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Table of contents

Table of contents...................................................................................1

Introduction............................................................................................2

Part 1 – operating instructions...............................................................3

How to start the CITEC HHD.........................................................................3

Normal use of the CITEC HHD......................................................................3

CITEC HHD memory function........................................................................3

Changing batteries........................................................................................5

Warranty…………………………………………………………………………...5

Maintenance..................................................................................................6

Calibration………………………………………………………………………….6

Ordering accessories.....................................................................................6

Important.......................................................................................................6

Part 2 - Description of test procedure and technique in practice...........7

Measurement technique................................................................................7

Measurement variables.................................................................................8

Indications.....................................................................................................9

Reference values.........................................................................................10

Measurement position.................................................................................11

Appendix 1 : Technical specifications CITEC HHD ..........................25

Appendix 2 : Reference values adults...............................................26

Appendix 3 a: Reference values boys and girls aged 4 - 8.................27

Appendix 3b : Reference values boys and girls aged 9 - 12...............28

Appendix 3c : Reference values boys and girls aged 13 - 16..............29

Appendix 4a/b: CITEC HHD measurement registration form..............30

Page 1/34 CITEC dynamometer

Introduction

With the CITEC dynamometer, the maximal voluntary contraction (MVC) can be

measured. This instrument can be used in many different disciplines , from sports /

training, research , consulting hours and at home.

This manual is divided in three parts:

I. Part 1 explaining how to use and operate the CITEC dynamometer

II. Part 2 explaining the procedure /technique in working with the CITEC dynamometer

Part 3 Appendix 1 Technical specification

Appendix 2, 3, 4 Reference values / forms

The CITEC HHD is available 2 models :

* Model 3002/30 with a range up to 500 Newton

* Model 3002/60 with a range up to 1000 Newton

For safe and effective use of the CITEC, knowledge and skills of manual muscle strength

tests are needed. Part 2 of this manual offers information about measurement

techniques and photo illustrated examples how the CITEC dynamometer can be used in

practice. These instructions are based on information from the publication “Hand held

Dynamometry” ( Ploeg, R.J.O. van der - Groningen: Dijkhuizen Van Zanten BV, 1992)

and is intended as a tool to learn how to use the CITEC dynamometer.

NOTE: Never use the shown values as absolute values. The relative difference of

measured values in time has to be monitored.

Risc management advice:

Examiner should only use the instrument after having read the operation-/

instruction manual.

Before start of usage, the CITEC should be fit for use and correctly calibrated.

Batteries should be placed as per instruction shown on rear side of instrument.

In case of blinking / odd figures on display, replace batteries

Avoid extreme temperatures, heavy shocks, vibrations, moisture, overloading, etc.

Install the adapters on the CITEC in a correct way



Part 1 – operating instructions

The CITEC is a hand held dynamometer (HHD), that facilitates a quick, objective and

reliable measurement of the quantitative muscle strength. This light and ergonomically

designed tool can be used with nearly all clinically relevant muscle groups.

On the CITEC HHD type 3002/ 6002, you find only one button: the [on/reset]-button.

Use this button to turn the CITEC HHD on (press short) and to reach the memory

function (press long).

The zero-level of the CITEC HHD is adjusted automatically.

How to start the CITEC HHD

To install the 2 batteries, remove the applicator installed.

Screw off the cover at the bottom of the CITEC HHD by turning it to the left.

Please note the instructions at the back of the CITEC HHD, as how to place the batteries

and replace the cover.

To turn the CITEC HDD on, press the [on/reset] button shortly (< 1 sec).

In the display the zero level [000] is shown – the CITEC HHD will shut off automatically

after appr. 15 seconds.

Normal use of the CITEC HHD

Start the CITEC HHD by pressing the [on/reset] button; the display shows

the zero level [000]. Install the desired applicator on the battery holder.

Your CITEC HHD is ready to measure now.

Press the installed applicator. In the display, the measured strength (peak force) is

shown. The force is shown in Newton; 1 kilogramme is appr. 10 Newton (9.80665

Newton).

After 15 seconds, the CITEC HHD will shut off automatically; during this period, the peak

force remains visible in the display.

