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Test-retest reproducibility and validity of the back-leg-chest strength

measurements

Article in Isokinetics and Exercise Science · August 2016

DOI: 10.3233/IES-160619

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Isokinetics and Exercise Science 24 (2016) 209–216 209
DOI 10.3233/IES-160619
IOS Press

Test-retest reproducibility and validity of the

back-leg-chest strength measurements
Gill A. Ten Hoora,∗ , Kirsty Muscha, Kenneth Meijerb and Guy Plasquia
a
Department of Human Biology, Nutrition and Translational Research in Metabolism, Maastricht University
Medical Center, Maastricht, The Netherlands
b
Department of Movement Sciences, Nutrition and Translational Research in Metabolism, Maastricht University
Medical Center, Maastricht, The Netherlands

Abstract.
BACKGROUND: A single measure to characterize overall muscle strength is advantageous because it saves time and costs of
evaluation. For this reason, the back-leg-chest (BLC) strength might be an appropriate single measure in characterizing total body
strength.
OBJECTIVE: To assess the test-retest reproducibility and smallest real difference (SRD) of the BLC dynamometer in healthy
adults and adolescents and to examine whether handgrip, knee-extensor and knee-flexor strength predict BLC strength in healthy
adults.
METHODS: Forty-five adults and 58 adolescents were recruited. In a first session back-leg-chest strength, handgrip strength,
and additionally, in adults, isometric knee-extensor strength, and knee-flexor strength were measured. In a second session, 2–5
days later, BLC strength was measured again for test-retest reproducibility.
RESULTS: Inter-session correlations of BLC strength were high (all r’s and ICC’s > 0.92). Bland-Altman-plots showed high
agreement. The SRD and SRD% were between 14–26, and 19% and 26% respectively. Strength variables (handgrip, knee-
extensor, and knee-flexor strength) explained 87% of the variance in BLC strength. A stepwise linear regression showed that
dominant knee extensor and flexor strength were the most important significant predictors of BLC strength (r 2 = 0.86).
CONCLUSIONS: This study demonstrated that the BLC dynamometer has reasonably high test-retest reproducibility and hence
may serve in some pertinent situations to be an appropriate tool for clinical, basic and applied research.

Keywords: Back-leg-chest dynamometer, knee extensor strength, knee flexor strength, handgrip strength, dynamometry, repro-
ducibility, validity

1. Introduction have simple, valid, and reliable instruments to measure

strength.
Skeletal muscle strength is fundamental for physical Muscle strength is typically measured using dy-
performance [1] and health [2,3]. Assessment of mus- namometry; it is based on having a person exert max-
cle strength is commonly used in physical examina- imal resistance (force) against a continuously moving
tions to determine possible impairments and physical (isokinetic) or an immovable (isometric) mechanical
disabilities, or in experimental settings to examine the lever, using a single muscle or a muscle group. Dy-
effects of interventions. Therefore, it is important to namometry is highly efficient for both clinical and re-
search purposes [4–8], and is often used to validate
other strength assessment techniques [9–11]. However
∗ Corresponding author: Gill A. ten Hoor, Department of Human
a disadvantage of some dynamometers is that they may
Biology, Nutrition and Translational Research in Metabolism, Maas-
tricht University Medical Center, P.O. Box 616, 6200 MD Maas-
be too expensive and/or impractical for some clini-
tricht, The Netherlands. Tel.: +31 43 3881908; E-mail: Gill.tenHoor cal settings. The most frequently used dynamometer
@MaastrichtUniversity.nl. is the handgrip dynamometer because of its cost ef-

ISSN 0959-3020/16/$35.00  c 2016 – IOS Press and the authors. All rights reserved
This article is published online with Open Access and distributed under the terms of the Creative Commons Attribution Non-Commercial License
(CC BY-NC 4.0).
210 G.A. Ten Hoor et al. / Back-leg-chest dynamometer testing

