Use of the modified sphygmomanometer test to assess muscle strength in children and adolescents: a systematic review

Martins, Júlia Caetano; Matos, João Osmar Teixeira; Alves, Taluane Vívian Gomes; Andrade, Alice Caroline Arnaldo; Aquino, Cecília Ferreira de

doi:10.1590/1809-2950/e23004523en

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SYSTEMATIC REVIEW • Fisioter. Pesqui. 31 • 2024 • https://doi.org/10.1590/1809-2950/e23004523en linkcopy

Use of the modified sphygmomanometer test to assess muscle strength in children and adolescents: a systematic review

Aplicación de la prueba del esfigmomanómetro modificada en la evaluación de la fuerza muscular en niños y en adolescentes: una revisión sistemática

Authorship SCIMAGO INSTITUTIONS RANKINGS

Evaluating muscle strength in the pediatric population allows comparing healthy and affected individuals, establishing recovery goals, tracking the results of interventions and the evolution over time due to health conditions, as well as monitoring load progression and level of training. The Modified Sphygmomanometer Test (MST) is a technique used to measure isometric muscle strength in this population. The objective of the study is to gather and synthesize studies that used MST to measure the muscular strength of children and adolescents, identifying the muscle groups, measurement properties investigated, and the applied protocols. Bibliographic search was conducted on the MEDLINE, Embase, PEDro, SciELO, and LILACS databases. Original, peer-reviewed studies published up to September 2021 that evaluated isometric muscle strength using MST in children and adolescents aged 0 to 19 years were selected. A total of 1,610 studies were identified, and 17 were considered eligible. Of these, 12 studies (70.6%) were conducted with a mixed population and five (29.4%) with only children and adolescents. The most evaluated muscle groups were hip adductors (47.5%) and handgrip (29.4%) with a predominance of the non-adapted sphygmomanometer (47.1%) and 20mmHg pre-insufflation (47.1%). Only six studies (35.3%) evaluated MST measurement properties . In conclusion, there are few studies aimed at the pediatric population, which hinders the standardization of MST application in clinical practice, despite being easy to access and handle.