CITEC HHD memory function

The measured value is visible in the CITEC display during 15 seconds after the last use.

You can write down the measured value on the registration form or the measured value

can be registered in the CITEC HHD memory.

Page 4/34 CITEC operating instructions

To register measured values in the CITEC HHD memory:

press the [on/reset]-button long (> 1 sec)

and then, press the [on/reset]-button short (< 1 sec)

the measured value can now be put on the desired memory position (15 positions)

within current test cycle memory position will automatically be chosen sequential

from off ( idle) position it will start again with memory position 1

The measured value will be put in the chosen memory position automatically.

The CITEC HHD will reset to the zero level and is ready for a new measurement .

To read the stored values from the CITEC HHD memory:

press the [on/reset]-button long (> 1 sec) when the CITEC is off (idle)

press the [on/reset]-button shortly (< 1 sec) to reach and read the memory positions

after 15 sec. CITEC automatically will be shut off

To clear the memory from the CITEC HHD:

press the [on/reset]-button long (> 1 sec) when the CITEC is off (idle)

press the [on/reset]-button shortly (< 1 sec) to reach the memory positions

click through the memory positions until position 99 (after position 15)

after 15 sec. in position 99 , memory is cleared

Connecting the CITEC HHD to the PC (optional)Optional, please ask our sales department .

Changing applicatorsAn applicator can be removed by simply pulling them off the CITEC. Another applicator

is installed the other way around: press to adjust the applicator.

Pinch grip / Fist grip applicator (optional)

Installing the pinch grip or fist grip applicator is slightly different.

First, remove the applicator installed. Then, screw off the round disc by turning it to the

left. Slide the pinch grip/ fist grip applicator over the battery holder. Adjust the applicator

by turning it to the right.

The fist grip applicator passes on the measured strength in a 1:2 ratio . Therefore, the

displayed strength needs to be multiplied by 2 !!


Changing batteries

The CITEC uses two 544 6.2 volt batteries, obtainable at photographic dealers, etc..

As battery power weakens, the display might show odd figures and / or will blink with

display value [888].

Please make sure using silver oxide or lithium batteries. There batteries will maintain the

required high voltage level.

Please replace both batteries. The lifetime of the batteries is subject to usage. For most

users, the batteries will last for more then 4- 6 months

To replace the batteries, remove the applicator installed. Screw off the button at the

bottom of the CITEC by turning it to the left. Remove the old batteries and place the new

ones. Please note the instructions at the back of the CITEC as to how to place the

batteries.

We recommend removing batteries if the CITEC is not used for more than 30 days. This

will reduce possible damage as a result of leakage and corrosion of the batteries

Warranty The warranty on the CITEC dynamometer is 1 year.

Excluded are defects caused by incorrect use, such as exposing the CITEC to

overloading, shocks, vibration, moisture , etc.

Excluded are calibration costs.

Maintenance

The CITEC does not require any special treatment.

For cleaning the CITEC you can use a soft cloth with eventually a non aggressive

detergent. Avoid liquid seeping into the interior of the CITEC.

Remove batteries if the CITEC is not used for more than 30 days to avoid damage

At the end of its life cycle instrument should be put into recycle depot.

Store the CITEC preferably at room temperature in its protective case.


Calibration

It is recommended to check or have checked the measured values every 6 months.

This can be done by a trained operator / technician against a known calibrated weight.

The measured values should be within +/- 3% of calibrated weight.

Our Service Department can help you and can take care of the calibration.

Problem Solving/Trouble Shooting

In case of default measurement, please check the status of batteries and replace them

both by new batteries of a correct type.

In case of blinking with display value (888) / odd values on the display, please replace

both batteries.

In case the CITEC does not react, replace both batteries - if this does not solve, please

contact our Service Department for further suggestions and actions.

Ordering accessories

Accessories, e.g. applicators, battery button, etc., can be ordered at C.I.T. Technics:

C.I.T. Technics

Rijksstraatweg 384

NL-9752 CR HAREN

The Netherlands

Tel.: +31 50 - 406 17 54

Fax: +31 50 - 406 15 58

e-mail: [email protected]

internet: www.citec.nu

Important

The CITEC model 3002/30 measures up to 500 Newton.