fectiveness, simplicity and portability [12]. However, University (ECP-05-09-2012-A1), and conforms with
the movement patterns performed during the execu- The Code of Ethics of the World Medical Association
tion of the handgrip test are not comparable to move- (Declaration of Helsinki), printed in the British Medi-
ment patterns of larger muscle groups, or performed in cal Journal (18 July 1964).
daily life or exercise training programs [4]. To over-
come this limitation, the BLC dynamometer might be 2.2. Measurements and procedures
an effective, simple and portable way to test total body
strength. The measurements in the adult population took
The BLC dynamometer is a device that measures place in the movement-lab of Maastricht University,
isometric force produced together by the back, leg whereas the measurements with adolescents took place
and arm muscles. Bethards and colleagues [13] stud- at the sports-ground of Dutch high school. For this rea-
ied test-retest reproducibility of the BLC dynamome- son, KES and KFS, measured by the Biodex (Biodex
ter in adults and reported reliabilities of 0.97 or higher, medical systems, Shirley, NY, USA), was only exam-
depending on the body position during the test. More- ined in adults. All test procedures were instructed by
over, both hand grip strength (HGS) and knee exten- the same investigator.
sor strength (KES) were shown to be related to over- All adults did a 5 minute warming up on a cycle er-
all muscle strength [6,14–17] and have therefore often gometer, at 60 rotations per minute and a self-selected
been used to indicate overall limb muscle strength [14, resistance. The adolescents warmed up by jogging on
18,19]. Findings by Bohannon [2] suggest that even a self-selected speed. Subsequently, the test sequence
though HGS and KES can be used as an indicator started with BLC strength testing, to ensure that the
for overall limb muscle strength in healthy adults, us- BLC strength test results would not be affected by
ing these measures solely is not fully recommended in the Biodex and handgrip measurements. Values of the
characterizing overall limb muscle strength. A single BLC strength, HGS, and in adults also KES and KFS
measure to characterize overall muscle strength is ad- were obtained on the same testing day (session 1) with
vantageous because it saves time and costs of evalua- three minutes of rest between the measures. In order
tion. For this reason, BLC dynamometer might be an to determine the test-retest reproducibility of the BLC
appropriate alternative single measure in characteriz- strength, the test procedure of the BLC dynamometer
ing overall limb muscle strength. Therefore the pur- was repeated for each participant two to five days after
pose of this study was twofold: first to examine test- the first test occasion, approximately at the same time
retest reproducibility and SRD of the BLC dynamome- of day (session 2). Individuals were asked to abstain
ter in healthy adults and adolescents and second, to from intense physical activity in the two days prior to
examine whether HGS, KES and knee flexor strength testing, and between the two test sessions, which were
(KFS) predict BLCS in healthy adults. 2–5 days apart.

2.2.1. Height and weight

2. Methods Height (in cm) and weight (in kg) was measured
using a SECA 761 analogue scale and a SECA 213
2.1. Subjects portable stadiometer (SECA Ltd. Medical Scales and
measuring systems) with participants wearing light
To investigate test-retest reproducibility of the BLC clothing without shoes.
dynamometer, 45 healthy adults (18–35 years; 23 fe-
male) among students and staff of Maastricht Uni- 2.2.2. Back-leg-chest strength
versity, and 58 healthy adolescents (12–15 years, 30 A calibrated BLC dynamometer (Baseline, New
boys, 28 girls) from a high school in the Netherlands York, USA; see Fig. 1) measures isometric muscle
were recruited. Participants with pathologies or dis- strength, recorded in kilograms (kg) and pounds (lb) of
orders compromising the ability to perform maximal force. When an external force is applied to a handle,
strength exercises were excluded. Before participation, which is attached to an adjustable chain, a steel spring
informed consent was obtained from all volunteers compresses and a pointer moves. The dial ranges from
(and for the adolescents also from the parents). This 0 to 300 kg (0 to 660 lb) in 10 kg (10 lb) increments.
study was approved by the Research Ethics Board of For the test, the length of the chain was adjusted to
Faculty of Psychology and Neuroscience, Maastricht the participants’ height by asking the subject to stand
 G.A. Ten Hoor et al. / Back-leg-chest dynamometer testing 211

a demonstration and a familiarization trial were given

for each arm. Then, the participants were instructed to
continuously squeeze for 3–5 seconds for three trials,
with a 30 second rest period between trials. The maxi-
mum value of the three trials was used for further anal-
ysis. Testing order (dominant/non-dominant) was bal-
anced. The dominant hand was determined by asking
the participants with which hand they write.

