strength measurement using a common hydraulic hands dynamometer
was used, and the authors explained that the arm would
be flexed to ninety degrees in both arms and three
voluntary contractions recorded in the dominant and non dominant hands
and the peak measurements on each hand were recorded and
for analysis the peak handgrip strength recording was used. Again,
(04:48):
all the patients underwent a cyclar gomita test using a
typical ramp protocol and the effort had to be maximal
and this was confirmed by achieving a respiratory exchange ratio
greater than are equal to one point one and a
maximal heart rate equal to or more than eighty five
percent of age predicted maximal heart rate. They explained the
standard way that maximal VO two was calculated, and they
(05:10):
also performed a body composition measurement using the so called
in body device prior to the sepad and so the
results After sorting through over two thy eight hundred patients
who had stress tests in that time period at that institution,
the authors found three hundred and sixteen patients to review
with a mean age of fifteen point one years, with
(05:31):
ninety three percent less than eighteen years at the time
of the study. The average height was one hundred and
sixty five sonometers and weight sixty one kilograms. And so
what were some of the most important findings that the
authors identified. First, they found that male patients had a
greater peak dominant hands and non dominant hand grip strength
than female patients, with the greater differences, perhaps not surprisingly,
(05:55):
being seen in the teenagers. Second, the peak dominant hand
grip strength was even more correlated with total body skeletal
muscle mass. Third, and this may be the most important observation,
peak dominant hand grip strength was most strongly correlated with
both peak oxygen consumption and peak work rate. In their discussion,
(06:15):
the author stated, and I quote. In this study, we
explored the relationship between hand grip strength, body composition, and
VO two peak in children and young adults. On c PET,
hand grip strength had a positive relationship with absolute VO
two peak, VO two peak Z score and peak work rate,
but not percent of predicted VO two peak. In addition,
(06:38):
hand grip strength was strongly and positively correlated with both
total and segmental skeletal muscle mass, but not atipacity. Lastly,
hand grip strength correlated to age, height and weight, and
these differences became more pronounced by sex in the mid
teen age years. The authors review how these data are
(06:58):
important because now we can go to this paper and
see precisely what the normative values for handgrip strength are
in young people, and that is of course the first
step in then assessing the value of this form of
testing in patients who are not healthy, like cancer patients
or congenital heart patients. Because of the close correlation between
skeletal muscle mass and hand grip strength, in this work,
(07:21):
the authors make the point that this may be a
reasonable and inexpensive circuit for complicated body composition assessments and
patients where these more sophisticated testing apparatuses are not available.
They wonder aloud if this simple test can serve as
a predictor of poor outcomes in children as it can
in adults. Given the inexpensive nature of this testing, the
(07:43):
authors state that multi center studies using this tool would
be easy to design and perform given how easy it
is to perform this form of testing, both technically and
from the perspective of cost. The authors provide a few
suggestions as to why there was a good association between
hand grip strength and VS two peak, but not with
percent of predicted VO two peak, and I'd suggest those
(08:05):
interested in exercise physiology read the paper for the interesting
suggestions about what hand grip strength may be measuring. The
authors then re review the findings of sex based differences,
particularly from the middle teen years onward, and they speak
of how the boys become taller and heavier and how
this is likely a partial explanation, as well as differences
(08:25):
in pubertal body composition. They explain the interesting observation that
women and men had similar handgrip strength if they had
a similar skeletal muscle mass, and how the differences between
the males and females likely was mostly mediated by differences
in the average skeletal muscle mass. They wonder if training
a muscular strength could be a modifiable risk factor for
(08:46):
overall frailty that could help patients like congenital heart disease patients.