The CITEC model 3002/60 measures up to 1000 Newton.

Do not exceed this range: this can cause damage to the load cell.

Avoid heavy shocks, extreme low or high temperatures, moist and aggressive

detergents.

For technical specifications, please refer to appendix 1


http://www.citec.nu/

mailto:[email protected]


Part 2 - Description of test procedure and technique in practice

The CITEC dynamometer is a device that can be used to measure the maximal

voluntary contraction (MVC). Proper use of the CITEC dynamometer demands a lot of

knowledge and skills of the of the examiner.

Our body counts many muscles, which cannot be investigated separately. In clinical

practice, one is always testing muscle groups. Therefore it is better to use the muscle

groups terms (e.g. elbow flexors rather than biceps muscle).

Precise standardization of the position of the subject, the dynamometer and the

examiner are of vital importance for a correct and reliable measurement. These standard

positions, for 13 muscle groups, are listed in this document.

Disrobing is not necessary in these positions, except of taking off the shoes in the case

of the foot dorsal- and plantar flexors.

Recommended is the use of a tissue between the applicator and the skin of the patient

Measurement technique

As stated, the measurement process asks knowledge and skills of the examiner.

A measurement is conducted as follows:

Press the on-reset button to turn the CITEC dynamometer on. The device is ready to

measure start.

The examiner checks the position and settings of the measurement and equipment.

The examiner instructs the patient to contract the muscle group in a controlled way

within for a couple of seconds and then to stop contraction on the signal of the

examiner.

The examiner holds the dynamometer in position (see descriptions below)

With the CITEC in position, the examiner tells the patient to contract the muscles in a

controlled way; not too fast, not too slow.

After app. 2 – 3 seconds, the examiner asks the patient to exert maximal effort (verbal

encouragement can be helpful).

Then, in app. 1 – 2 seconds, the examiner slowly overcomes the strength and stops

the measurement on the moment the patient gives away.

After the measurement, the CITEC display shows the measured strength for 15

seconds. Then, the devices shuts off automatically.

When the on-reset button is pressed, the CITEC is ready for a new measurement.

Page 9/34 how to use the CITEC dynamometer

NOTE: measure at least 3 times and take the average value

The process as described above follows the ‘break technique’. An alternative method is

the ‘make technique’. A brief description:

Break technique

In a careful break test, the examiner slowly overcomes the strength and stops on the

moment the subject gives away. In practice, this means a movement of the segment of ±

1 cm (wrist extensors) to ± 5 cm (hip flexors, elbow flexors) in ± 1 second. In fact, there

is an eccentric movement and therefore it is essential to ascertain that the velocity of the

moving segment is always low.

Make technique

An alternative is the make test, which is strictly isometric. The examiner just holds the

dynamometer in position and the subject is pressing against the applicator of the

dynamometer in otherwise exactly the same standard position and conditions.

With the make test, it is more difficult to determine whether there has been a MVC and

suboptimal cooperating persons are less willing to exert maximal effort.

A break test, as it were, forces them to produce a real MVC. With the break test, the

examiner feels a characteristic tight elastic resistance, which is called “follow through”.

Moreover, the results in cooperative normals and patients show only minor differences

between make and break (3% more force with break).

Measurement variables

Repetitions

During a single session it is advisable to carry out 3 measurements and to average

these three values. Under normal circumstances with cooperative persons, these values

differ <15%. The minimum rest period between the contractions should be about 5

seconds.

Furthermore it is advisable to always start with a test measurement.

Feedback

During the tests the subject does not receive instantaneous feedback. Of course the

subject is, in most cases, informed afterwards about his performance.


Instruction to the subject

In a break test, the subject is instructed to increase to maximum exertion, without jerk, in

about one to two seconds and to maintain this effort until the examiner gives the

command to relax. The subject is informed about the test purpose and procedures.

Encouragement

Verbal encouragement is given, especially on the moment the examiner perceives that

the subject is giving way, e.g. “hold, hold”.