2.2.4. Isometric knee extensor and knee flexor

strength
For measuring isometric KES and KFS, the Biodex
System 3 Pro dynamometer was used. Moments were
recorded in Newton meters (Nm) with the Biodex Ad-
vantage Software for Windows. Participants were in a
seated position, whereby the hip and knee joint were
flexed at 80◦ and 90◦ respectively. The knee angle was
measured by a goniometer to ensure the appropriate
angle of the knee joint. The lateral femoral epicondyle
of the knee was lined-up with the axis of the lever arm
Fig. 1. Back-leg-chest dynamometer.
of the Biodex dynamometer. To prevent compensatory
movement, the upper leg and thorax were stabilized
on the base of the BLC dynamometer with extended with straps. The lever arm was attached just proximal
knees. Subsequently, the handle was positioned at the (ca. 3 cm) to the ankle joint. Familiarization trials of
height of the intra-articular space of the knee joint. For submaximal effort were performed for both isometric
the test, participants had to stand on the base, with and isokinetic knee flexion and extension. After a short
knees and hips flexed slightly while the lower back rest period of 30 seconds the actual test was performed,
had to maintain an appropriate lordotic curve. Subjects whereby the participants were asked to provide maxi-
were asked to lift in a vertical direction by providing mal voluntary isometric contractions for 5 seconds at
continuous isometric contractions of the extensors of 30◦ , 50◦ , 70◦ , 90◦ and 99◦ of knee flexion and exten-
the knees, hips, and lower back while holding the han- sion. Resting periods of 30 seconds were applied be-
dle. Participants were asked to increase the pull in a tween each contraction to reduce fatigue and prevent
safe manner gradually and reach the maximal force muscular strain. Because the weight of the lower leg
in three seconds, while keeping this pull for another and the lever arm of the dynamometer caused passive
two seconds. After demonstration and a familiarization knee moments, maximal moments had to be corrected
trial, three trials were performed, with rest periods of for these passive moments. The passive moments were
30 seconds between trials. Maximal strength for the measured before the actual test, by asking the par-
three trials was used for further analysis. ticipant to relax the tested leg. Maximal knee flexion
and extension strength was determined by fitting a cu-
2.2.3. Handgrip strength bic polynomial function to the five joint moment data.
Dominant and non-dominant HGS was measured The y-top of the polynomial was considered the peak
using the Jamar R
hydraulic hand dynamometer. The moment and was used for further analysis. The order
R
of Biodex measurements (dominant and non-dominant
Jamar handgrip dynamometer is a portable device
that measures HGS in kilograms and pounds with in- leg) were balanced, whereby the dominant leg was de-
crements of 2 kg (or 2.5 lb). Isometric HGS was termined by asking the individuals which leg would be
measured according to the American Society of Hand preferred to kick a ball with.
Therapists [20]. In short, the participants sat in a chair
without arm rests. The shoulder remained at 0◦ flexion, 2.3. Statistical analyses
abduction and rotation, the elbow was flexed at 90◦
and wrist was positioned between 0◦ and 30◦ dorsiflex- IBM SPSS statistics 20 was used for data analysis.
ion and between 0◦ and 15◦ of ulnar deviation. First, Independent samples T-tests were used to identify gen-
212 G.A. Ten Hoor et al. / Back-leg-chest dynamometer testing