Keywords
adolescents; children; muscle strength

Study(study design)	Objectives	Sample	Sphygmomanometer fitting and calibration	Protocol
Helewa et al., 198110 (cross-sectional)	To evaluate the concurrent criterion validity and inter-rater reliability of the sphygmomanometer and a weight measurement method for measuring knee EXT strength in individuals with rheumatoid arthritis	Population: individuals with rheumatoid arthritis	Adaptation: bag and cuff	Muscle group: knee EXT
Database/source		N=5	Equipment preparation: 20mmHg pre-inflation	Familiarization with the test: the methods were explained to each individual and pre-tested on the opposite leg
(MEDLINE)		Age: 18 to 65 years	Calibration: Yes	Number of repetitions: 1
Ethical approval NR		Gender: F: 3 (66%)		Contraction time: 5s
		M: 2 (34%)		Resting time: NR
		BMI: NR		Verbal stimulus: NR
				Participant positioning: SP, upper limbs at the side of the body, thighs supported, hip joint flexed at 45° and knee flexed at 90°;
				The examiner passively positioned the subject’s MI to maintain a 90° angle at the knee joint; the individual was asked to maintain the position while the examiner applied resistance gradually (with open hands on the equipment).
				Position of the equipment: placed above the ankle, longitudinally
Balogun et al., 199024	To evaluate the modified sphygmomanometer reproducibility during HG force measurement; determine the relations between the modified sphygmomanometer and dynamometer readings, derive a linear regression equation to predict HG strength from modified sphygmomanometer measurements and to determine the relative contribution of age, body, weight, and height to predicting HG strength	Population: healthy adolescents and adults	Adaptation: bag	Muscle group: HG
(cross-sectional)		N=34	Equipment preparation: 20mmHg pre-inflation	Familiarization with the test: each individual underwent two experimental sessions
Database/source		Age: 16 to 28 years	Calibration: NR	Number of repetitions: 2, considering the higher value
(retrieved from Toohey et al., 2018)29		Gender: F: 6 (18%)		Contraction time: 5 s + 2 s for reading
Ethical approval NR		M: 28 (82%)		Resting time: 5 min
		BMI: NR		Verbal stimulus: NR
				Participant positioning: standing with the shoulder adducted and rotated neutral, elbow joint kept in full extension and the forearm in a neutral position
				Equipment Position: palm
Dunn, 199316	To gather data on HG strength of typical children aged 3 to 7 years using MST, and to compare the HG strength of a preliminary sample of children with rheumatic disorders with the HG strength of typical children	Population: children with rheumatic disorders and typical children	Adaptation: bag	Muscle group: HG
(cross-sectional)		N=273	Equipment preparation: 20mmHg pre-inflation	Familiarization with the test: the position was explained verbally and demonstrated as many times as necessary
Database/source		Age: 3 to 7 years	Calibration: Yes	Number of repetitions: 3, analysis with arithmetic mean
(MEDLINE)		Gender: F: 132 (48%);		Contraction time: NR
Ethical approval NR		M: 141 (52%)		Resting time: 15s
		BMI: NR		Verbal stimulus: Yes
				Participant positioning: child seated in a chair, hip joint flexed at 90° bilaterally, both feet resting on the floor before the chair. upper limbs adducted, elbows flexed at 90°, forearm supinated and wrist in neutral position
				Equipment position: palm
Koch and Simenson, 199233	To document how the muscles of the distal extremities of upper limbs may function as a primary resource for hand function, ADLs, and mobility in children with spinal muscular atrophy type II and to describe the natural history of the disease	Population: children with spinal muscular atrophy type II	Adaptation: NR	Muscle group: HG
(prospective cohort)		N=10	Equipment preparation: NR	Familiarization with the test: NR
Database/source		Age: NR	Calibration: NR	Number of repetitions: NR
(MEDLINE)		Gender: NR		Contraction time: NR
Ethical approval NR		BMI: NR		Resting time: NR
				Verbal stimulus: NR
				Participant positioning: NR
				Equipment Position: NR
Barden et al., 199515	To describe a physical therapy protocol for treating wrist subluxation in children with arthritis	Population: children with arthritis	Adaptation: NR	Muscle group: HG
(case report)		N=2	Equipment preparation: NR	Familiarization with the test: NR
Database/source		Age: 5 and 17 years	Calibration: NR	Number of repetitions: 3 (analysis with the highest value)
(MEDLINE)		Gender: F: 1 (50%);		Contraction time: 10s
Ethical approval NR		M: 1 (50%)		Resting time: NR
		BMI: NR		Verbal stimulus: NR
				Participant positioning: NR
				Equipment Position: NR
Soares & Riedel, 199725	To compare the manual forceps of individuals affected by leprosy with healthy individuals using a neonatal sphygmomanometer	Population: individuals with leprosy and unaffected	Adaptation: bag (neonatal sphygmomanometer)	Muscle group: palmar pinch, tree-point pinch, and lateral pinch
(cross-sectional)		N=78	Equipment preparation: 20mmHg pre-inflation	Familiarization with the test: NR
Database/source		Age: 15 to 55 years	Calibration: NR	Number of repetitions: NR
(MEDLINE)		Gender: NR		Contraction time: NR
Ethical approval NR		BMI: NR		Resting time: NR
				Verbal stimulus: NR
				Participant positioning: NR
				Position of the equipment: palmar pinch: between the thumb and each of the fingers; lateral pinch: between the thumb and the side of the index finger; and three-point pinch: between the index and middle fingers, middle and ring fingers, ring and little fingers
Perossa et al., 199819	To investigate the intra-examiner reliability of manual shoulder and hip muscle assessment using MST	Population: typical student volunteers	Adaptation: none	Muscle group: FLX, EXT, ABD, shoulder RI and RE, EXT, hip FLX and ABD
(cross-sectional)		N=80	Equipment preparation: 20mmHg pre-inflation	Familiarization with the test: the participant was allowed to practice the movements before performing the test
Database/source		Age: 19 to 22 years	Calibration: NR	Number of repetitions: NR