Rewards

Goal setting, competition and non-medical spectators are to be avoided.

Test room

There are no special requirements for a test room. A patient can be investigated in an

outpatient’s department, a clinic or at home. It is self-evident that not all 13 muscle

groups can be tested in an intensive treatment unit, but in a supine position still 7 muscle

groups can be measured, for instance in a Guillain-Barré patient.

Pain

Complaints about pain, especially when elicited by the contraction, can disturb a correct

measurement. The result will be probably too low. The patient gives away abruptly and

the examiner does not observe a follow through contraction.

Some patients can proceed after having received extra explanation and encouragement.

However, sometimes it is impossible to give a proper judgment in these cases.

Discomfort caused by the applicator of the dynamometer when pushed against bony

surfaces (e.g. dorsum of hand) can be prevented by extra padding/tissue, for instance

additional high density foam.

Indications

What is the purpose of muscle strength quantification?

In the first place, muscle strength quantification with a dynamometer offers a more

objective measurement than manual tests with so called ordinal data. This offers

enhanced possibilities to evaluate therapies with larger sensitivity. The development of

the patient in time can be followed more accurately. Also, measuring results can be

compared to reference values for normal functioning muscle groups.


For which patients the dynamometer can be used?

Periodical muscle group strength measurement is used for patients with neuromuscular

disorders, e.g. polymyosities, muscle dystrophy and Guillain Barré syndrome. Results of

physiotherapy, medication therapy and other kinds of treatment can be evaluated more

accurately.

Reference values

In appendix 2, you’ll find a table with reference values for adults. These values are

based on measurements with 50 normal women and 50 normal men in the age of 20 –

60 years. For quick practical clinical purposes, the 5th and 50th centile values will

suffice. For experienced examiners, results of repeated measurements will differ

between 10% and max 20%.

In appendix 3, you’ll find tables with age-related reference values for 11 muscle groups

in normal boys and girls, aged 4-16 years (mean values).

Values measured can be written on patient measurement form as per appendix 4. This

form can be downloaded from our website www.citec.nu.



Measurement position

Below, you find some useful measurement tips and details for measuring 13 clinically

relevant muscle groups. The reference values are a result of measurements conducted

as described below.

The information is based upon research, medical literature and experience. Variation is

possible, as long as a standardized method is used for repetitions.

When choosing the position, the examiner should consider the comfort of the patient as

well as the characteristics of the particular muscle group. Measurement should not be

conducted when contraction of the muscle group is impeded.


Muscle group 1: Neck extensors

position of subject Sitting upright in a chair with a firm back; head up at 90º

from horizontal

position of dynamometer Back of the head, lower rim of applicator just above ear

shelf level

position of examiner Standing behind subject

fixation Both hands fixate the elbow-rests

Additional remarks

Some patients experience pain in their neck extensors (in my experience notably

patients with tension headache), which will influence MVC and reliability.

The tendency of the subject

to elongate these muscles

by bending the trunk

backwards is prevented by

the chair. In the described

examiner position, it is not

possible to measure

beyond +/- 125N. Most

normal subjects are

stronger than this value.

For males a value <125 N

must be regarded as

subnormal.


Muscle group 2: Neck flexors

position of subject Sitting upright in a chair with a firm back; head up at 90º

from horizontal

position of dynamometer Centre of forehead, lower rim of applicator just above

eyebrows


fixation Both hands fixate the elbow-rests

Additional remarks

Some patients experience pain in their neck flexors, which will influence MVC and

reliability. Not infrequently pain is caused by pressure of the dynamometer on the

forehead. This difficulty

can be removed by a small

soft pad between the

applicator and the

forehead.

The subject will have a

natural tendency to

elongate these muscles by

bending the trunk forward,

which cannot be prevented

totally, but a fast

movement must be

avoided, because this will

result in a fast eccentric

contraction and a higher

value.


Muscle group 3: Shoulder abductors

position of subject Sitting upright in a chair sitting upright; shoulder 90º

abducted, elbow 135º flexed, forearm pronated

position of dynamometer Lateral epicondyle of humerus

position of examiner Standing next to subject

fixation None

Additional remarks

For a good symmetry it is advisable to bring both arms in the position described.