Table 1
der differences. Test-retest reproducibility of the BLCS Study sample characteristics
was tested using the Intraclass Correlation Coefficient
Total Male Female
(ICC) in order to determine the correlation and agree- Mean (SD) Mean (SD) Mean (SD) p
ment between values. Bland-Altman plots were used to Adolescents
visualize the agreement between the two BLCS-tests N 58 30 28
and examine the homo- or heteroscedastic nature of the Age (year) 13.9 (1.1) 13.8 (1.2) 13.9 (1.0) 0.84
distribution of the differences. The Height (m) 168.0 (9.2) 171.9 (9.4) 163.9 (7.0) 0.001
√SRD was calculated Weight (Kg) 54.5 (9.2) 55.7 (9.5) 53.2 (8.9) 0.32
using the formula: 2.77 × SD × (1-ICC). When cor- BMI (kg/m2 ) 19.2 (2.1) 18.7 (2.0) 19.8 (2.2) 0.07
relations between the difference score and mean score BLC-strength 1 (kg) 68.1 (24.3) 79.2 (27.1) 56.3 (13.4) < 0.001
> 0.30, SRD%’s were calculated. The SRD% was cal- BLC-strength 2 (kg) 73.1 (27.1) 84.1 (34.4) 60.8 (13.7) 0.001
culated using the formula SRD% = SRD/M × 100%. HGS d (Kg) 34.1 (8.5) 37.8 (9.5) 30.0 (4.8) < 0.001
An SRD% < 30% was seen as acceptable level of mea- HGS nd (Kg) 32.1 (7.6) 36.3 (7.8) 27.7 (4.2) < 0.001
Adults
surement error (see also [21]). N 45 22 23
Pearson’s correlations were used to identify asso- Age (year) 25.2 (3.6) 26.5 (3.9) 23.9 (2.8) 0.01
ciations of maximal HGS, isometric knee flexion and Height (m) 175.1 (9.1) 181.5 (6.7) 168.6 (6.1) < 0.001
Weight (Kg) 72.0 (12.6) 81.4 (7.9) 63.0 (9.1) < 0.001
extension peak moments, and maximal back-leg-chest
BMI (kg/m2 ) 23.5 (2.8) 24.7 (2.7) 22.3 (2.4) 0.003
strength. A multiple regression model is used to deter-
BLC-strength 1 (kg) 93.6 (48.9) 132.5 (39.0) 56.3 (19.0) < 0.001
mine whether HGS or KES and KFS predict back-leg- BLC-strength 2 (kg) 95.6 (43.3) 129.3 (33.2) 63.4 (22.0) < 0.001
chest strength. In the regression procedure, the BLCS- HGS d (Kg) 44.2 (19.4) 54.7 (22.3) 34.0 (7.7) < 0.001
test of session 1 served as the dependent variable. In HGS nd (Kg) 41.7 (18.1) 51.8 (20.3) 32.0 (7.8) < 0.001
KES d (Nm) 206.7 (73.0) 259.6 (63.3) 153.8 (32.2) < 0.001
the first model, only gender was added as the inde-
KES nd (Nm) 93.2 (30.9) 114.2 (29.4) 72.3 (12.8) < 0.001
pendent variable. The second model analyzed the fol- KFS d (Nm) 197.7 (69.9) 253.3 (57.1) 146.9 (29.0) < 0.001
lowing strength variables: HGS of the dominant hand, KFS nd (Nm) 92.9 (28.8) 112.6 (26.7) 75.0 (16.2) < 0.001
HGS of the non-dominant hand, KES of the dominant
leg, KES of the non-dominant leg, KFS of the domi- cents. A high degree of reproducibility was found be-
nant leg and KFS of the non-dominant leg. In the third tween BLC strength measurements, for male adults an
model, gender and the aforementioned strength vari- ICC = 0.93 (95% CI: 0.90–0.98); for female adults,
ables were combined. Stepwise regressions were used ICC = 0.92 (95% CI: 0.88–0.98); for male adolescents,
to determine the most important predictors. ICC = 0.83 (95% CI: 0.66–0.80); for female adoles-
cents, ICC = 0.83 (95% CI: 0.52–0.95). The mean be-
tween day variation for BLC strength was 2.67 ± 12.36
3. Results Kg in adults, and 1.21 ± 15.85 Kg in adolescents, with
no differences in gender (p = 0.05 for adults, and p =
A total of 103 participants were examined, 45 adults, 0.64 for adolescents). Bland-Altman plots show test-
and 58 adolescents. Descriptive statistics for the main retest reproducibility of the BLC dynamometer in ses-
characteristics of the participants by age and gender sion 1 and session 2 using the error score (see Fig. 2).
are presented in Table 1. The female and male adults Correlations between the difference score (Y-axis of
slightly differed by age (p = 0.01). Males were signif- Blant-Altman plot) and mean score (X-axis of Blant-
icantly taller, heavier, and stronger on all strength tests Altman plot) are r = −0.36 for adults, and r = 0.28
(all p s < 0.001). In the adolescent population, no dif- for adolescents. Therefore SRD%’s are calculated for
ferences were found in age (p = 0.86) or weight (p = adolescents, while those for adults should be viewed
0.32), but boys were signifcantly taller, and stronger on with reserve.
all strength tests (all p s < 0.001). The SRD% was calculated using the formula SRD%
= SRD/M × 100%. An SRD% < 30% was seen as
3.1. Test retest reproducibility for the BLC acceptable level of measurement error (see also [21,
dynamometer p. 3]).
SRD’s and SRD%’s for male adults (26.2 and
The correlations between the measures of the BLC 19.9%), female adults (15.7 and 26.5%) and female
dynamometer-test in session 1 and session 2 were high adolescents (15.0 and 25.6% were all within the ac-
for both female (r = 0.92) and male (r = 0.93) adults, ceptable level of measurement error. Only the SRD
and female (r = 0.83) and male (r = 0.94) adoles- and SRD% for boys (34.2 and 42.2%) were not. How-
 G.A. Ten Hoor et al. / Back-leg-chest dynamometer testing 213