The authors conclude this work with some comments about the
limitations and start by reviewing how it was believed that
no patient in this work had actual cars pathology, but
may not be generalizable to non hospital based populations of children,
and they mention how they did not exclude patients with
(09:08):
pulmonary or orthopedic issues that might have affected outcomes. They
speak of limitations of the cyclorgometer test, especially in young
patients and possible inaccuracies with this form of testing, and
speak of the absence of Tanner staging in the data set,
making it hard to know what stage of puberty the
patients were in who participated. And finally, they used a
(09:30):
form of body composition assessment with bioelectric impedance testing that,
though accurate, is not as accurate as the so called
DAXA testing which is the gold standard for body composition. Well,
this is certainly not the usual pediatric cardiology paper we
have on this podcast, but I thought it of interest
in that it suggests that a fairly inexpensive and easy
(09:51):
to administer test can yield results that are associated closely
with other more sophisticated markers of cardiovascular health. Two, I'm
interested to know a bit more about skeletal mass assessment,
how it's done, and why it's important. And also, what
if anything, we know about this form of testing in
the congenital heart disease patient group. Is this, for example,
(10:14):
a test that we could potentially use as ubiquitously as
a vital sign in clinic like blood pressure, to give
us a general overview of patient health. I'm unsure, but
I'm excited that we have doctor Powell today with us
to better inform us of the possible benefits of this
form of testing, and so in the interest of time,
let's move forward to our conversation with the works. Senior
(10:34):
author joining us now to discuss this week's work is
doctor Adam Powell. Doctor Powell is a graduate of the
Medical University of South Carolina and he performed his residency
at Wright State University Wright Patterson Air Force Base. During
his time in the Air Force, he was promoted to
the level of major in the Air Force and he
was the recipient of the Air Force Achievement Medal and
(10:56):
the Air Force Commendation Medal. And we certainly thank doctor
Powell for his service to our nation. Following this, he
did his fellowship at Cincinnati Children's Hospital in cardiology, and
he also completed a master's program in exercise physiology at
the University of Florida. It is delight in an honor
to have him join us this week to discuss the
UK's work. Welcome doctor Powell to PD HART.
Speaker 3 (11:17):
I'm here now with doctor Adam Powell of Cincinnati Children's Hospital. Adam,
thank you very much for joining us this week on
PD Heart.
Speaker 4 (11:24):
Hi. Thanks Bob. I'm excited to.
Speaker 3 (11:25):
Be here, really excited to have you. You are the
first cardiologist who is an exercise physiologist that we've had on.
Only took me three hundred and thirty nine episodes to
get one, So thank you, Adam. Sometimes when I start
out these interviews, I'll ask the author if they could
maybe summarize for the audience what they believe as the author,
(11:45):
are maybe the three or four most important observations made
in your work?
Speaker 4 (11:49):
Well, absolutely, I'm so.
Speaker 5 (11:51):
I think my first kind of take home points sounds
somewhat simple, but I think it's wildly important. Is that
peak handgrip strength. It's cheap, it's reproducible, and it's easy
to perform in children and young adults with congeneral heart disease.
Especially as an assessment of skeletal muscle strength.
Speaker 4 (12:09):
Wells.
Speaker 5 (12:10):
Hand grip strength is strongly associated with total it's segmental
skeletal muscle strength, peek work great and peak oxygen consumption.
And hand grip strength tends to increase throughout childhood, with
sex based differences beginning around adolescents likely ready to expected
pubial changes.
Speaker 3 (12:30):
I see you know, Thank you, Adam. That was great,
you know you've demonstrated in your work as you just
mentioned that peak hand grip strength correlates with more skeletal
muscle mass. And I'm going to ask you to excuse
the simplicity of this question by abozo here, but how
does bioelectric impedance give us the answer about body composition?
(12:51):
And perhaps more a foolish question, why is skeletal mass
assessment important for children and adults?
Speaker 6 (12:58):
No?
Speaker 5 (12:59):
I think this is good and this is important, especially
because you know, up until I don't know ten twenty
years ago, bioelectrical impedance analysis technology was pretty lacking, but
it's improved quite a bit over the past couple decades.