Bending to the contra lateral side must be avoided. This elongates the deltoid muscle

and will influence the result.

In this position gravity has a marked influence. In patients with severe weakness in these

muscles an alternative would be a supine position with otherwise the same

standardisation.


Muscle group 4: Elbow flexors

position of subject Supine, shoulder adducted, elbow 90º flexed, forearm

supinated

position of dynamometer Just proximal to wrist crease (flexor surface)

position of examiner Standing next to subject

fixation Subject grasps edge of examination couch with

contralateral hand

Additional remarks

The subject must ly flat with at most one cushion, otherwise the standard position will be

interfered with. There is a tendency to move the shoulder up and forward, elongating the

biarticular biceps muscle.

Especially the male elbow

flexors can be very strong.

Above 200N it is often

necessary for the examiner

to sit directly against the

supinated forearm to give

additional support to

prevent pulling the subject

form the examination

couch. It is impossible to

measure both elbow flexors

from one side.


Muscle group 5: Elbow extensors

position of subject Supine, shoulder adducted, elbow 90º flexed, forearm

supinated

position of dynamometer Just proximal to wrist crease (extensor surface)


fixation Subject grasps edge of examination couch with

contralateral hand

Additional remarks

The subject must ly flat with at most one cushion, otherwise the standard position will be

interfered with. Many subject have a tendency to raise the elbow, but with proper

instructions this can be

prevented.


Muscle group 6: Wrist extensors

position of subject Sitting, forearm supported and pronated, wrist in neutral

position, fingers flexed

position of dynamometer Just proximal to 3rd metacarpal head

position of examiner Standing in front of the subject

fixation None

Additional remarks

The examiner can measure this muscle group very comfortably by holding the

dynamometer with both hands and by increasing the force by just leaning with his own

weight. This must be done slowly

and with caution app. 1-2

seconds. Especially in these

muscles a brisk break test will

give an enormous increase in

strength, which must be avoided.

The wrist joint is placed on the

edge of a table. This edge must

not be too sharp, because this

will produce pain in situ.

Prevention is easy by one or two

folded tissues under the wrist

joint. The same applies for the

dynamometer, pressing on the

metacarpalia.

In the measuring position

described above, gravity plays a

role, but this is of no practical

importance. If the wrist extensors

are so weak that gravity cannot

be overcome (+/- 2-3N), there

still would be no readable deflection on the dynamometer scale.


Muscle group 7: Three point grip

position of subject Sitting, forearm pronated, wrist extended

position of dynamometer Distal phalanx of thumb under applicator, distal two

phalanges of dig 2 and 3 above, scale of dynamometer

directed to examiner


fixation none

Additional remarks

This is the only test in which the contraction is truly isometric. The examiner must

prevent that the 4th and 5th finger are compressing the dynamometer too. Prevention is

easily possible by bending these two fingers before the contraction.


Muscle group 8: Hip abductors

position of subject Supine, hip 45º flexed, knee 90º flexed, contralateral knee

supported by chest of examiner

position of dynamometer Lateral epicondyle of knee

position of examiner Standing on right side of the subject, chest of examiner

against right knee

fixation Subject grasps edge of examination couch with both hands

Additional remarks

The right and left hip abductors are difficult to measure separately because for

stabilisation of the pelvis the contra lateral abductors must contract too. Therefore both

sides are tested at the

same time and the

weakest side will

determine the result. This

drawback is not very

serious, because

weakness of these

muscles seldom occurs

unilaterally, but nearly

always bilaterally and

symmetrically, as in

proximal myopathies.


Muscle group 9: Hip flexors

position of subject Supine, hip and knee 90º flexed, ankle supported by

examiner

position of dynamometer Anterior surface of distal thigh

position of examiner Standing on right side of the subject, right arm supporting

lower part of the leg


Additional remarks

Some synergistic hip flexor muscles are biarticular (rectus femoris, tensor fasciae latae

and sartorius) and the subject will try to elongate these muscles by bending the knee.

Supporting the lower part of the leg counteracts this unwanted movement effectively.