40 adult female 50 adolescent female

adult male
30 adolescent male
40
20
30
10

0 20
0 50 100 150 200 250
-10 10

-20
0
-30 0 20 40 60 80 100 120 140 160

-10
-40

-50 -20

Fig. 2. Blant-Altman plot’s indicating the mean difference with limits of agreement between BLC-test 1 and BLC-test 2 in adolescents and adults.

Table 2
ever, when taking out the one boy that did not fit in Correlations of handgrip strength, leg extension strength, leg flexion
the limits of agreement (as clear single outlier; see also strength, with back-leg-chest strength (session 1)
Fig. 2), the SRD and SRD% decreased to an accept- Back-leg-chest strength
able 17.6 and 22.1% respectively In very general terms Adolescents
these scores indicate that an increase of at least 20% Male Female
will be needed to evidence an improvement in BLC; Dominant hand Handgrip 0.71∗∗∗ 0.38∗
for a healthy and strong subject this would constitute Non-dominant hand Handgrip 0.78∗∗∗ 0.31
Adults
a major undertaking. On the other hand, it might be a Dominant hand Handgrip 0.45∗ −0.04
more realistic cutoff in some clinical situations where Non-dominant hand Handgrip 0.49∗ 0.11
this type of strength is low and therefore exceeding the Dominant leg Extension 0.65∗∗∗ 0.67∗∗∗
20% should be a reasonable objective. Flexion 0.81∗∗∗ 0.60∗∗
Non-dominant leg Extension 0.56∗∗ 0.71∗∗
Flexion 0.56∗∗ 0.65∗∗∗
3.2. Strength measure correlates ∗∗∗ p < 0.001; ∗∗ p < 0.01; ∗ p < 0.05.

In adults (males and females separated), significant

costs of evaluation. In the past, Bethards and col-
correlations were found between the BLC strength and
HGS in males, but not in females. All KES and KFS leagues [13] show a high intra-rater reproducibility
were significantly related to BLC strength. No signifi- of BLC dynamometer measures in adults. Our study
cant correlations between HGS and KES or KFS were replicated the results found by Bethards, but then sepa-
found (all p’s > 0.07; data not shown). In adolescents, rately for male and female healthy adults. Additionally,
BLC strength was significantly correlated with HGS in we demonstrated that the BLC dynamometer provides
boys, but not in girls (see Table 2). In Supplemental reasonable reproducibility of BLC strength in healthy
Digital Content file 2, a full correlation matrix can be adolescents. Furthermore, the present study showed
found. that in adult participants, HGS, KES and KFS effec-
Gender predicted 62% of BLC strength, whereas the tively predict BLC strength measured with the BLC
strength variables explained a significant proportion of dynamometer. These findings advocate the use of the
87% of the variance. The complete model, with both BLC dynamometer in examining overall limb muscle
gender and strength variables, explained variance by strength, at least in healthy adults. The results of the
88% (Table 3). A stepwise linear regression shows that present study imply the applicability of the BLC dy-
dominant KES and KFS were the most important sig- namometer. Together with its simplicity and portabil-
nificant predictors of BLC strength (r2 = 0.86). ity, this – up till now seldom used – apparatus might be
an appropriate tool in research lab, field research, and
clinical settings.
4. Discussion Currently, the usefulness of the BLC dynamometer
has been described rarely [22–24]. Coleman and col-
A single measure to characterize overall muscle leagues [22] used the BLC dynamometer in patients
strength is advantageous because it saves time and with Multiple Myelema, and showed that, fatigue,
214 G.A. Ten Hoor et al. / Back-leg-chest dynamometer testing