(retrieved from Souza et al., 2013)6		Gender: F: 40 (50%);		Contraction time: NR
Ethical approval NR		M: 40 (50%)		Resting time: 30 to 35s
		BMI: NR		Verbal stimulus: NR
				Participant positioning: Shoulder FLX: seated, shoulder flexed at 30°;
				Shoulder EXT: seated, shoulder extended at 20°;
				Shoulder ABD: seated, shoulder abducted at approximately 35°;
				RI: seated, elbow flexed at 90°;
				RE: seated, elbow flexed at 90°;
				Hip EXT: prone position, equipment behind the knee. Participant bent their leg at 90º and raised their thigh 15º to 20º from the table;
				Hip FLX: supine position, with thigh and knee bent at 90º. Equipment positioned in the anterior region near the knee;
				Hip ABD: LD, equipment on the side of the knee, instructed to initiate the action by pushing upwards
				Equipment Position: Shoulder FLX: on the forearm above the elbow;
				EXT of shoulder: on the inside of the forearm;
				Shoulder ABD: in the middle of the forearm;
				Shoulder RI: NR;
				Shoulder RE: above the outside of the wrist;
				Hip EXT: behind the knee;
				Hip FLX: in front of the knee;
				Hip ABD: on the side of the knee
Suresh et al., 200826	To evaluate hand muscle weakness using dynamometry as an indicator of alteration in motor nerve function detected by the voluntary test of muscles innervated by the ulnar and median nerves	Population: individuals newly diagnosed with multibacillary leprosy	Adaptation: cuff	Muscle group: HG, palmar pinch, and lateral pinch
(prospective cohort)		N=303	Equipment preparation: 20mmHg pre-inflation	Familiarization with the test: all test procedures were described in detail in a procedure manual
Database/source		Age: 12 to 60 years old (mean of 32.8)	Calibration: NR	Number of repetitions: 3, analysis with arithmetic mean
(MEDLINE)		Gender: F: 83 (27%)		Contraction time: NR
Ethical approval		M: 220 (73%)		Resting time: NR
Indian Council of Medical Research and the Research Ethics Committee of the JALMA Central Institute of Leprosy in Agra		BMI: NR		Verbal stimulus: Yes
				Participant positioning: seated in a chair whose arms served as support for the upper limbs, feet resting on the floor. Palmar pinch: forearm in neutral position, wrist slightly extended, finger joints slightly flexed, thumb between flexion and opposition, interphalangeal joint extended; lateral pinch: UL close to the trunk, elbow flexed, forearm pronated, wrist extended, metacarpophalangeal joint of the index finger flexed, interphalangeal joints extended, thumb in opposition. HG: shoulder abducted, elbow flexed at 90°, forearm in neutral position, wrist extended
				Equipment Position: NR
Malliaras et al., 200918	To identify reliable hip flexibility and strength measures among junior elite soccer players with and without groin pain	Population: soccer players	Adaptation: none	Muscle group: Hip ABD
(prospective cohort)		N=29	Equipment preparation: 10mmHg pre-inflation	Familiarization with the test: measurements were taken after a trial, for familiarization
Database/source		Age: 15 to 21 years	Calibration: NR	Number of repetitions: NR
(retrieved from Toohey et al., 201514)29		Gender: M: 29 (100%)		Contraction time: NR
Ethical approval		BMI: NR		Resting time: NR
La Trobe University, Melbourne, Australia				Verbal stimulus: NR
				Participant positioning: supine position, three angles of hip flexion: 0°, 30° and 45°
				Equipment position: between the player’s knees
Delahunt et al., 201127	To evaluate the intra-rater reliability of a commercially available sphygmomanometer to measure ADD compression values in Irish soccer athletes and to determine if different compression values are associated with the three commonly used test positions	Population: Irish soccer athletes	Adaptation: none	Muscle group: Hip ABD
(cross-sectional)		N=18	Equipment preparation: 10mmHg pre-inflation	Familiarization with the test: 3 practical trials were allowed in each test position for familiarization with the protocol
Database/source (retrieved from Hodgson et al., 201428)		Age: 21.11±2.53 years	Calibration: NR	Number of repetitions: 3, considering the higher value
Ethical approval		Gender: M: 18 (100%)		Contraction time: NR
College Dublin University		BMI: NR		Resting time: 2 min
				Verbal stimulus: NR
				Participant positioning: supine position with arms crossed and head resting on a cushion. Hip joints were kept in neutral rotation in each of the test positions. Three angles: 0º, 45º and 90º hip flexion
				Position of the equipment: between the knees at the most prominent point of the medial femoral condyles
Delahunt et al., 201127	To investigate adductor muscle activity and concomitant pressure values while performing hip ADD compression test at 0°, 45° and 90° hip flexion of Irish soccer athletes without any history of groin injury	Population: Irish soccer athletes	Adaptation: none	Muscle group: Hip ABD
(cross-sectional)		N=18	Equipment preparation: 10mmHg pre-inflation	Familiarization with the test: three attempts at submaximal practice were allowed in each test position for familiarization with the procedures.
Database/source		Age: 21.11±2.53 years	Calibration: NR	Number of repetitions: 3, considering the higher value
(MEDLINE)		Gender: M: 18 (100%)		Contraction time: 5s
Ethical approval College Dublin University		BMI: NR		Resting time: NR
				Verbal stimulus: NR
				Participant positioning: at 0° the hip joint was kept in a neutral rotation position. For the 45° and 90° hip flexion test positions, the knee joint was held at 90° flexion
				Equipment position: the sphygmomanometer cuff was placed between the knees
Coughlan et al., 201432	To establish normative values of the ADD compression test in asymptomatic junior elite rugby players and to investigate whether there are differences between the player’s position on the field and the category	Population: asymptomatic rugby players	Adaptation: none	Muscle group: Hip ABD