Muscle group 10: Knee extensors

position of subject Prone, knee 90º flexed

position of dynamometer Anterior surface of distal shant

position of examiner Standing on right side of the subject


Additional remarks

The knee extensors in normal subjects are so strong they cannot be measured. Beyond

±160N it is difficult to maintain a proper position and to avoid gliding of the dynamometer

of the shin. Normally knee

extensors are far stronger

than 160N and if this value

is surpassed hardly there

still must be the suspicion

of a pathological condition.


Muscle group 11: Knee flexors

position of subject Prone, knee 45º flexed

position of dynamometer Heel



Additional remarks

Because all hip flexors are biarticular there is a strong tendency to elongate these

muscles by raising the buttocks. Even with clear instructions this is hardly to suppress

and without doubt it will

influence the result. A belt

over the posterior pelvis

could help, but this would

be time consuming and

the test-retest results in

normals where not much

worse compared with

other muscle groups. A

large part of the healthy

subjects and patients

develops cramp during the

contraction. Formerly we

measured with a knee

flexed 90º and in that

position cramp occurred

even more often, hindering

correct strength

assessment. It is clear that

cramp will negatively

influence the strength level

and the reliability of the

results.


Muscle group 12: Foot dorsiflexors

position of subject Supine, foot 90º dorsiflexed

position of dynamometer Just proximal to metatarsophalangeal joints (dorsal surface)



Additional remarks

This muscle group is not easy to measure. In my experience it is difficult to determine on

which moment the muscle gives away. Giving away of these muscles consists of a minor

displacement of the foot,

but with careful inspection

this slight movement can

be perceived.


Muscle group 13: Foot plantarflexors

position of subject Supine, foot 90º dorsiflexed

position of dynamometer Just proximal to metatarsophalangeal joints (plantar

surface)



Additional remarks

Normal foot plantar flexors are far too strong to test! Only in the case of rather severe

weakness this muscle group comes within the measuring range.

The same difficulties are

encountered as in the foot

dorsi flexors: it is an

arduous task to determine

whether the muscles give

away. Many patients with

a severe paresis of the

plantar flexors have some

degree of contracture and

the test cannot be carried

out in the 90º dorsiflexion

standard position. In these

cases it is extra difficult to

measure a real voluntary

contraction and not the

passive stretching of the

muscle.


Appendix 1: Technical specifications CITEC HHD

Measurement scale Type CT 3002/30 0 - 500 Newton Type CT 3002/60 0 - 1000 Newton

Accuracy load cell 0,1% (maximum)

Accuracy display 0,1% (full scale)

Power 2 pieces V 28 PX / 4SR44 6.2 volt batteries ( silver oxide/lithium))

Operation One button (on/reset); auto shut-off after appr. 15 seconds

Display 3-digit display

Dimensions Ca 150 x 85 x 85 mm

Weight 250 gr.

Standard applicators

- finger applicator (little surfaces)

- ‘arm’ applicator (larger surfaces)

- flat applicator (flat surfaces)

Optional applicators

Optional

- - fist grip applicator

- pinch grip applicator

- pain pressure applicator

- connection to the PC

Memory functions 15 memory positions available

Page 27/34 appendix

Appendix 2: Reference values adults in Newton

Reference values women men

# Centile value P5 P50 P5 P50

1 Neck extensors 118 >125 >125 >125

2 Neck flexors 49 75 107 >125

3 Shoulder abductors 75 105 111 160

4 Elbow flexors 146 190 216 >250

5 Elbow extensors 80 105 115 156

6 Wrist extensors 81 111 126 170

7 Three point grip 65 86 94 125

8 Hip abductors 174 238 223 >250

9 Hip flexors 124 167 190 >250

10 Knee extensors >160 >160 >160 >160

11 Knee flexors 78 122 118 162

12 Foot dorsiflexors 164 235 232 >250

13 Foot plantarflexors >250 >250 >250 >250

These reference values are based on measurements with 50 normal women and 50

normal men in the age of 20 – 60 years. For quick practical clinical purposes, the 5th and

50th centile values will suffice. For experienced examiners, results of repeated

measurements will differ between 10% and max 20%.