Table 3
Multiple regression analyses predicting back-leg-chest strength from gender (model 1), handgrip
strength, leg extension strength, and leg flexion strength (model 2), and a combination (model 3)
Model 1 Model 2 Model 3
Standardized β Standardized β Standardized β
Gender −0.79 − −0.13
Dominant hand Handgrip − −0.16 −0.18
Non-dominant hand Handgrip − 0.27 0.27
Dominant leg Extension − 0.24 0.22
Flexion − 0.50 0.43
Non-dominant leg Extension − 0.10 0.10
Flexion − 0.07 0.06
Adjusted R2 0.62 0.87 0.88

pain, sleep, mood and functional performance are in- Second, some participants experienced the BLC dy-
terrelated. Sadeghi and colleagues [23] concluded that namometer test as unpleasant, because of soreness of
the BLC dynamometer is not related to heart rate/work the lower back during the test that disappeared imme-
hardness. By using the BLC dynamometer, Sener and diately or within several hours after the test. For this
colleagues [24] found that muscle strength is related to reason, clear instructions about the correct body posi-
quality of life, depression, and anxiety symptomatol- tion, emphasizing the maintenance of an appropriate
ogy in patients with fibromyalgia. lordotic curve of the lumbar spine, is essential. More-
By using the SRD and SRD%, a rough relative
over, in order to appease participants, it is important
smallest measurement change that can be interpreted
to provide information about possible sensational feel-
as a real difference was calculated [25]. Although the
ings during and after the test, and explain that these
Blant Altman plots showed some heteroscedasticy, the
values found in this study are similar to findings in feelings are a normal response to unusual exertion and
other studies looking at test-retest reproducibility of do not imply tissue damage.
isometric strength tests, e.g. in hand function tests [21], Third, we used two BLC dynamometers in one of
and knee extension and flexion tests [26]. our subsequent studies, measuring about 800 healthy
adolescents aged 12–15 years in school setting. Both
4.1. Other practical applications: Considerations for apparatus broke during the experiment (i.e. the pointer
use stopped moving). Although the apparatus were quickly
and easily fixed, our impression is that the inner work
Several other factors, limitations and strengths have (plastic toothed wheels) should be replaced by higher
to be considered concerning the use of BLC dy- quality materials.
namometer as a measure. First, the apparatus induces Fourth, our study had a relatively small sample size
execution of static contractions, which are required and examination of the strength predictor variables
less often in daily life compared to dynamic con- KFS and KES was studied in adult participants. There-
tractions. Moreover, rehabilitation and training pro- fore, further research is necessary to examine whether
grams often focus on dynamic training modes. While these results can be generalized to other age groups.
isometric training is suggested to be more effective At last, the difference between the first and second
than isokinetic training [24–26], this training mode BLC dynamometer measure were within the limit of
is limited as it increases strength at a specific train-
agreement (except for a few outliers), but sometimes
ing angle, but with slight transference to other muscle
still very large. In each study, the pro’s (i.e. portabil-
lengths [27,28,30]. Since the BLC dynamometer mea-
ity and testing larger muscle groups outside the lab
sures muscle strength in one angle, it provides limited
information about muscle function. However, the BLC setting) and con’s (variability in measures) need to be
dynamometer can be used in multiple ways, where dif- considered carefully. For example, for a normal subject
ferent strengths can be measured by instructing differ- to increase the BLC strength reading by 20% might be
ent body positions. In this study, specific instructions a major task. On the other hand, it might serve in some
were given to participants for using the BLCS. Future clinical situations where this type of strength is low and
studies should examine the applicability of the BLC therefore exceeding the 20% should be a reasonable
dynamometer for other muscle groups. objective.
 G.A. Ten Hoor et al. / Back-leg-chest dynamometer testing 215

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