And what bioelectrical impedance analysis or BIA, as I might
slip up and say it during this, what it does
(13:20):
is it non evasively measures body composition using the premise
that electricity is conducted at different speeds through different tissue types.
Electricity goes differently through muscle versus out of post tissue
versus whatever versus both. While dual energy X ray absorbed
geometry or GETXA is regarded as the gold standard for
(13:41):
body composition, BIA is used more and more frequently in
clinical or research settings, not just in since I Children's,
but in other children's hospitals too around the country. BIA
also has the advantage of being smaller. It's more convenient
for the patient because they don't have to go across
the hospital the radiology department and a DEXA. And I
(14:02):
think maybe most importantly it is DEXA uses ionizing radiation
while BIA doesn't.
Speaker 3 (14:09):
I see, I see, yeah, go ahead, I'm sorry, Ada'm
go ahead.
Speaker 5 (14:13):
Oh no, no, actually, so I think that I'm trying.
I think we now have this easy to use tool
to measure body composition. Body compositions impoint our patients because
there was actually a pretty good amount of data that
shows that our patients with contineral heart disease tend to
have lower scale to muscle mass and higher at a
(14:34):
post tissue to compare to those without Kean heart disease.
Speaker 4 (14:37):
Multiple studies have shown that.
Speaker 5 (14:38):
I think, you know, we showed it back in twenty
twenty in the study that we published in JAHA, which
is noteworthy because we looked at young adults children with
a fontance circulation using BIA, which agreed previously with the
smaller studies looking at DEXA.
Speaker 4 (14:55):
In this population.
Speaker 5 (14:57):
These differences kind of help for a window for us
into the fitness of these patients with digital heart disease BMI.
Speaker 4 (15:05):
It can be misleading.
Speaker 5 (15:07):
We can have one patient with a BMI but an
unusually high skeletal muscle mass and a low body fat percentage.
You know, their level of fitness is only different usually
than someone with the opposite low skeleter muscle mass and
high body fat percentage. And knowing this this can help
me when I'm interpreting an exercise test, when I'm interpreting
(15:29):
a cardio upon an exercise test. If I get a
body composition on a patient digital heart disease and their
skeletal muscle mass is high, their body fat percentage is low,
but their peak VO two is unusually low compared to
that level of muscle compared to whatever their underlying diagnoses is,
it makes me raise an eyebrow. It makes me second guess,
(15:50):
you know, maybe some of the validity of my measurements.
Speaker 4 (15:53):
Was the machine calibrated correctly? Was there a gas leak?
Speaker 5 (15:56):
Maybe I use the wrong prediction equation, I think, I
think either way, FORSTED me to look at the data
a little bit closer and maybe interpret the test in
a different way.
Speaker 3 (16:04):
Interesting. Interesting, very interesting, And excuse the naive to hear Adam,
but I'm guessing in general, patients who have more skeletal
masks are on average healthier. Is that right, have better
exercise tolerance in general?
Speaker 4 (16:20):
Yeah, that is true. And I think.
Speaker 5 (16:25):
Since there's been minimal, minimal studies in our cogeneral art
plot patients looking at skeleton muscle mass comparing to peak
VO two, we don't know for sure if that's the case,
but just in some of the minimals kind of smallest
days we've had, included some of our work with fontanes,
you know, we have seen that those with higher peak
VO two didn't have kind of a more higher functioning,
(16:49):
higher athletic look, looking built with more skeletal muscle mass
and lower ataplocities.
Speaker 3 (16:56):
I see, Yeah, I guess that makes good sense. So
how should the strong correlation you showed between hand grip
strength and measures of exercise ability at SEPET help us
in assessing kids exercise abilities? I mean, can this close
correlation mean that a sort of quick and dirty hand
grip strength test could potentially screen our patients for those
(17:18):
who maybe need a SEAPET and maybe even ferret out
those in whom it may not be needed.