Page 28/34 appendix

Appendix 3a: Reference values boys/girls aged 4 – 8 in Newton

# Age (years) 4 5 6 7 8

1 Neck

flexors

Boys

Girls

--

--

--

--

48 (9)

55 (8)

64 (11)

60 (7)

56 (8)

56 (10)

2 Shoulder

abductors

Boys

Girls

62 (20)

68 (26)

55 (10)

47 (9)

97 (27)

75 (17)

92 (29)

91 (18)

98 (19)

94 (25)

3 Elbow

extensors

Boys

Girls

--

--

--

--

73 (8)

73 (8)

85 (15)

85 (14)

90 (18)

82 (10)

4 Elbow

flexors

Boys

Girls

78 (24)

69 (21)

70 (12)

66 (12)

103 (21)

105 (9)

121 (32)

103 (20)

124 (23)

115 (16)

5 Wrist

extensors

Boys

Girls

--

--

--

--

77 (11)*

66 (6)*

89 (25)

74 (13)

87 (15)*

75 (11)*

6 Three point

grip

Boys

Girls

33 (10)

30 (4)

37 (9)*

28 (3)*

46 (9)

44 (11)

50 (9)

47 (9)

56 (12)

53 (9)

7 Hip

flexors

Boys

Girls

--

--

--

--

182 (39)

162 (31)

182 (57)

184 (50)

225 (40)**

175 (36)**

8 Hip

abductors

Boys

Girls

--

--

--

--

128 (40)

109 (26)

124 (32)

122 (24)

131 (30)

117 (18)

9 Knee

extensors

Boys

Girls

--

--

--

--

156 (33)

148 (24)

157 (38)

177 (47)

185 (41)

166 (30)

10 Knee

flexors

Boys

Girls

111 (15)

92 (25)

105 (20)

99 (15)

158 (38)

154 (33)

180 (45)

171 (35)

185 (20)*

160 (23)*

11 Foot

dorsiflexors

Boys

Girls

71 (22)

75 (20)

76 (23)

76 (15)

104 (11)

95 (17)

130 (25)

114 (18)

137 (24)

121 (17)

mean values (SD); Significant difference at *P 0.05 and ** P 0.01These reference values are based on measurements with 270 normal children: 139 boys and 131 girls, aged 4-16 years, after informed consent. For further details please refer to Beenakker, E.A.C., Van der Hoeven, J.H., Fock, J.M., Maurits, N.M. Reference values of maximum isometric muscle force obtained in 270 children aged 4-16 years by hand-held dynamometry. Neuromuscular Disorders 2001;441-446

Page 29/34 appendix

Appendix 3b: Reference values boys/girls aged 9 – 12 in Newton

# Age (years) 9 10 11 12

1 Neck

flexors

Boys

Girls

66 (9)

55 (12)

74 (20)

55 (25)

67 (13)

67 (15)

70 (16)

76 (15)

2 Shoulder

abductors

Boys

Girls

110 (31)

91 (27)

136 (26)**

81 (17)**

110 (39)

129 (25)

118 (29)

123 (27)

3 Elbow

extensors

Boys

Girls

89 (22)

91 (24)

120 (18)**

84 (20)**

103 (31)

108 (25)

104 (31)

117 (24)

4 Elbow

flexors

Boys

Girls

134 (24)

125 (28)

173 (19)**

134 (21)**

153 (30)

172 (25)

160 (25)

168 (28)

5 Wrist

extensors

Boys

Girls

97 (15)*

80 (21)*

121 (21)**

80 (17)**

100 (19)

112 (16)

108 (21)

127 (23)

6 Three point

grip

Boys

Girls

58 (9)

56 (14)

78 (15)**

54 (11)**

70 (24)

73 (13)

72 (16)

72 (11)

7 Hip

flexors

Boys

Girls

232 (53)

195 (48)

261 (74)**

177 (25)**

245 (65)

264 (55)

198 (38)

232 (61)

8 Hip

abductors

Boys

Girls

153 (33)

124 (35)

174 (47)**

104 (25)**

151 (63)

140 (22)

158 (41)

171 (44)