(cross-sectional)		N=104	Equipment preparation: 10mmHg pre-inflation	Familiarization with the test: before the validity test, each participant became familiar with the protocol, was informed about the test procedure and allowed to perform three submaximal efforts in each of the test positions
Database/source		Age: 17.56±0.54 years	Calibration: NR	Number of repetitions: 3, considering the higher value
(retrieved from Souza et al., 201634)6		Gender: M: 104 (100%)		Contraction time: NR
Ethical approval		BMI: NR		Resting time: 15s between each rep and a 45s rest between each test position
College Dublin University				Verbal stimulus: NR
				Participant positioning: supine position, with the head resting on the stretcher and the arms on the chest. Three angles: 0º, 45º and 90º hip flexion
				Equipment position: the cuff was positioned so that the middle third rested at the most prominent point of the medial femoral condyles
Hodgson et al., 201428	To determine the normative values of hip ADD strength in professional rugby players using a sphygmomanometer cuff in different test positions	Population: rugby players	Adaptation: none	Muscle group: Hip ABD
(cross-sectional)		N=81	Equipment preparation: 20mmHg pre-inflation	Familiarization with the test: all participants were familiar with the tests and had received training in their use to improve inter-rater reliability
Database/source (Embase)		Age: <18 to >30 years	Calibration: NR	Number of repetitions: NR
Ethical approval NR		Gender: M: 81 (100%)		Contraction time: 2 to 3s
		BMI: 29.0kg/m2 (3.0kg/m2)		Resting time: NR
				Verbal stimulus: NR
				Participant positioning: 0° test: athlete in SP on the pedestal with the ankles together. 60° test: athlete in SP and then flexing the knee and hip until the heel of the foot aligned with the medial joint line of the opposite knee, the other foot was brought to mirror this position, providing approximately 60° of hip flexion. 90° test with support, the athletes were instructed to place their legs in 90° hip and knee flexion and the examiner made the corrections relevant to the position while resting their arms under the athletes’ knees and instructing them to relax to perform the test. For the 90° test without support, the athlete maintained this position without support of the examiner
				Equipment Position: NR
Roe et al., 201634	Firstly, to investigate the magnitude of the change in ADD strength after a match in rugby players using the ADD compression test. Secondly, to examine the relation between game displacement demands and changes in ADD strength	Population: rugby players	Adaptation: none	Muscle group: Hip ABD
(prospective cohort)		N=14	Equipment preparation: 10mmHg pre-inflation	Familiarization with the test: NR
Database/source		Age: 17.4±0.8 years	Calibration: NR	Number of repetitions: 3, considering the higher value
(retrieved from Tiernan et al., 201930)		Gender: M: 14 (100%)		Contraction time: NR
Ethical approval		BMI: NR		Resting time: 30s
Leeds Beckett University				Verbal stimulus: NR
				Participant positioning: SP with hip joints positioned in neutral rotation
				Equipment position: between the knees at the most prominent point of the medial condyles
Toohey et al., 201829	To investigate sphygmomanometer intra- and inter-rater reliability for assessing ADD compression test and isometric strength of the hip ABD muscles and to establish its concurrent validity for evaluating the same measurements compared with the reference standard of portable dynamometry	Population: soccer players	Adaptation: cuff	Muscle group: Hip ADD and ABD
(prospective cohort)		N=32	Equipment preparation: 10mmHg pre-inflation	Familiarization with the test: NR
Database/source		Age: 23.9±4.5 years	Calibration: Yes	Number of repetitions: NR
(MEDLINE)		Gender: M: 32 (100%)		Contraction time: 5s
Ethical approval		BMI: NR		Resting time: 60s
La Trobe University (FHEC13/064)				Verbal stimulus: NR
				Participant positioning: LD with the tested LL positioned superiorly at 0° flexion and abduction at the hip and full knee extension. Knee of the LL positioned inferiorly was flexed at 90° to provide stability
				Equipment position: the center of the device was placed 5cm proximal to the lateral malleolus
Tiernan et al., 201930	To investigate the relation between ADD compression force values, subjective markers of recovery, and training load in elite rugby players	Population: elite rugby players	Adaptation: none	Muscle group: Hip ABD
(prospective cohort)		N=19	Equipment preparation: 10mmHg pre-inflation	Familiarization with the test: players were familiar with all testing protocols as a result of previous years of monitoring
Database/source		Age: 19.7±1.1 years	Calibration: NR	Number of repetitions: 1
(MEDLINE)		Gender: M: 19 (100%)		Contraction time: 2 to 3s.
Ethical approval		BMI: NR		Resting time: NR
University of Limerick				Verbal stimulus: NR
				Participant positioning: players lay on the floor with their hips held in a neutral position, knees bent at 90°, and hips flexed at 45°
				Equipment position: between the knees with the middle third of the cuff located at the most prominent point of the medial femoral condyles
Vishesh et al., 202031	To measure dominant HG strength with a modified sphygmomanometer and Its association with various hand and forearm anthropometric measurements in basketball and volleyball players	Population: basketball and volleyball players	Adaptation: cuff	Muscle group: HG
(cross-sectional)		N=60	Equipment preparation: 20mmHg pre-inflation	Familiarization with the test: NR
Database/source		Age: 15 to 20 years	Calibration: NR	Number of repetitions: 3
(Embase)		Gender: F: 16 (27%)		Contraction time: NR
Ethical approval NR		M: 44 (73%)		Resting time: 5s
		BMI: 18.57±2.33		Verbal stimulus: NR
				Participant positioning: players were positioned in a straight-backed chair, with both feet fully supported on the floor. Each player was instructed to place their left hand on the right thigh and assume the position with adducted shoulders in neutral rotation. For the arm tested, the elbow was flexed up to 90°, the forearm and wrist were in a neutral position, and the fingers were flexed
				Equipment Position: NR