Speaker 5 (17:24):
I think that's a good question, and it's definitely something
that I'm interested to how to evaluate fitness with more
easy to use, more widely assessible measures. I don't think
our data, though, supports elimination of sepet who hand grip
strength as opposed to using hand grip strength as another
(17:47):
measure of assessing fitness. I think the main reason why
is hand grip strength measures peak muscular strength, which is
different than a peak VO two which measures aerobic fitness.
They use energy systems, they have different mechanisms, and we
improve them through different means. Our studies show there's really
(18:09):
strong correlation between two and peak VO two in measured
in middle leaters per minute, but when we dug deeper,
there's a much weaker association in peak VO two with
index by Z score or percent of predicted peak. And
I think teasing that out through the multi variable analysis,
the strongest predictors of hand group strength for age, s
(18:31):
DEX and scalt muscle mass, and so I think hand
group strength may not be a great surrogate for peak
VO two, but it could be a potentially good surrogate
for total scale to muscle mass. EIE is expensive, it's
it's quick, it has a lot of advantages of a DEXA,
but it still is prohibitive to some places.
Speaker 4 (18:53):
And so if we can find someone.
Speaker 5 (18:55):
That some way to approximate that to at least give
us a good estimate that we could get the benefit
of it with a much easier, much cheaper measure, I.
Speaker 3 (19:04):
See very interesting. Well, for those in the audience, Doctor
Powell was really nice to speak with us late on
Monday evening, so after a full workday. So I'm gonna
wrap it up and just ask you, you know, what
do we know about handcrup strength in the congenital heart
disease patient? And do you have any thoughts on how
this could be used in the evaluation or the serial
(19:25):
follow up of our congenital heart disease patient. As I
was thinking this reading this paper, I was wondering, you know,
should this very inexpensive test be as ubiquitous in our
cardiac evaluation of patients as something like a vital sign
like blood pressure? And how do you foresee this potentially
aiding in our care of the congenital heart disease child
(19:46):
or maybe even the ADHD patient.
Speaker 5 (19:48):
Yes, I mean this is the real question, and this
is the question really gets me excited. I think this
paper is really just the first step in hopefully getting
to that point. In Cincinnati, we use BI eight hand
grip strength on every single patient that we do a
cordial pullmer exercise test with. We also measure hand grip
(20:09):
strength in every patient who's going to be listed of
a heart transplant. We use it to any patient where
we have concern for clinical frailty. We also use it
as an outcome measure in children and adults who's enrolled
in our podiac rehab program. I don't think we're quite
yet ready to have enough evidence to say that it
(20:30):
should be another vital sign. I do think we could
get closer after a few extrastoms. I think first and
foremost with this, there have been minimal studies looking at
hand grip strength and a general heart disease. I think
the minimal ones that have been done have focused largely
on looking at hand grip strength in ipsilado and contralateral
(20:51):
upper extremities in those that have had a BT shunt,
with hand group strength being lower on the side.
Speaker 4 (20:58):
Where the b T shant occurs.
Speaker 5 (21:01):
It really hasn't been much research on hand group strength
and congenital heart patients without a BT shot, which is
the vast majority of them. Handgrip is is really strong
prognostic indicator of negative outcomes and older adults, and it's
(21:21):
romanticine critics a fact criticise they do routinely do hand
group strength as kind of a screener or potential negative outcomes.
Maybe it rolling in and rehab looking for other things,
but we don't have that evidence yet, so I think
we need to approve that.
Speaker 4 (21:38):
In the CHD population.
Speaker 5 (21:40):
I think the other interesting thing about band group too
is you know, there's this this paradigm called frailty which
is really really big in adult medicine and it's kind
of starting to make its way into cogenital cordiology as well.
Speaker 4 (21:57):
And one of the five oponents of.
Speaker 5 (22:00):
Frailty is strength and usually assessed by hand grup strength.
And this is a this is a risk factor that
has been thrown both at Cincinnati and other hospital of
like Mercy, Kansas City, that the more frail you are,
the higher your frailty scores are, you know, the worse
your clinical outcomes are. But we've also shown that we
(22:23):
can modify this risk factor through exercise, therapy, through whatever
change in clinical measures we.