9 Knee

extensors

Boys

Girls

194 (30)

173 (57)

267 (47)**

198 (57)**

239 (65)

265 (36)

225 (43)

250 (71)

10 Knee

flexors

Boys

Girls

195 (40)

180 (54)

268 (48)**

175 (29)**

218 (64)

246 (52)

201 (34)

221 (54)

11 Foot

dorsiflexors

Boys

Girls

141 (31)

137 (32)

154 (18)**

130 (21)**

149 (26)

178 (25)

170 (28)

177 (34)

mean values (SD); Significant difference at *P 0.05 and ** P 0.01

Page 30/34 appendix

Appendix 3c: Reference values boys/girls aged 13 – 16 in Newton

# Age (years) 13 14 15 16

1 Neck

flexors

Boys

Girls

98 (40)

92 (17)

129 (42)

96 (15)

143 (36)

108 (27)

141 (33)

87 (14)

2 Shoulder

abductors

Boys

Girls

159 (46)

154 (26)

205 (44)

178 (18)

219 (36)**

173 (29)**

253 (54)**

173 (38)**

3 Elbow

extensors

Boys

Girls

128 (42)

118 (26)

158 (42)

129 (23)

175 (46)

141 (37)

182 (64)**

107 (36)**

4 Elbow

flexors

Boys

Girls

195 (26)

201 (23)

253 (50)*

193 (32)*

287 (55)**

198 (48)**

276 (68)*

215 (30)*

5 Wrist

extensors

Boys

Girls

153 (42)

152 (14)

195 (41)*

155 (6)*

218 (49)**

166 (26)**

237 (58)**

147 (28)**

6 Three point

grip

Boys

Girls

96 (25)

84 (11)

133 (17)*

96 (13)*

127 (29)*

99 (17)*

140 (22)**

106 (18)**

7 Hip

flexors

Boys

Girls

289 (60)

308 (51)

337 (66)

281 (72)

301 (69)

288 (70)

395 (102)*

301 (42)*

8 Hip

abductors

Boys

Girls

225 (58)

227 (52)

306 (83)

244 (30)

356 (87)**

257 (68)**

312 (106)

244 (59)

9 Knee

extensors

Boys

Girls

296 (70)

346 (49)

370 (61)*

280 (69)*

362 (76)

325 (79)

396 (90)

373 (81)

10 Knee

flexors

Boys

Girls

273 (59)

301 (38)

307 (64)

271 (76)

327 (76)

282 (61)

382 (80)

336 (57)

11 Foot

dorsiflexors

Boys

Girls

218 (55)

214 (29)

257 (60)

207 (31)

267 (50)*

220 (40)*

291 (60)*

232 (30)*

mean values (SD); Significant difference at *P 0.05 and ** P 0.01

Page 31/34 appendix

Appendix 4a: CITEC HHD measurement registration form

Patient information:

Patient number

Patient name

Measurements

Measurement date

Measurement location right left right left right left right left

Analysis:

Note: the CITEC measurement registration form can be downloaded from our website www.citec.nu Values in Newton

Page 32/34 appendix


Appendix 4b: CITEC HHD measurement registration form with references

Patient information:

Patient number

Patient name

Measurements

Measurement date

Measurement location right left right left right left right left

References in N women men References women men

Centile value P5 P50 P5 P50 Centile value P5 P50 P5 P50

Neck extensors 118 >125 >125 >125 Hip flexors 124 167 190 >250

Neck flexors 49 75 107 >125 Hip abductors 174 238 223 >250

Shoulder abductors 75 105 111 160 Knee extensors >160 >160 >160 >160

Elbow flexors 146 190 216 >250 Knee flexors 78 122 118 162

Elbow extensors 80 105 115 156 Foot dorsiflexors 164 235 232 >250

Page 33/34 appendix

Wrist extensors 81 111 126 170 Foot plantarflexors >250 >250 >250 >250

Threepoint pinch 65 86 94 125

Your notes:

Appendix 3 d: reference values fistgrip men/women in Newton

Note : Values measured with the CITEC HHD has to be multiplied with factor 2 !!

Page 34/34 appendix

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