Study (study design)	Measurement properties	Muscle groups	Results
Helewa et al., 198110 (cross-sectional)	Concurrent criterion validity	Knee extensors	r=0.92 to 0.94
Balogun et al., 199024	Concurrent criterion validity	Handgrip	r=0.84 to 0.99
(cross-sectional)	Intra-rater reliability	Handgrip	r=0.84 to 0.99
Perossa et al., 199819 (cross-sectional)	Intra-rater reliability	Shoulder flexors, extensors, abductors, and internal and external rotators; flexors, extensors, hip abductors	ICC=0.86 to 0.97
Malliaras et al., 200918 (prospective cohort)	Intra-rater reliability	Hip adductors	ICC=0.81 to 0.94
Malliaras et al., 200918 (prospective cohort)	Inter-rater reliability	Hip adductors	ICC=0.80 to 0.83
Delahunt et al., 201127 (cross-sectional)	Intra-rater reliability	Hip adductors	ICC=0.89 to 0.92
Toohey et al., 201829 (prospective cohort)	Intra-rater reliability	Hip adductors and abductors	ICC=0.61 to 0.92
	Inter-rater reliability	Hip adductors and abductors	ICC=0.77 to 0.91
	Concurrent criterion validity	Hip adductors and abductors	r=0.77 to 0.91

Author	Validity of concurrent criteria	Intra-rater reliability	Inter-rater reliability
Helewa et al., 198110 (cross-sectional)	Excellent	NE	NE
Balogun et al., 199024 (cross-sectional)	Moderate	Excellent	NE
Perossa et al., 199819 (cross-sectional)	NE	Weak	NE
Malliaras et al., 200918	NE	Moderate	Moderate
(prospective cohort)	NE	Moderate	Moderate
Delahunt et al., 201127 (cross-sectional)	NE	Weak	NE
Toohey et al., 201829 (prospective cohort)	Weak	Weak	Weak

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[1] ^Caption:
ABD: abductors; ADD: adductors; ROM: range of motion; ADLs: activities of daily living; SP: supine position; LD: lateral decubitus; EXT: extensors; F: female; FLX: flexors; BMI: body mass index; M: male; LL: lower limbs; min: minutes; mmHg: millimeters of mercury; UL: upper limbs; NR: not reported; HG: handgrip; ER: external rotators; IR: internal rotators; s: seconds; MST: modified sphygmomanometer test.