Speaker 4 (22:30):
Need to do.
Speaker 5 (22:32):
So not only can we identify something that could potentially
foreshadow badness and negative outcomes of our patients, but we
can do.
Speaker 4 (22:42):
Something about it.
Speaker 5 (22:44):
And so I think that's kind of where I'm hoping
that this aper kind of starts that conversation, and I
know other people around the country are also looking at
similar things, because I do think, you know, the more accessible,
the cheaper that we can be endless less trained we
need to be to assess these things, hopefully on your patients,
(23:06):
we can help.
Speaker 3 (23:07):
Yeah, yeah, well, I certainly love the idea of assessing
something that we can modify, specifically that of recommending or
prescribing exercise for our patients, which, of course, as an
exercise physiolgist, I know, I don't need to tell you
that increasingly we're learning that the power of exercise, which
(23:30):
is probably greater than almost any medication that we can
give our patients, and so something that gives us a
clue as to who would benefit from it strikes me
as something that could be very important, particularly if it's
an inexpensive and easy test to do. As you demonstrate
in this paper. So Adam, I can't thank you enough
for joining us this week. You gave us a lot
(23:51):
to think about. Thank you for being our first exercise
physiology cardiology to cardiologist to join the podcast. It is
a great pleasure and an honor to have you joined.
Thank you so much.
Speaker 5 (24:01):
Thanks a lot, and yesterday has any questions or the
other thoughts, please reach out to me for tonight sounds great.
Speaker 4 (24:08):
Thank you again.
Speaker 1 (24:09):
Well, I think we all learned a bit more about
exercise and how we measure it and why it's important
from doctor Powell today. I found his final points about
the importance of skeletal mass and strength and how this
is a potential modifiable risk factor to be of great interest,
and it's something that I think we are rapidly coming
to grips with to use a pun and I'm excited
to see the work on this simple test of strength
(24:31):
over time in our patient groups, because based on this
paper and conversation tonight, it seems that strength may well
be an important thing to measure in the congenital heart
disease patient and one where we may have a chance
of improving overall outcomes if we come to solutions to
improve the strength of our single ventrical and other congenital
heart patients. Clearly, there's a lot to study in this topic,
(24:53):
but I'm very appreciative to doctor Powell for wetting our
appetite for more information on this exciting new endeavor within
the world of congenital heart disease. To conclude this three
hundred and thirty ninth episode of ped Hart Pediatric Cardiology,
today we hear an extra special pairing of two giants
of opera in the nineteen seventies, the spectacular Italian soprano
(25:15):
Renazzo Scotto and the magnificent tenor Jose Carreras, taken from
a live performance of Verdi's La Traviata, And we hear
the duet Undi Felice, which is part of Act one
of the opera, where Violetta mitel Fredo for the very
first time. Just listen to the beauty of Scotto's voice
matching with the lovely timber and planget sound of young
(25:38):
Carreras at the start of his career. This is the
sort of early Carrera's performance that makes the listener easily
understand why he is so highly thought of in operatic history.
Thank you for joining me for this episode, and thanks
once again.
Speaker 7 (25:52):
To doctor Powell.
Speaker 1 (25:53):
I hope we'll have a good week ahead.
Speaker 6 (25:59):
HEDI by staying back when them.
Speaker 4 (26:25):
Seeing you.
Speaker 7 (26:42):
People the safing.
Speaker 8 (26:50):
Either listen to me. He's thirty as a.
Speaker 7 (27:10):
Shot. Body are all shut.
Speaker 6 (27:14):
Body are very CIC.
Speaker 7 (27:53):
He saty.
Speaker 4 (27:58):
We thirty s of the.
Speaker 7 (28:06):
Pylos, the.
Speaker 2 (28:26):
IC.
Speaker 7 (28:34):
They t let Cody, the
Speaker 8 (28:51):
Oh it tr
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